HIT and epidural catheter

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sevodex1

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Situation with a thoracic epidural inserted for esophagectomy-that needs to be removed.
POD 3 now: platelets of 59 (baseline 121) , rest of coags normal.
Patient is HIT positive now (was on SQ heparin for DVT prophylaxis ). Has an upper extremity DVT which needs anticoagulation anyways.
Needs argatroban as per HIT protocol and for the DVT .

How would you guys proceed ?
1. Start argatroban , wait for platelet count to rise, stop argatroban in 1-2 days , hold argatroban for few hours and remove the catheter?
or
2. wait to start argatorban , recheck platelet count in 24 hrs and remove epidural before starting argatroban?

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I would just pull it and do frequent neurochecks. Start argatroban in 4 of hrs. Don't ask me for evidence because I don't have any.

PS: Does he really have HIT? How was the diagnosis made?
 
Why not give platelets until > 80 and then pull it before starting argatroban
 
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Agree. Pull it out. Wait a couple hours and start argatroban.

HIT is a prothrombotic state. The plts are being consumed which is why they are low so giving plts doesn't solve anything. Even with that said guidelines will say give plts if pt is actively bleeding or undergoing a procedure that is high risk of bleeding.

I have personally done a C/S on a pt with a plt count of 4k who had TTP and the patient oozed more than usual but did not hemorrhage as I was expecting. I did not give any plts.
 
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