SAFETY ALERT!

heparin sodium
HEP-ah-rinHepalean, Heparin Lock Flush Solution (with Tubex), Heparin Sodium Injection, Hep-Lock, Hep-Pak Pregnancy risk category: C Pharmacologic class: Anticoagulant Therapeutic class: Anticoagulant

Available Forms
Products are derived from beef lung or pork intestinal mucosa.

heparin sodium
Carpuject: 5,000 units/ml Premixed I.V. solutions: 1,000 units in 500 ml of normal saline solution; 2,000 units in 1,000 ml of normal saline solution; 12,500 units in 250 ml of half-normal saline solution; 25,000 units in 250 ml of half-normal saline solution; 25,000 units in 500 ml of half-normal saline solution; 10,000 units in 100 ml of D5W; 12,500 units in 250 ml of D5W; 20,000 units in 500 ml of D5W; 25,000 units in 250 ml D5W; 25,000 units in 500 ml D5W Single-dose ampules and vials: 1,000 units/ml, 5,000 units/ml, 10,000 units/ml, 20,000 units/ml, 40,000 units/ml Syringes: 1,000 units/ml, 2,500 units/ml, 5,000 units/ml, 7,500 units/ml, 10,000 units/ml, 20,000 units/ml Unit-dose vials: 1,000 units/ml, 2,500 units/ml, 5,000 units/ml, 7,500 units/ml, 10,000 units/ml, 20,000 units/ml Vials (multidose): 1,000 units/ml, 2,000 units/ml, 2,500 units/ml, 5,000 units/ml, 10,000 units/ml, 20,000 units/ml, 40,000 units/ml

heparin sodium flush

Syringes: 1 unit/ml, 10 units/ml, 100 units/ml Vials: 10 units/ml, 100 units/ml

Indications & Dosages

Full-dose continuous I.V. infusion therapy for deep vein thrombosis (DVT), MI, pulmonary embolism

Adults: Initially, 5,000 units by I.V. bolus; then 20,000 to 40,000 units/day by I.V. infusion with pump. Titrate hourly rate based on PTT results (every 4 to 6 hours in the early stages of treatment). Children: Initially, 50 units/kg I.V.; then 25 units/kg/hour or 20,000 units/m2 daily by I.V. infusion pump. Titrate dosage based on PTT.

Full-dose subcutaneous therapy for DVT, MI, pulmonary embolism

Adults: Initially, 5,000 units I.V. bolus and 10,000 to 20,000 units in a concentrated solution subcutaneously; then 8,000 to 10,000 units subcutaneously every 8 hours or 15,000 to 20,000 units in a concentrated solution every 12 hours.

Full-dose intermittent I.V. therapy for DVT, MI, pulmonary embolism

Adults: Initially, 10,000 units by I.V. bolus; then titrated according to PTT, and 5,000 to 10,000 units I.V. every 4 to 6 hours.

Fixed low-dose therapy for prevention of venous thrombosis, pulmonary embolism, embolism associated with atrial fibrillation, and postoperative DVT
Adults: 5,000 units subcutaneously every 12 hours. In surgical patients, give first dose 2 hours before procedure; then 5,000 units subcutaneously every 8 to 12 hours for 5 to 7 days or until patient can walk.

Consumptive coagulopathy (such as disseminated intravascular coagulation)

Adults: 50 to 100 units/kg by I.V. bolus or continuous I.V. infusion every 4 hours. Children: 25 to 50 units/kg by I.V. bolus or continuous I.V. infusion every 4 hours. If no improvement within 4 to 8 hours, stop heparin.

Open-heart surgery
Adults: For total body perfusion, 150 to 400 units/kg continuous I.V. infusion. Frequently, a dose of 300 units/kg for procedures estimated to last less than 60 minutes, or 400 units/kg for those estimated to last more than 60 minutes, is used.

Patency maintenance of I.V. indwelling catheters

Adults: 10 to 100 units I.V. flush. Use sufficient volume to fill device. Not intended for therapeutic use.

Administration
I.V.

