Guidelines for the Therapeutic Dosing of Unfractionated Heparin Guidelines developed by the UWHC Center for Drug Policy

Revised by: Anne Rose, PharmD Reviewed by: Anticoagulation Task Force Coordination: Sara Smith-Shull, Pharm.D., MBA. Director, Center for Drug Policy Approved by P&T: January 2004 Last Review Date: November 2010 Next Scheduled Review: November 2012 A. The prescriber will initiate the heparin protocol by entering an order to begin heparin per protocol. 2.0 The order must specify the intended dosing regimen and if an initial bolus is desired. 2.1 The following intensity regimens are available: Low Intensity Regimen acute MI treated with alteplase, tenecteplase or abciximab/eptifibatide/tirofiban (note: no bolus is recommended if less than 6 hours from arterial sheath removal) Medium Intensity Regimen non-ST segment myocardial infarction, mechanical valve High Intensity Regimen established deep vein thrombosis, pulmonary embolism, ventricular/atrial thrombus B. Once the prescriber orders the heparin protocol, the nurse takes the following steps: 1.0 Review initial order for desired dosing regimen (low, medium, high intensity) and whether a bolus is indicated. Bolus Dose (units/kg) 60 70 80 Maximum Bolus (units) 4000 7000 10,000 Initial Infusion (units/kg/hr) 12 15 18 Maximum Initial Infusion Rate (units/hr) 1000 1400 2000

Regimen Low Medium High

2.0 Determine bolus based on actual body weight. Use best estimate of true weight if unable to weigh patient. Record weight in Health Link. 3.0 Laboratory Monitoring 3.1 STAT baseline aPTT and PT/INR prior to initiating heparin infusion if not available 3.2 STAT baseline CBC and platelet if not available 3.3 CBC and platelet 24 hours after initiating heparin therapy and every other day thereafter for up to 14 days or until therapy is discontinued. 3.4 Stat aPTT 6 hours after initiation of heparin infusion. 4.0 Heparin is a high-alert medication. An additional double-check is required as specified in Hospital Administrative Policy 8.33 must be performed on all boluses, when IV pump programming is outside of the established IV pump decision support software (Alaris Guardrails ) limits, and when a new bag of heparin is hung.

5.0 Prepare and administer the initial heparin bolus. If NO bolus is ordered, proceed to step 6. 5.1 Document bolus in Health Link 5.2 Use heparin 1000 units/mL vial for bolus from floor stock. 6.0 Initiate heparin infusion. 6.1 Document infusion rate in Health Link in mL/hr 6.2 Use heparin 25,000 units/500 mL D5W premixed bags. 6.3 Other heparin concentrations are not allowed for use. 7.0 Titration of heparin therapy 7.1 Check STAT aPTT 6 hours after initiation and 6 hours after any rate change. 7.2 Prior to adjusting the heparin infusion confirm the ordered intensity. 7.3 Adjust the rate as indicated in the appropriate dosing table until aPTT is therapeutic. Use a supplemental bolus if ordered. 7.4 Record each heparin rate adjustment in mL/hr in the heparin flow sheet. 7.5 Once 3 consecutive aPTTs (drawn every 6 hours) are therapeutic, order routine aPTT only every 24 hours with the am labs. 7.6 If a rate adjustment becomes necessary or the infusion is held for any reason and restarted, recheck aPTT in 6 hours and repeat the above process. 8.0 If heparin is being used therapeutically, no modification of these protocol orders is allowed. While discouraged, if patient circumstances require heparin dosing that differs from established protocols, specific orders must be written. Separate heparin order sets are available for patients on ECMO or ventricular assist devices. Low and Medium Intensity (Arterial Thrombosis) Heparin Anticoagulation Dose Adjustments
aPTT (seconds)* <34 34-35 36-37 38-46 47-56 57-66 67-86 87-100 >100 Bolus/Hold Give supplemental bolus if ordered & inform MD Give supplemental bolus if ordered & inform MD 0 0 0 0 Hold infusion 1 hour & inform MD Hold infusion 1 hour & inform MD Hold infusion 1 hour & inform MD Infusion 100 units/hr = 2 mL/hr 100 units/hr = 2 mL/hr 50 units/hr = 1 mL/hr NO CHANGE 50 units/hr = 1 mL/hr 100 units/hr = 2 mL/hr 150 units/hr = 3 mL/hr 200 units/hr = 4 mL/hr 200 units/hr = 4 mL/hr

High Intensity (Venous Thromboembolism) Heparin Anticoagulation Dose Adjustments

aPTT (seconds)* <34 34-38 39-44 45-60 61-75 76-90 91-115 >115 Bolus/Hold Give supplemental bolus if ordered & inform MD Give supplemental bolus if ordered & inform MD 0 0 0 Hold infusion 1 hour & inform MD Hold infusion 1 hour & inform MD Hold infusion 1 hour & inform MD Infusion 100 units/hr = 2 mL/hr 100 units/hr = 2 mL/hr 50 units/hr = 1 mL/hr NO CHANGE 100 units/hr = 2 mL/hr 150 units/hr = 3 mL/hr 200 units/hr = 4 mL/hr 200 units/hr = 4 mL/hr

*aPTT should be rounded to the nearest whole number. (If < 0.5 round down, if 0.5 round up.) If two consecutive aPTTs are greater than 115 seconds, patient should not be maintained on the heparin protocol. Recommend consultation with Pharmacy and/or Hematology for assistance with dosing.

If two consecutive aPTTs are subtherapeutic, a consultation with Pharmacy or Hematology is recommended for assistance with dosing. 9.0 Monitoring 9.1 Every eight hours: Inspect line/surgical/wound sites for bleeding and check patient for symptoms indicating bleeding such as hematomas, bruising, and respiratory symptoms. Contact MD for any signs of bleeding. 10 Provider should be notified if: 10.1 Baseline aPTT > 34 seconds or baseline INR > 1.2 9 10.2 Platelet count decreases > 50% from baseline or if count falls below 100 x10 /L 10.3 Hemoglobin decreases by > 2 g/dL from baseline 10.4 aPTT is < 36 seconds or > 66 seconds if patient is on low or medium intensity regimen 10.5 aPTT is < 39 seconds or > 75 seconds if patient is on high intensity regimen 10.6 Patient has any deterioration in neurologic status C. Relative Contraindications and Precautions 1.0 Therapeutic heparin infusions should be used with caution in patients with: 1.1 Hypersensitivity to heparin 1.2 Increased risk for hemorrhagic complications 1.3 Patients who are actively bleeding 1.4 Thrombocytopenia 1.5 Less than 72 hours post-op 1.6 Recent hemorrhagic stroke

Reference: Antithrombotic and thrombolytic therapy: American College of Chest Physicians Evidence-Based Clinical th Practice Guidelines (8 Edition). Chest. 2008;133(6 Suppl):67S-887S.