THROMBOCYTOPENIA

Thrombocytopenia is characterized by a decreased platelet count (less than 150,000/mm3), the most common cause of bleeding disorders.

Etiology

  • Decreased platelet production
    • Infiltrative diseases of bone marrow,
    • Leukaemia,
    • Aplastic Anemia,
    • Myelofibrosis,
    • Myelosuppressive therapy,
    • Radiation therapy;
    • Inherited disorders such as
      • Fanconi's anemia (FA, is a rare, inherited blood disorder that leads to bone marrow failure)
      • Wiskott-Aldrich syndrome (a rare X-linked recessive disease characterized by eczema, thrombocytopenia, immune deficiency, and bloody diarrhea).
  • Increased platelet destruction—
    • Infection (eg, HIV or hepatitis C),
    • Drug-induced (eg, heparin or quinidine),
    • ITP,
    • DIC.
  • Abnormal distribution or sequestration in spleen.
  • Dilutional thrombocytopenia—after haemorrhage, RBC transfusions.

Clinical Manifestations

  • Usually asymptomatic (with platelet counts greater than 50,000/mm3).
  • When platelet count drops below 20,000/mm3:
    • Petechiae occur spontaneously.
    • Ecchymoses occur at sites of minor trauma (venipuncture, pressure).
    • Bleeding may occur from mucosal surfaces, nose, GI and GU tracts, respiratory system, and within CNS. nasal and gingival bleeding
    • Menorrhagia is common.
  • Excessive bleeding may occur after procedures (dental extractions, minor surgery, biopsies).
  • Thrombotic complications (arterial and venous) and areas of skin necrosis are associated with heparin-induced thrombocytopenia.

Diagnostic Evaluation

  • CBC with platelet count
    • Haemoglobin —decreased
    • Haematocrit—decreased
    • Platelets—decreased
  • Bleeding time - prolonged.
  • Prothrombin time (PT)—prolonged.
  • Partial thromboplastin time (PTT)—prolonged.
  • Platelet aggregation test for heparin-dependent platelet antibodies—positive.

Medical Management

  • Treat underlying cause.
  • Platelet transfusions.
    • If platelet production is impaired, platelet transfusions may increase the platelet count and stop bleeding or prevent spontaneous hemorrhage.
    • If excessive platelet destruction occurs, transfused platelets are also destroyed, and the platelet count does not increase. The most common cause of excessive platelet destruction is idiopathic thrombocytopenic purpura.
  • Steroids or IV immunoglobulins may be helpful in selected patients.
  • Heparin-induced thrombocytopenia:
    • Discontinue heparin,
    • Use alternate anticoagulant therapy due to high risk of venous and arterial thromboses in these patients (direct thrombin inhibitors, such as lepirudin or argatroban hirudin),
    • Avoid platelet transfusions.

Nursing management

Risk for Injury related to bleeding due to thrombocytopenia.

  • Institute bleeding precautions.
    • Avoid use of plain razor, hard toothbrush or floss, I.M. injections, tourniquets, rectal procedures, suppositories.
    • Administer stool softeners, as necessary, to prevent constipation.
    • Restrict activity and exercise when platelet count is less than 20,000/mm3 or when active bleeding occurs.
  • Monitor pad count and amount of saturation during menses;
  • Administer or teach self-administration of hormones to suppress menstruation, as prescribed.
  • Administer blood products, as ordered.
  • Monitor for signs and symptoms of allergic reactions, anaphylaxis, and volume overload.
  • Evaluate urine, stools, and emesis for gross and occult blood.

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