THROMBOCYTOPENIA

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 DEFINITION

 Reduction of platelet below 1,50,000/mL

 a/c , severe or prolonged decrease from the normal

range can result in abnormal hemostasis that is
manifested as prolonged bleeding from minor
trauma to spontaneous bleeding without injury.
 Causes of Thrombocytopenia


Inherited
 Fanconi anemia (pancytopenia)
 Hereditary thrombocytopenia
Acquired
 Immune
 Immune thrombocytopenic purpura (ITP)
 Neonatal alloimmune thrombocytopenia
Nonimmune

 Shortened circulation
 Thrombotic thrombocytopenic purpura (TTP)

 Disseminated intravascular coagulation (DIC)

 Heparin-induced thrombocytopenia (HIT)
 Splenomegaly/splenic sequestration

 Turbulent blood flow (hemangiomas, abnormal

cardiac valves, intraaortic balloon pumps)
 Decreased production
 Drug-induced marrow suppression
 Chemotherapy

 Viral infection (hepatitis C virus, HIV
cytomegalovirus)
 Bacterial infection (sepsis)
 Alcoholism/bone marrow suppression
 Myelodysplastic syndrome (MDS)
 Myelofibrosis
 Aplastic anemia
 Hematologic malignancy (leukemias, lymphomas,
myeloma)
 Solid tumor infiltrating bone marrow
 Radiation to the bone
 Food, Drug, and Herbal Causes of
Thrombocytopenia

 Thiazide diuretics
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 Alcohol
 Estrogen
 Chemotherapeutic drugs
 Digoxin
 Nonsteroidal antiinflammatory drugs
 Antibiotics: penicillins, cephalosporins, sulfonamides
 Other antiinfectives: rifampin, ganciclovir,
amphotericin B
 Analgesics: aspirin and aspirin-containing drugs,
acetaminophen
 
 Antipsychotics and antiseizures: haloperidol, valproate,
lithium
 Platelet glycoprotein inhibitors: abciximab, tirofiban,
eptifibatide
 H2 antagonists: cimetidine, ranitidine
 Gold compounds: auranofin
 Spices: ginger, cumin, turmeric, cloves
 Vitamins: vitamin C, vitamin E
 Heparin
 Herbs: evening primrose, feverfew, garlic, ginger, ginkgo
goldenseal
 Quinine compounds: tonic water, china bark, Peruvian
bark, yellow cinchona
 
 Immune thrombocytopenic purpura

Abnormal destruction of circulating platelets

 Thrombotic thrombocytopenic purpura

characterised by hemolytic anemia, thrombocytopenia,

neurologic abnormalities.
Usually associated with hemolytic uremic syndrome it is called
TTP-HUS
 Heparin induced thrombocytopenia and thrombosis syndrome
 Pathophysiology of ITP

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Platelets are coated with antibodies

In spleen recognized as foriegn body

Destroyed by macrophages
P/P of thrombotic thrombocytopenic

Enhanced agglutination of platelet

Due to deficiency of plasma enzyme that breakdown

Von Willebrand clotting factor into normal size

Formation of microthrombi that deposit in arterioles

and capillaries

Hemolytic anemia, thrombocytopenia, neurologic

abnormalities
Heparin induced thrombocytopenia and
thrombosis syndrome

 Type I (mild) HITTs- no clinical consequences
 Type II HITTs, platelet destruction and vascular
endothelial injury
 
Platelet factor 4 binds to heparin

Complex bind to platelet surface, further activation of platelet

and release a of more PF4(positive feedback loop)

Antibodies formed against the complex and removed from

circulation

Thrombocytopenia and platelet fibrin thrombi

Neutrilization of heparin

More heparin needed for therapeutic use

 Clinical manifestation

 Usually asymptomatic
 Bleeding, usually mucosal or cutaneous
Mucosal bleeding may manifest as epistaxis and
gingival bleeding, and large bullous hemorrhages.
Bleeding into the skin is manifested as petechiae,
purpura, or superficial ecchymoses
 Prolonged bleeding after routine procedures such as
venipuncture or IM injection
 Weakness, fainting, dizziness, tachycardia,
abdominal pain, and hypotension.
 
