Weightbased heparin protocol using antifactor xa monitoring. Only 9 patients, however, weighed 100 kg range 1011. It is important to note that the most critical factor in reducing the risk of recurrent thromboembolism is reaching a therapeutic ptt within 2448 hours. Your patient is currently receiving an infusion based on 18unitskghour. Evaluation of 2 weightbased protocols for administration. Lowmolecularweight heparin enoxaparin vs dextran 70. Set up favourite journals and register for email alerts. Keywords anticoagulation, obesity, unfractionated heparin ufh, venous thromboembolism vte. Heparin drip calculation practice problems for nurses. Weightbased argatroban dosing nomogram for treatment of heparininduced thrombocytopenia article pdf available in annals of pharmacotherapy 431. Venous thromboembolism prophylaxis adult inpatient.
The trial was not designed to examine the efficacy of heparin therapy but to examine the use of the nomogram for labor requirements, costs of monitoring, safety, length of heparin therapy, and. Founded in 1991, the ihi recommends that clinicians use heparin protocols based on the patients weight. Evaluation of current heparin weight based protocol in. Types of heparin heparin is available in two forms. Removal of recommendations for heparin monitoring and dose titrations using ptt key practice recommendations 1. Ufh, most commonly used in the form of heparin sodium, is an anticoagulant that is widely used in patients with massive pulmonary embo lism, for patients who are unstabl e or may require procedures or thrombolysis. Adult heparin drip protocol ventura county, california. Since then, several modifications have been made, including introduction of a lowertarget protocol. Data collected previously within this institution concluded that the initial heparin infusion rate in the highintensity, weight based, intravenous iv heparin protocol should be adjusted from 18 to 15 unitskgh based on actual body weight in patients who are more than 50% above ideal body weight ibw. Retrospective evaluation of dosing body weight for. This article is brought to you for free and open access by spark. The weightbased heparin dosing nomogram compared with a.
Eligible patients in both preimplementation and postimplementation groups were. Adult heparin infusion protocol this protocol reflects current evidence based clinical practice. Therapeutic dosing of unfractionated heparin adult emergency. Heparin infusion guidelines anticoagulation services. Preparations from porcine or bovine intestinal mucus. Unfractionated heparin infusion for treatment of venous. Traditional regimens that normally begin with uhr are less likely to achieve this.
Every where i go its something differentcruikshank, weight based, some personal kind, just anything. Neither nor any other party involved in the preparation or publication of this. Patients age 18 years or older receiving heparin therapy for greater than or equal to 24 hours identified. A heparin protocol is an established procedure for administering heparin, the anticoagulant used in a variety of applications for more than 12 million patients each year in the u. The effectiveness of an existing non weight based heparin nomogram in achieving a therapeutic aptt was compared sequentially with that of a weight based heparin nomogram in 89 and 84 consecutive. The authors make no claims of the accuracy of the information contained herein. It is not a substitute for appropriate clinical evaluation and does not supersede clinical judgment.
We applaud the recent updates to the ninth edition of the american college of chest physicians on antithrombotic therapy. Protocols based on total body weight increase the risk of a. Comparison of fixeddose weightadjusted unfractionated. A ufh dosage protocol based on patient sex, age, height, and weight produced improved initial target antifactor xa levels compared with a weight based protocol. Evaluation of 2 weightbased protocols for administration of. Utility of a weightbased heparin nomogram for patients. Pharmacokinetics of subcutaneous low molecular weight heparin. Therapeutic dosing of unfractionated heparin adult. In 1996, a weightbased protocol for administration of heparin was implemented and assessed at the authors institution. Do not start in patients who have had tpa, for ischemic stroke, within 24 hours.
Dvtpe with risk factorsadvanced age this second option allows the user to modify the weight based nomogram based on local protocol s. It is important for organizations to use evidence based practice guidelines when developing protocols to manage bleeding events. Uw medicine heparin infusion ultra low intensity algorithm 2019. Controversy exists regarding the use of dose capping of weight based unfractionated heparin ufh infusions in obese and morbidly obese patients. In the older version, the nurse accessed a computer menu of eight variations of the heparin protocol. Safety and efficacy of a highintensity, weightbased. Low molecular weight heparin lmwh general dosing guidelines. American college of chest physicians evidencebased. Pharmacokinetics of subcutaneous low molecular weight heparin enoxaparin in dogs article pdf available in journal of the american animal hospital association 456. Achievement of anticoagulation by using a weight based heparin dosing protocol for obese and nonobese patients.