Draw blood to establish baseline coagulation parameters before therapy. Use an infusion pump to provide maximum safety. Check continuous infusions regularly, even when pumps are in good working order, to ensure correct dosing. Place notice above patient's bed to caution I.V. team or laboratory personnel to apply pressure dressings after taking blood. During intermittent infusion, always draw blood 30 minutes before next scheduled dose to avoid falsely elevated PTT. Blood for PTT may be drawn 4 hours after continuous I.V. heparin therapy starts. Never draw blood for PTT from the tubing of the heparin infusion or from the infused vein, because falsely elevated PTT will result. Always draw blood from the opposite arm. Don't skip a dose or try to catch up with a solution containing heparin. If solution runs out, restart it as soon as possible, and reschedule bolus dose immediately. Monitor PTT. Concentrated heparin solutions (more than 100 units/ml) can irritate blood vessels. Never piggyback other drugs into an infusion line while heparin infusion is running. Never mix another drug and heparin in same syringe when giving a bolus. Incompatibilities: Alteplase; amikacin; amiodarone; amphotericin B cholesteryl; ampicillin sodium; atracurium; caspofungin; chlorpromazine; ciprofloxacin; codeine phosphate; cytarabine; dacarbazine; dantrolene; daunorubicin; dextrose 4.3% in sodium chloride solution 0.18%; diazepam; diltiazem; dobutamine; doxorubicin; doxycycline hyclate; droperidol; ergotamine; erythromycin gluceptate or lactobionate; filgrastim; gentamicin; haloperidol lactate; hydrocortisone sodium succinate; hydroxyzine hydrochloride; idarubicin; kanamycin; labetalol; levofloxacin; levorphanol; meperidine; methadone; methylprednisolone sodium succinate; morphine sulfate; nesiritide; netilmicin; nicardipine; penicillin G potassium; penicillin G sodium; pentazocine lactate; phenytoin sodium; polymyxin B sulfate; prochlorperazine edisylate; promethazine hydrochloride; quinidine gluconate; reteplase; 1/6 M sodium lactate; solutions containing a phosphate buffer, sodium carbonate, or sodium oxalate; streptomycin; sulfamethoxazole and trimethoprim; tobramycin sulfate; trifluoperazine; triflupromazine; vancomycin; vinblastine; warfarin.

Subcutaneous

Give low-dose injections sequentially between iliac crests in lower abdomen deep into subcutaneous fat. Inject drug subcutaneously slowly into fat pad. Don't massage injection site; watch for signs of bleeding there. Alternate sites every 12 hoursright for morning, left for evening. Record location.

Action
Accelerates formation of antithrombin III-thrombin complex and deactivates thrombin, preventing conversion of fibrinogen to fibrin. Duratio Route Onset Peak n I.V. Immediate Unknown Variable Subcut. 2060 min 24 hr Variable Half-life: 1 to 2 hours. Half-life is dose-dependent and nonlinear and may be disproportionately prolonged at higher doses.

Adverse Reactions
CNS: fever. EENT: rhinitis. Hematologic: hemorrhage , overly prolonged clotting time , thrombocytopenia , white clot syndrome . Metabolic: hyperkalemia , hypoaldosteronism. Skin: irritation, mild pain, hematoma, ulceration, cutaneous or subcutaneous necrosis, pruritus, urticaria. Other: hypersensitivity reactions, including chills, anaphylactoid reactions .

Interactions
Drug-drug Antihistamines, digoxin, quinine, tetracycline: May interfere with anticoagulant effect of heparin. Monitor patient for therapeutic effect. Antiplatelet drugs, salicylates: May increase anticoagulant effect. Use together cautiously. Monitor coagulation studies and patient closely. Cephalosporins, penicillins: May increase risk of bleeding. Monitor patient closely. Nitroglycerin: May decrease effects of heparin. Monitor patient closely. Oral anticoagulants: May increase additive anticoagulation. Monitor PT, INR, and PTT. Thrombolytics: May increase risk of hemorrhage. Monitor patient closely. Drug-herb Angelica (dong quai), boldo, bromelains, capsicum, chamomile, dandelion, danshen, devil's claw, fenugreek, feverfew, garlic, ginger, ginkgo, ginseng, horse chestnut, licorice, meadowsweet, motherwort, onion, passion flower, red clover, white willow: May increase risk of bleeding. Discourage herb use. Drug-lifestyle Smoking: May interfere with anticoagulant effect of heparin. Discourage smoking.

Effects on Lab Test Results

May increase ALT, AST, and potassium levels.

