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/clinical/cckm-tools/content/order-sets/inpatient/hospital-wide/name-98211-en.cckm

201709271

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Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Inpatient,Hospital-wide

IP - HIT (Heparin Induced Thrombocytopenia) - Adult - Supplemental [3596]

IP - HIT (Heparin Induced Thrombocytopenia) - Adult - Supplemental [3596] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Hospital-wide


IP - HIT (Heparin Induced Thrombocytopenia) - Adult - Supplemental [3596]
UW Health Guidelines for Diagnosis and
Treatment of Heparin Induced Thrombocytopenia
URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/?path=/content/cpg/hematology-and-
coagulation/name-97532-en.cckm
Diagnosis of HIT
Diagnosis of HIT (Single Response) [226917]
Scoring is a 4T score to determine if the patient is low, intermediate, or high risk. Complete
categories. based on the summation of all
Low Risk (4T score 0-3) - No further laboratory
testing needed. Patient unlikely to have HIT and
no interruption of heparin is needed. Please exit
the order set [226913]
4T 2 Points 1 Point 0 Points
Thrombocytopeni
a
• PLT fall > 50%
AND nadir > 20
AND no surgery
within previous 3
days
• PLT fall > 50% but
surgery within
previous 3 days
• PLT fall 30-50% or
nadir 10-19K
• PLT fall < 30%
• Any PLT fall with
nadir <10K
Timing of PLT
count fall
• Fall 5-10 days
after heparin
• Fall within 1 day
after heparin and
exposed to
heparin within past
5-30 days
• Fall 5-10 days after
heparin but unclear
(e.g. missing PLT)
• Fall in 1 day after
heparin with
exposure in past 31-
100 days
• Fall after 10 days
• Fall < 4 days
without recent
heparin exposure
Thrombosis or
other sequelae
• Confirmed new
thrombosis
• Skin necrosis at
injection site
• Anaphylactoid
reaction to IV
heparin bolus
• Adrenal
hemorrhage
• Recurrent VTE
while on therapeutic
anticoagulants
• Suspected
thrombosis
• Erythematous skin
lesions at heparin
injection sites
• Thrombosis
suspected
Other causes of
Thrombocytopeni
a
• No alternative
explanation for
platelet fall
• Sepsis without
proven source
• Thrombocytopenia
associated with
initiation of
ventilator
• Other
• Within 72 hrs of
surgery
• Confirmed
bacteremia or
fungemia
• Chemo/radiation
within 20 days
• DIC due to non-
HIT cause
• Post-transfusion
purpura
• Drug induced
thrombocytopenia
• Other
Clinical Suspicion Scoring: 0-3 = Low, 4-5 = Intermediate, 6-8 = High
Page 1 of 5
Printed by LIND, JANNA S [JSL237] at 9/28/2017 11:50:23 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

No further laboratory testing needed. Patient unlikely to have HIT and no interruption of heparin
is needed. Please exit the order set.
Note: [950018] ONCE
Intermediate Risk (4T score 4-5) or High Risk (4T
score 6-8) [232839]
HEPARIN INDUCED PLATELET AB [HCHEPAB] NEXT AM For 1 Occurrences, Routine
Is the patient receiving any anticoagulant? Yes
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition?
Note: No Heparin [950010] 4 X DAILY (NOTE ACKNOWLEDGE)
Note: No Low Molecular Weight Heparin
[950011]
4 X DAILY (NOTE ACKNOWLEDGE)
Positive Heparin Induced Platelet Ab (ELISA) test
[226915]
HEPARIN DEP AB SEROTONIN RELEASE
ASSAY [HCHDPLT]
NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition?
Note: No Heparin [950010] 4 X DAILY (NOTE ACKNOWLEDGE)
Note: No Low Molecular Weight Heparin
[950011]
4 X DAILY (NOTE ACKNOWLEDGE)
Treatment of HIT
If the Heparin induced platelet Ab (ELISA) or Heparin dependent Ab serotonin release assay
(SRA) are negative then the patient does NOT have HIT. No treatment needed.
Patient Monitoring [105393]
Measure Weight For Dose Calculations
[NURMON0054]
ONCE, Starting today For 1 Occurrences, Routine
Neurovascular Checks [NURMON0045] EVERY 8 HOURS, Starting today, Routine
Location:
Evaluate patient for signs and symptoms of
thrombosis/clotting.
Contingency Parameters [105394]
Page 2 of 5
Printed by LIND, JANNA S [JSL237] at 9/28/2017 11:50:23 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

