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Heparin Drip Protocol

BY: JENNA HENSEL


SAMANTHA LACLAIR
DANIELLE GILFUS

Action of Heparin

Potentiates the inhibitory effect of anti thrombin on factor Xa and


thrombin.

Higher doses neutralize thrombin preventing the conversion of


fibrinogen to fibrin.

Prevention of extension of existing thrombi

Davis Drug guide pg 644

Purpose of Heparin Drip

Leading therapeutic option for multitude of thrombotic disorders

PE

DVT

Atrial fibrillation

Acute coronary syndrome

Arterial/Venous clot (non coronary)

Stroke

Transient ischemic attack

Adverse Reactions

* Antidote:
Protamine
Sulfate
(1mg/100units
heparin)

If

heparin is not monitored during administration severe adverse reactions can occur
including:
Spontaneous bleeding
Heparin induced thrombocytopenia (HIT), severe immune reaction causes severe
reduction in platelet count and a paradoxical reaction which increases venous and/or
arterial thrombosis.
Implement bleeding precautions and assess for bleeding tendencies:

Use soft tooth brush, electric razor, avoid IM injections


Keep room free of clutter, non slip footwear & floor clean and dry
Only axillary and oral temps., reduce risk for constipation, avoid ASA, and other anticoagulants.
Assess urine/stool for hematuria, frank or occult (black tarry) bleeding in stool
Assess for bleeding gums & mucous membranes, hemoptysis, and hematemesis
Assess for ecchymosis, petechiae, purpura

Therapeutic range of aPTT

Auburn Community Hospital Policy

Therapeutic aPTT is 55-80 sec

Upstate University Hospital Policy

Route
Duration
IV continuous

Therapeutic aPTT is 55-70 sec

Onset

Peak

immediate

5-10 minutes

2-6hrs

ACH Heparin Drip Protocol

Solution: 25,000 units/ 500ml D5w = 50 units/ml

This solution is available pre-mixed, can be mixed with NS also.

Horizon pump must be used & physician must specify heparin dose
to be administered

Heparin administration cannot be interrupted by other medication.

Compatibility must be assessed to administer secondary


medication at Y-site. If questioned call pharmacy.

If medication is incompatible check with MD to obtain secondary IV


site.

ACH Table of IV Heparin Doses


Heparin/ 24 hours

Heparin/ hour

ML. Hour *

12,100 units

500 units

10ml/hr

15,600 units

650 units

13ml/hr

18,000 units

750 units

15ml/hr

20,400 units

850 units

17ml/hr

21,600 units

900 units

18ml/hr

24,000 units

1,000 units

20ml/hr

26,400 units

1,100 units

22ml/hr

27,600 units

1,150 units

23ml/hr

30,000 units

1,250 units

25ml/hr

31,400 units

1,350 units

27ml/hr

* Based on using a solution of


25,000 units of heparin per 500
ml d5w, or 50 units per ml

* Round all loading doses to


closest 100 units

Round all infusion rates to


closest 50 units/hr

Dosing Regimens

Physician specifies heparin dosage in terms of units/hr. (based on wgt.)

Low Intensity
G
Therapy
(e.g. stroke or high risk for
bleeding)

Loading Dose: None


Initial infusion rate: 25,000
units in NS 500 ml at 12
units/kg/hr. Do not exceed
1200 units/hr

Moderate Intensity
Therapy (e.g. ACS, A-fib,
Thrombolytic therapy)

Loading Dose: 60unit/kg IV


X1 up to max 5,000 units
Initial infusion rate: 25,000
units in NS 500 ml at 12
units/kg/hr. Do not exceed
1200 units/hr

High Intensity
Therapy
(e.g. DVT, PE,)

Loading Dose: 80 units/kg IV


X1 up to max 10,000 units
Initial infusion rate: 25,000
units in NS 500 ml at 18
units/kg/hr. Do not exceed
1800 units/hr.

* Subsequent dosage adj. based on aPTT with all therapies.

Lab Draws per protocol

CBC, aPTT, PT, STAT prior to starting heparin infusion.

CBC every other day with AM blood draw

aPTT 6 hrs after starting infusion or dosage change

When target range of aPTT of 55-80 secs is obtained:

Obtain aPTT in 6hrs, if two consecutive aPTTs are in therapeutic range


schedule aPTT for Q 24 hrs.

Evidence Based Practice

In 1993 dosing based on weight became standard in hospital policies

In 2008 studies performed concluded that a high percentage of pts achieved


target therapeutic range within the first 24hours of therapy, when the dosage was
weight based.

Studies proved that a lower loading dose were just as effective as a higher doses
and the lower doses resulted in decrease adjustments in rate of infusion and
decrease in lab draws.

Loading dose study: 26units/kg compared to 80units/kg

aPTT not as accurate as thought: correlation of blood concentration of


heparin not as exact, monitoring the antifactor Xa is a more accurate
study.

aPTT is still used merely as a substitute for antifactor Xa test. (less costly)

Evidence Based practice

Only one third of dose administered binds to antithrombin

This is the fraction responsible for the anticoagulant effect

Studies showed that heparin IV is just as safe as, subq injections


if administered in the appropriate dose.

Audits performed in 2001 further proved

heparin dosage adjustments were greatly improved and


more effective when adjusted by weight-dosage regimen.

QSEN & National Patient Safety


Goals

Safety : Minimize risk of harm to patients through system effectiveness


and individual performance

Safety is ensured through the policy and procedure by monitoring aPTT Q 6


hrs to prevent heparin induced thrombocytopenia.

Dosing is exact based on the patients weight and diagnosis.

The pump is always used to deliver a precise dosage.

Assess compatibly of meds administered through Y-Site.

Q&A

A pt is receiving a Heparin Drip infusion into a peripheral IV line. The


MD has ordered a STAT 20mg Lasix IVP, what should the nurse do first?

A. Assess for compatibility of Lasix with heparin

B. Stop Heparin Drip

C. Call MD

D. Push Lasix into Heparin IV infusion

Q&A

The MD has ordered a heparin infusion for a pt with an active DVT.


What labs would the nurse anticipate to be ordered prior to starting the
infusion? Select all that apply.

A. CBC

B. Potassium

C. BUN/Cr

aPTT

PT

Q&A

Your pt has a DVT of the right calf and the physician ordered 500ml
D5W with 25,000 units of heparin at 1050 units/hour. Calculate the flow
rate in ml/hr.

A. 18ml/hr

B. 180ml/hr

C. 21ml/hr

D. 50ml/hr

References
American Heart Association. (2001). Guide to Anticoagulant Therapy:
Heparin. Retrieved from:
http://circ.ahajournals.org/content/103/24/2994.full.pdf+html
Bucher, L., Camera, I., Lewis, S. L., McLean- Heitkemper, M., Ruff- Dirksen, S.
(2011). Medical-Surgical Nursing: Assessment and Management of
Clinical Problems. St. Louis: Elsevier/Mosby.
Hazard Vallerand, A., Sanoski, C. A. (2013). Daviss Drug Guide. Danvers: F.A.
Davis Company.
Smith, M. L. & Wheeler, K.E. (2010). Weight-based heparin protocol using
antifactor Xa monitoring. American Society of Health-System
Pharmacist Inc, Volume 67, 371-373. doi: 10.2146/ajhp090123