May increase INR, PT, and PTT. May decrease platelet count. Drug may cause false elevations in some tests for thyroxine level.

Contraindications & Cautions

Contraindicated in patients hypersensitive to drug. Conditionally contraindicated in patients with active bleeding, blood dyscrasia, or bleeding tendencies, such as hemophilia, thrombocytopenia, or hepatic disease with hypoprothrombinemia; suspected intracranial hemorrhage; suppurative thrombophlebitis; inaccessible ulcerative lesions (especially of GI tract) and open ulcerative wounds; extensive denudation of skin; ascorbic acid deficiency and other conditions that cause increased capillary permeability. Conditionally contraindicated during or after brain, eye, or spinal cord surgery; during spinal tap or spinal anesthesia; during continuous tube drainage of stomach or small intestine; and in subacute bacterial endocarditis, shock, advanced renal disease, threatened abortion, or severe hypertension. Use cautiously in women during menses or after childbirth and in patients with mild hepatic or renal disease, alcoholism, occupations with high risk of physical injury, or history of allergies, asthma, or GI ulcerations. Use cautiously in women older than age 60 because of an increased risk of bleeding. Overdose Signs & Symptoms: Bleeding, nosebleeds, hematuria, tarry stools, easy bruising, petechial formations.

Nursing Considerations

Although heparin use is clearly hazardous in certain conditions, its risks and benefits must be evaluated. If a woman needs anticoagulation during pregnancy, most prescribers use heparin. Alert: Some commercially available heparin injections contain benzyl alcohol. Avoid using these products in neonates and pregnant women if possible. Drug requirements are higher in early phases of thrombogenic diseases and febrile states; they are lower when patient's condition stabilizes. Elderly patients should usually start at lower dosage. Check order and vial carefully; heparin comes in various concentrations. Alert: USP and international units aren't equivalent for heparin. Alert: Heparin, lowmolecular-weight heparins, and danaparoid aren't interchangeable. Alert: Don't change concentrations of infusions unless absolutely necessary. This is a common source of dosage errors. Alert: There is the potential for delayed onset of heparin-induced thrombocytopenia (HIT), a serious antibody-mediated reaction resulting from irreversible aggregation of platelets. HIT may progress to the development of venous and arterial thromboses, a condition referred to as heparin-induced thrombocytopenia and thrombosis (HITT). Thrombotic events may be the initial presentation for HITT, which can occur up to several weeks after stopping heparin therapy. Evaluate patients presenting with thrombocytopenia or thrombosis after stopping heparin for HIT and HITT Draw blood for PTT 4 to 6 hours after dose given subcutaneously. Avoid I.M. injections of other drugs to prevent or minimize hematoma.

Measure PTT carefully and regularly. Anticoagulation is present when PTT values are 1 1/2 to 2 times the control values. Monitor platelet count regularly. When new thrombosis accompanies thrombocytopenia (white clot syndrome), stop heparin. Regularly inspect patient for bleeding gums, bruises on arms or legs, petechiae, nosebleeds, melena, tarry stools, hematuria, and hematemesis. Monitor vital signs. Alert: To treat severe overdose, use protamine sulfate (1% solution), a heparin antagonist. Dosage is based on the dose of heparin, its route of administration, and the time since it was given. Generally, 1 to 1.5 mg of protamine per 100 units of heparin is given if only a few minutes have elapsed; 0.5 to 0.75 mg protamine per 100 units heparin, if 30 to 60 minutes have elapsed; and 0.25 to 0.375 mg protamine per 100 units heparin, if 2 hours or more have elapsed. Don't give more than 50 mg protamine in a 10-minute period. Abrupt withdrawal may cause increased coagulability; warfarin therapy usually overlaps heparin therapy for continuation of prophylaxis or treatment. Look alike-sound alike: Don't confuse heparin with Hespan. Look alike-sound alike: Don't confuse heparin sodium injection 10,000 units/ml and Hep-Lock 10 units/ml.

Patient Teaching

Instruct patient and family to watch for signs of bleeding or bruising and to notify prescriber immediately if any occur. Tell patient to avoid OTC drugs containing aspirin, other salicylates, or drugs that may interact with heparin unless ordered by prescriber. Advise patient to consult with prescriber before starting herbal therapy; many herbs have anticoagulant, antiplatelet, or fibrinolytic properties