Notify Provider If: [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg):
If systolic blood pressure < (mmHg):
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C):
If temperature < (C):
If heart rate > (bpm):
If heart rate < (bpm):
If respiratory rate >:
If respiratory rate <:
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL):
Other: Baseline activated partial thromboplastin time is
greater than 34 seconds,Activated partial
thromboplastin time greater than 100
seconds,Hemoglobin decreases by more than 2 g/dL
from baseline,Baseline international normalized ratio
(INR) is greater than 1.2,Platelet count less than 100
K/uL,Any signs of bleeding or clotting,Any
deterioration in neurological status
Medications - NOTE orders [232570]
Note: No Heparin [950010] 4 X DAILY (NOTE ACKNOWLEDGE)
Note: No Low Molecular Weight Heparin [950011] 4 X DAILY (NOTE ACKNOWLEDGE)
Medications - Treatment of HIT [105158]
If the heparin induced platelet Ab (ELISA) or heparin dependent Ab serotonin release assay
(SRA) are negative then the patient does NOT have HIT. No treatment needed.
Planned surgery or procedure within 24 hours or
CrCl less than 30 mL/min [232573]
Parenteral anticoagulation recommended until patient stabilized and platelets recovered.
argatroban 50 mg/50mL in 0.9% sodium chloride
infusion [148035]
2 mcg/kg/min, Intravenous, CONTINUOUS
Argatroban dose limit: aPTT not to exceed 100
seconds OR 10 mcg/kg/min.
Contact the ordering physician/team for aPTT levels
and adjustments to argatroban rates. Ordering
physician/team to adjust dose to maintain an aPTT
at 1.5 - 3 times the baseline value.
CrCl greater than 30 mL/min (Single Response)
[232575]
Parenteral anticoagulation recommended until patient stabilized and platelets recovered.
fondaparinux (ARIXTRA) injection - Note: order
for patients less than 50 kg [800090]
5 mg, Subcutaneous, 1 X DAILY Starting today with
First Dose Include Now
fondaparinux (ARIXTRA) injection - Note: order
for patients 50 - 100 kg [800090]
7.5 mg, Subcutaneous, 1 X DAILY Starting today
with First Dose Include Now
fondaparinux (ARIXTRA) injection - Note: order
for patients over 100 kg [800090]
10 mg, Subcutaneous, 1 X DAILY Starting today with
First Dose Include Now
apixaban (ELIQUIS) tab [155775] 5 mg, Oral, 2 X DAILY Starting today with First Dose
Include Now
dabigatran (PRADAXA) cap [143263] 150 mg, Oral, 2 X DAILY Starting today with First
Dose Include Now
Page 3 of 5
Printed by LIND, JANNA S [JSL237] at 9/28/2017 11:50:23 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

rivaroxaban (XARELTO) tab [148913] 15 mg, Oral, 2 X DAILY Starting today with First
Dose Include Now
Continue until platelet count recovers then decrease
to 20 mg 1 x daily.
Laboratory - Draw Now - Fondaparinux, apixaban, dabigatran, rivaroxaban [105494]
now if not completed in the past 24 hours.Draw
PROTHROMBIN TIME/INR [PT] STAT, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Draw for baseline prior to anticoagulant administration.
HEMOGLOBIN [HGB] STAT, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Draw for baseline prior to anticoagulant administration.
CREATININE [CRET] STAT, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Draw for baseline prior to anticoagulant administration.
Laboratory - Other Labs - Fondaparinux, apixaban, dabigatran, rivaroxaban [105495]
HEMOGLOBIN [HGB] EVERY OTHER DAY For 3 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PLATELET COUNT [PLT] EVERY OTHER DAY For 3 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CREATININE [CRET] EVERY OTHER DAY, Starting today For 3
Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Laboratory - Draw Now - Argatroban Infusion [105397]
Draw now if not completed in the past 24 hours.
PROTHROMBIN TIME/INR [PT] STAT, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Draw for baseline prior to argatroban administration
HEMOGLOBIN [HGB] STAT, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Draw for baseline prior to argatroban administration
PTT [PTT] STAT, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Draw for baseline prior to argatroban administration
Laboratory - Other Labs - Argatroban Infusion [105399]
Page 4 of 5
Printed by LIND, JANNA S [JSL237] at 9/28/2017 11:50:23 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

HEMOGLOBIN [HGB] EVERY OTHER DAY For 3 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PLATELET COUNT [PLT] EVERY OTHER DAY For 3 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PTT [PTT] CONDITIONAL, Starting today For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Every 2 hours after
initiation or rate adjustment of argatroban. Draw
routine every 24 hours once the PTT has been in
therapeutic range 2 consecutive times.
Diagnostic Tests and Imaging [108777]
US PERIPHERAL DOPPLER BILATERAL -
LOWER EXTREMITY [R93970]
ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Upper or Lower Extremity? Lower Extremity
Radiology Specialty Area: ULTRASOUND
Current signs and symptoms? Clinical Suspicion of
Heparin Induced Thrombocytopenia (HIT)
What specific question(s) would you like answered by
this exam? Presence of Deep Vein Thrombosis (DVT)
Relevant recent/past history? Clinical Suspicion of
Heparin Induced Thrombocytopenia (HIT)
For scheduling purposes, does the patient require
general anesthesia, sedation or anxiolytics? Note:
ordering provider is responsible for prescribing oral
anxiolytics or arranging peds anesthesia / sedation
services. See reference link above.
If being performed remotely, where?
Transport Method: Floor Determined/Entered
US PERIPHERAL DOPPLER BILATERAL -
UPPER EXTREMITY [R93970]
ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Upper or Lower Extremity? Upper Extremity
Radiology Specialty Area: ULTRASOUND
Current signs and symptoms? Clinical Suspicion of
Heparin Induced Thrombocytopenia (HIT)
What specific question(s) would you like answered by
this exam? Presence of Deep Vein Thrombosis (DVT)
Relevant recent/past history? Clinical Suspicion of
Heparin Induced Thrombocytopenia (HIT)
For scheduling purposes, does the patient require
general anesthesia, sedation or anxiolytics? Note:
ordering provider is responsible for prescribing oral
anxiolytics or arranging peds anesthesia / sedation
services. See reference link above.
If being performed remotely, where?
Transport Method: Floor Determined/Entered
Page 5 of 5
Printed by LIND, JANNA S [JSL237] at 9/28/2017 11:50:23 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org