Heparin dosing calculator custom options available. To standardize heparin anticoagulation therapy at university hospital. Guidelines for administration of anticoagulation for. Initial dosing of iv heparin for vte is either weight based 80 unitskg bolus and 18 unitskgh infusion 49 x 49 raschke, ra, reilly, bm, guidry, jr, fontana, jr, and srinivas, s. Delayed efficient anticoagulation with heparin in patients. A free powerpoint ppt presentation displayed as a flash slide show on id. Select the dose adjustment nomogram based on indication for ufh use 1. Vailoces, year1999 heparin is an anticoagulant widely used for the treatment and prevention of. Based on our study, heparin dosing based on actual body weight without a dose cap is safe and effective. Identify factors andor comorbidities affecting andor contributing to perfusion. Kaplanmeier curves for the primary outcomes favored the weight based nomogram p weight based heparin group, 60 of 62 patients 97% exceeded the therapeutic threshold within 24 hours, compared with 37 of 48 77% in the standard care group p sep 21, 2004 heparin protocols are crazy. Therefore, it is appropriate to use abw in a weight based heparin dosing protocol for this.
Monitoring for initial lmwh therapy, including bridging. Abw is more readily available in the medical charts without the need for manual. Redesign of a weightbased heparin protocol for improved. Unfractionated heparin infusion protocol objective. The clinical outcomes of a traditional non weight based method were compared with a newly designed standard protocol that related the heparin dose to patient weight.
According to the ihi, a weightbased heparin protocol helps provide timely adjustments to dosages, which in turn helps to decrease the risk of adverse drug events. Health, general heparin dosage and administration nurses comparative analysis physicians. Order as needed rebolus for subtherapeutic antixa, if warranted. College lab week 1 objectives unit i perfusionrelated to alterations in perfusion weekly course objectives.
Identify commonly used treatments, identified by standards of care, for patients. Adult heparin drip protocol this protocol reflects current evidence based clinical practice. Then, depending on the patients gender, indication for heparin, and route of heparin administration, the nurse selected one of. Use best estimate of true weight if unable to weigh patient.
Guidance for the practical management of the heparin ncbi. Per the intravenous high intensity heparin nomogram for dvtpe, the infusion dose should be increased by 2 unitskghour. Pdf weightbased argatroban dosing nomogram for treatment. Few studies have compared the effect of weight based heparin protocols in obese and nonobese patients 9,10. Order standard heparin infusion with starting rate defaulted based on indication. Evaluation of an unfractioned heparin pharmacy dosing protocol. In 1996, a weight based protocol for administration of heparin was implemented and assessed at the authors institution. These changes warranted reevaluation of the standard and lowertarget protocols. Heparin protocols are standardized procedures personnel at a hospital or clinic follow when they administer heparin to reduce the chance of errors. Develop a different weight based protocol for patients receiving thrombolytics or g2b3a inhibitors, whose heparin doses will need to be lower.
This article is brought to you for free and open access by the college of. Heparin dosing calculator custom options available globalrph. This article will describe the performance improvement process and the overall goal to decrease the percentage of patients exceeding the initial therapeutic aptt. In addition to heparin and warfarin, each of the direct oral anticoagulants have different reversal mechanisms. Limitations of a standardized weightbased nomogram for. The relative time to achieve therapeutic anticoagulation, the number of additional intravenous heparin injections required and the length of hospitalization were all evaluated. Because of the lack of definitive evidence, the ninth edition and the recent update are silent on how to address weight based ufh in the. The weight based heparin dosing nomogram compared with heparin. Dosing of ufh in morbidly obese and obese critically ill patients based on actual body weight and a reduced initial dose was associated with similar time to first therapeutic aptt and steady state. Dec 03, 2019 333 unitskg subcutaneously followed by 250 unitskg subcutaneously every 12 hours. Fractionated, low molecular weight heparin lmwh sc administration. Weight based nomogram used for heparin therapy in nomogram patients. Therefore, it is appropriate to use abw in a weightbased heparin dosing protocol. Averageweight methodology in weightbased unfractionated.
Raschke ra, reilly bm, guidry jr, fontana jr, srinivas s. Heparin protocols determine when heparin will be used. National patient safety goal for anticoagulant therapy. Apr 24, 2020 heparin protocols are standardized procedures personnel at a hospital or clinic follow when they administer heparin to reduce the chance of errors.