 Cerebral hemorrhage may be fatal in persons with
ITP
 vascular ischemic problems can manifest with subtle
confusion, headache, or even serious manifestations
such as seizures and coma
 
 The platelet count is decreased in cases of
thrombocytopenia
 Prothrombin time (PT) and activated partial
thromboplastin time (aPTT), can be normal even in
severe thrombocytopenia
 Bone marrow examination
 ITP-positive antigen specific assay or 14C-serotonin
release assay for HIT
 Increase of lactic dehydrogenase (LDH)
 Collaborative Care


Immune Thrombocytopenic Purpura
 Corticosteroids eg: Prednisolone
 Platelet transfusions
 Splenectomy
 Intravenous immunoglobulin
 Anti-Rho(D)
 Danazol : ↑ CD4 Tcells and decrease immune response

 Immunosuppressives: cyclosporine, cyclophosphamide,

azathioprine ,mycophenolate mofetil
 High-dose cyclophosphamide or combination
chemotherapy
 
 Thrombotic Thrombocytopenic Purpura
 Plasmapheresis (plasma exchange)
 High-dose prednisone
 Splenectomy
 Dextran
 Chemotherapy (vincristine [Oncovin], vinblastine
[Velban])
 Immunosuppressives (cyclophosphamide [Cytoxan],
rituximab [Rituxan])
 
Heparin-Induced Thrombocytopenia and Thrombosis
Syndrome
 Direct thrombin inhibitor (lepirudin [Refludan],
argatroban [Acova])
 Indirect thrombin inhibitor (fondaparinux [Arixtra])
 Plasmapheresis (plasma exchange)
 Protamine sulfate
 Coumadin
 Thrombolytic agents
 
Decreased Platelet Production
 Identification and treatment of cause
 Corticosteroids
 Platelet transfusions
 Nursing management

 1) have no gross or occult bleeding,
 (2) maintain vascular integrity, and
 (3) manage home care to prevent any complications
related to an increased risk for bleeding.
 Interventions : Health Promotion

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 Discourage excessive use of over-the-counter (OTC)
medications known to be possible causes of acquired
thrombocytopenia.
 Encourage persons to have a complete medical
evaluation if manifestations of bleeding tendencies
(e.g., prolonged epistaxis, petechiae) develop.
 Observe for early signs of thrombocytopenia in the
patient receiving cancer chemotherapy drugs.
 Acute Intervention

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 In the patient with thrombocytopenia, bleeding is
usually from superficial sites; deep bleeding (into
muscles, joints, and abdomen) usually occurs only
when clotting factors are diminished.
 minor nosebleed or new petechiae may indicate
potential hemorrhage and the health care provider
should be notified.
 If an IM or subcutaneous injection is unavoidable,
the use of a small-gauge needle and application of
direct pressure for at least 5 to 10 minutes after
injection is indicated or application of an ice pack
may be helpful.
 
 In a woman with thrombocytopenia, menstrual
blood loss may exceed the usual amount and
duration.
• Counting sanitary napkins used during menses is
another important intervention to detect excess
blood loss.
• Suppression of menses with hormonal agents may be
indicated during predictable periods of
thrombocytopenia to reduce blood loss from menses
 
 The proper administration of platelet transfusions is
an important nursing responsibility.
 Nursing diagnosis


 Impaired oral mucous membrane related to low
platelet counts and/or effects of pathologic
conditions and treatment as evidenced by oral
bleeding
 Risk for injury related to low platelet counts and
treatments
 Ineffective management of therapeutic regimen
related to lack of knowledge of disease process,
activity, and medication