Usual Adult Dose for Patency Maintenance of Indwelling Intravenous Devices. Rivaroxaban The protocol was approved by the Detroit Medical Center's Pharmacy & Therapeutics Committee and Wayne State University, Investigational Review Board. These include the indirect anticoagulants, unfractionated heparin (UFH), low-molecular-weight heparins (LMWHs), fondaparinux, and danaparoid, as well as the direct thrombin inhibitors hirudin, bivalirudin, and argatroban. Protamine Dosing Guidelines Page 2 of 2 Guidelines for Low Molecular Weight Heparin Protamine sulfate neutralizes about 60% of the anti-factor Xa activity. Heparin Dosing: By bolus. Adult heparin infusion protocol This protocol reflects current evidence-based clinical practice. in the protamine dose calculation. Heparin dose, duration and indication, as well as aPTT (in seconds) were collected, per protocol. Some guidelines note that intermediate dose anticoagulation can be considered for critically ill patients. Heparin resistance, defined as an inadequate response to heparin at a standard dose for achieving a therapeutic goal occurs in approximately 5 to 30% of patients. LMWH Protocols Fixed dose vs. dose based on anti-Xa Target anti-Xa level 0.25-0.35 U/ml Enoxaparin Loading dose 0.15 mg/kg Maintenance dose 0.05 mg/kg/hr Mean filter life 31 hrs Nadroparin, dalteparin Loading dose 15-25 IU/kg Maintenance dose 5-10 IU/kg/hr Median filter life 18-50 hrs Pont AC de et al. 4.1.2.1. Selection of Initial Warfarin Dose along indication and target range for treatment: – Heparin use (bolus or continuous, irrespective of dose), adjudicated based on whether or not a patient had an active order for heparin as of the last treatment in the prior month. Second, heparin is administered into the circuit priming solution before the blood is in contact with plastic surfaces (10,000 iu heparin/1,000 ml of 0.9% NaCl). 4.1.2.To initiate the protocol for inpatient, the patient’s appropriately-credentialed practitioner will select the “Warfarin Dosed per Collaborative Practice Protocol” order in the CPOE system. There is considerable variation in individual anticoagulant responses to heparin. For Adult. For questions or concerns about any of the content, please contact nilesh.patel@duke.edu. Low-dose heparin reduces the risk of venous thrombosis and fatal PE by 60% to 70%. Crit Care Med 2000 Our study focused on only the high-intensity heparin protocol without maximum dose limits, as recommended by current guidelines 3 – 5 based on a previous study by Raschke et al. Spruill WJ, Wade WE, Huckaby WG, et al. This article describes the pharmacology of approved parenteral anticoagulants. There may be circumstances where the bolus dose omitted, for example if the patient is receiving another anticoagulant agent and a delayed onset of Loading dose 5000 units, alternatively (by intravenous injection) loading dose 75 units/kg, followed by (by continuous intravenous infusion) 18 units/kg/hour, alternatively (by subcutaneous injection) 15 000 units every 12 hours, laboratory monitoring essential—preferably on a daily basis, and dose adjusted accordingly. Heparin sodium may prolong one-stage prothrombin time; when heparin sodium is given with dicumarol or warfarin sodium, a period of at least 5 hr after last intravenous dose or 24 hr after last subcutaneous dose should elapse before blood is drawn if a valid prothrombin time is to be obtained All of the content provided on this website, including text, treatments, dosages, outcomes, charts, protocols, cards, graphics, photographs, images, advice, messages, and forum postings, are for informational purposes only and DOES NOT CONSTITUTE PROVIDING OF MEDICAL ADVICE and is not intended to be a substitute for independent professional medical judgment, advice, diagnosis, or … Maximum initial bolus 8000 units. We report an effort to educate house staff regarding heparin dosing guidelines from the American College of Chest Physicians Consensus Conference on Antithrombotic Therapy. For patients weighing less than 60 kg: Administer a bolus dose of heparin sodium 60Standard Risk Protocol units/kg(1). Tips. Heparin. Heparin resistance. Purpose: To provide optimal management of anticoagulation for in-center hemodialysis patients through the use of heparin. For haemofiltration on critical care use yellow table below to calculate bolus dose. Clexane, the calculated dose of Clexane (see low molecular weight heparin protocol) should usually be administered as soon as the intravenous heparin is ceased, assuming the patient was not over-anticoagulated on heparin at the time. Use heparin sodium 5,000 units in 5ml ampoules. Third, the dose of heparin is based on the patient's body weight. Additionally, PSN related to heparin infusions are reviewed throughout the year. Heparin flush, 10 or 100 units/mL, is injected as a single dose into an intravenous injection device using a volume of solution equivalent to that of the indwelling venipuncture device. This protocol was updated in June 2009 to include dosage adjustments based on the results of a heparin assay test. Factors predisposing to the development of heparin resistance, include: If treating a severe pulmonary embolism give 10,000units IV bolus as a loading dose instead. Heparin Protocol . A weight-based heparin protocol also helps provide timely adjustments to dosages, which in turn helps to decrease the risk of adverse drug events. Major and minor bleeding events were recorded. Ambiguous