At our institution a weight based heparin nomogram was in place, however an initial data analysis revealed a large percent of the initial aptt levels were above therapeutic range. Heparin is a potent anticoagulant medication, and a patient could become very ill if care providers make a mistake. Achieving target antifactor xa activity with a heparin. Unfractionated heparin dosing for venous thromboembolism. At 2 affiliated community teaching hospitals, we compared the activated partial thromboplastin time aptt values in morbidly obese and nonmorbidly obese patients using a standardized nomogram and determined factors associated with achieving a supratherapeutic aptt value. Begin therapy with warfarin at a dose of 5 mg or less per day with dosage adjustments based on serial inr. Perhaps the most striking aspect of our protocol is the relatively small ufh loading dose of 26 unitskg, compared with the 80unitskg dose promoted by the american college of chest physicians. Efficacy of rd heparin a lmwh and warfarin for prevention of. However, studies showed that weight based nomogram may be more effective than the standard care nomogram. Exemplars used this week are htn, cad, and acute mi 1. Rationale b leeding is the most common complication of all anticoagulants. Venous thromboembolism prophylaxis adult inpatientambulatory.
Mechanism of action of heparin unfractionated heparin, low molecular weight heparin, fondaparinux duration. The weight based heparin dosing nomogram compared with a standard care nomogram. Review the following related to unfractionated heparin ufh, low molecular weight heparins. Conclusion fixeddose subcutaneous unfractionated heparin is as effective and safe as lowmolecular weight heparin in patients with acute venous thromboembolism and is suitable for outpatient treatment. The extra vasculature present in obese patients appears to have minimal effect on the dosing of heparin.
Validation of a weightbased nomogram for the use of. What drives me craziest is the differing concentrations of heparin. Heparin is a heterogeneous mixture of unbranced polysaccharide chains. All hospitalized patients should be evaluated for both bleeding and vte risk within 24 hours of admission, upon transferring level of care, and periodically during the. Start the infusion at 2mlshour 1,000 unitshour check aptt ratioaptt sec 4 hours after infusion start. Unfractionated heparin infusion protocol hospital quality institute. Watch out for tail chasing, the phenomenon in which the ptt is low, so the dose is raised, but then the ptt is high, so the dose is lowered to where it was before and then the ptt gets low again. Perhaps the most striking aspect of our protocol is the relatively small ufh loading dose of 26 unitskg, compared with the 80unitskg dose promoted by the american college of. Heparin overview1 heparin is a glycosaminoglycan which inhibits the mechanism that induces the clotting of blood and the formation of stable fibrin. The seventh accp conference on antithrombotic and thrombolytic therapy. Weight based argatroban dosing nomogram for treatment of heparin induced thrombocytopenia article pdf available in annals of pharmacotherapy 431.
The prescriber will initiate the heparin protocol by writing an order to begin. Give dose by slow iv push, never to exceed 50 mg over a 10minute period references 1. Heparin infusion algorithms anticoagulation services. It has been recognized in the literature that patients in whom heparin infusion therapy is dosed according to weight based nomograms achieve earlier therapeutic range, shorter length of stay, and fewer. Lowmolecular weight heparin enoxaparin vs dextran 70. A fixeddose protocol for heparin therapy, in which an initial loading dose and infusion rate were specified by physicians and partial thromboplastin times ptts were determined every 12 hours, was revised to determine dosing based on patient weight and diagnosis and to include more levels of dose adjustment and additional laboratory tests. Evaluation of current heparin weight based protocol in obese. Switching from weightbased loadcontinuous dosing to nonweight based.
Prior to 2016, heparin dosing was based on standard care nomogram. Protocols create a simple, clear guideline for how to handle this medication and. Ppt heparin powerpoint presentation free to view id. A weightbased heparin protocol for improved anticoagulation. Heparin dosing nomograms began to appear in the literature as early as 1985, 1 although it was not until 1993 that a weight based dosing protocol began to become the standard. In general, weight based nomograms are much more likely to achieve therapeutic levels within 48 hours. After completion of a successful trial period for safety assessment of nomogram use and with continuing ethics committee approval, a prospective, singleblind, randomized, human clinical trial to examine the use of the nomogram was initiated. Implement weightbased heparin protocols ihi institute. Comparison of heparin dosing based on actual body weight. To address this quality issue and improve clinical value, allina health created a systemwide interdisciplinary team to standardize iv heparin therapeutic guidelines and monitor the impact of the. Confusion exists when dosing heparin using a weight based nomogram in the obese population. In july 2017, a new heparin protocol was implemented with changes for weight based dosing. Aug 23, 2006 treatment was administered entirely out of hospital in 72% of the unfractionated heparin group and 68% of the lowmolecular weight heparin group.
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