Abstract | November 8, 2021
A Triple HIT Dilemma: Balancing Pulmonary Emboli, Hemorrhagic Shock, and HIT Syndrome
Learning Objectives
- Review treatment options for HIT.
- Understand argatroban dose-adjustments for critically ill patients.
Introduction: Heparin Induced Thrombocytopenia (HIT) is a dangerous immunologically mediated drug reaction to unfractionated heparin. It is important to personalize management for these patients especially if they have a comorbid condition, including recently resolved bleed and obesity.
Case Presentation: A 67-year-old man with morbid obesity (BMI 43) and recent prostatectomy was admitted 2 weeks for bilateral pulmonary emboli (PE). He was discharged on an enoxaparin bridge to warfarin therapy, then re-admitted for hemorrhagic shock due to a retroperitoneal hematoma. Anticoagulation was held until his hemoglobin stabilized. He was then started on heparin.
The day after starting heparin therapy, his max temperature was 99.9°F, blood pressure 122/72 mmHg, respiratory rate 18 breaths/minute, and 96% O2 saturation on 2L nasal cannula. He had right flank bruising and legs symmetrical with 1+ edema to knees. We ordered a CBC, CMP, coagulation studies, hepatitis panel, and CT abdomen.
Over the next 24 hours, the patient’s platelets decreased from 111 to 70 and his hemoglobin was 8.0. His HIT score was 5 and his platelet serotonin-release assay was positive. Differential diagnoses for thrombocytopenia are HIT, disseminated intravascular coagulation, and medication-induced.
Final Diagnosis: Heparin-Induced Thrombocytopenia.
Management: Heparin drip was discontinued, and an alternative anticoagulant for his HIT and PEs was sought. Due to the patient’s BMI of 43 and lack of data in this population, a direct oral anticoagulant (DOAC) could not be used. We chose to use a low-dose argatroban therapy (typically for critically ill). Although our patient was no longer critically ill, this strategy balanced the need to anticoagulate with the risk of further hemorrhage and allowed for rapid reversal if needed. His platelet counts are improving and his hemoglobin remains stable. The treatment plan for this patient is to transition from argatroban to fondaparinux for three months continued outpatient anticoagulation for provoked PE’s.