heparin dosing terms. Heparin infusion Warfarin If immediate therapeutic anticoagulation is desired: Overlap therapeutic heparin dose with warfarin for at least 5 days AND until INR is in therapeutic range for 24 hours. Loading Dose: Give heparin sodium by intravenous (IV) bolus approximately 75units/kg using actual bodyweight. (For use when anticoagulation therapy with Low Molecular Weight Heparins or Fondaparinux is not indicated) Dosing and Monitoring Guidelines This review is done to assess adherence to the dosing and monitoring nomograms, assess time to achieving therapeutic ranges, evaluate critical values, and bleeding outcomes. Intravenous Therapeutic Dose Heparin Guidelines for Adults Therapeutic range for APTT ratio is 1.5 to 2.5 Indications for Therapeutic Intravenous Heparin Infusion include: As adjunctive therapy to fibrin specific thrombolytic (tenecteplase) in the treatment of ST Elevation Myocardial Infarction (STEMI) The evidence to inform decision making is limited, making current guidelines equivocal and imprecise. requiring IV unfractionated heparin anticoagulation therapy. There was a significant difference between aPTT among all three groups, and heparin dose between TH and post-TH even after correcting for age, sex, body mass index, heparin rate, and APACHE II score (p<0.001). If immediate therapeutic anticoagulation is not desired: Initiate warfarin as clinically needed irrespective of time of last heparin dose. 18 units/kg/hr IV (TBW) with standard boluses and titrations per protocol (max initial rate 2,000 units/hr) Patients escalated to therapeutic anticoagulation based on D -dimer ≥ 5,000 ng/mL may resume “ High Dose Prophylaxis ” (see under Critically Ill) once D … Achievement of anticoagulation by using a weight-based heparin dosing protocol for obese and nonobese patients. The upper limit of aPTT in our lab is 200 sec. Population: Adult patients . Charts of adult medical-surgical patients who received heparin infusions between June 1982 and December 1983 were re … Moreover, indications for anticoagulation interruption may be unclear. UFH is a heterogeneous mixture of glycosaminoglycans that bind to antithrombin via a … STAT protamine sulfate – see dosing recommendations below Time From Last Dose Of Enoxaparin Protamine Sulfate Dose LESS than 8 hours 1 mg protamine for every 1 mg of enoxaparin Initially by intravenous injection. 2. Select the dose adjustment nomogram based on indication for UFH use 1.1 Gradual heparin nomogram 122 123 Among general surgical patients, the incidence of fatal PE was reduced from 0.7% in controls to 0.2% in one study (P<0.001) 120 and from 0.8% to 0.3% (P<0.001) in a larger analysis that included orthopedic surgical patients. Initial Heparin dose per physician order using heparin 1,000 units/ml vial. Heparin . Three patients experienced a major bleeding event. First, unfractionated heparin is administered via the circuit. (Based on heparin half-life 45-60 min) c. Give dose by slow IV push, never to exceed 50 mg over a 10-minute period References 1. Include both the loading dose and subsequent bolus doses in the protocol. Below, you will find links to calculators, quick links to policies, and just-in-time training. The Duke Heparin Protocol helps manage floor based heparin infusions at Duke University Hospital. These start with obtaining an accurate weight and using a standardized dosing chart. Removal of recommendations for heparin monitoring and dose titrations using PTT Key Practice Recommendations 1. Round off doses to reasonable numbers that staff can work with — for example, do not select a dose of 1273.6 units/ hour. Conclusions: Current dosing protocols for IVUH should not be utilized during TH. 1. with heparin or other anticoagulants is a common clinical dilemma. Heparin is used either to treat an existing blood clot (therapy) or to prevent the development of a blood clot (prophylaxis). Key Revisions 1. infusion was evaluated by retrospective chart review in a California hospital. It is not a substitute for appropriate clinical evaluation and does not supersede clinical judgment. 3 Our primary goals were to improve prescribing patterns for initial maintenance heparin doses, rebolus doses in response to subtherapeutic activated partial thromboplastin time, and subsequent adjustment of maintenance doses. Administer a bolus dose of heparin sodium 4,000 units(1). – Oral anticoagulant use, defined as an open medication order spanning the first day of the calendar month. Use of a protocol for pharmacist determination of heparin sodium dosages administered by continuous i.v. ICD 10 code: N18.6, End-Stage Renal Disease . heparin infusions, initial and maintenance heparin dose adjustments, and transitioning between dosing nomograms. heparin infusion administrations. 2 We also excluded cases involving violation of the protocol, including cases in which patients were transitioned from a lower-dose heparin protocol, received customized doses, or had a dosing weight different … Rx ULTRA LOW Heparin Infusion Protocol • Nurse adjusts heparin dose using a standardized algorithm to maintain Anti-Xa between 0.1 – 0.3 units/mL • Anti-Xa checks remain at every 6 hours for the duration of the infusion Rx Heparin Infusion, Provider Managed • Provider must ORDER all doses and dose … When heparin is indicated because a patient has a clotting problem and she needs treatment to limit the formation of new clots, the heparin protocols must be followed.