Heparin Injection

Dosing: Adult
Note: Many concentrations of heparin are available ranging from 1 unit/mL to 20,000 units/mL. Carefully
examine each prefilled syringe or vial prior to use ensuring that the correct concentration is chosen. Heparin
lock flush solution is intended only to maintain patency of IV devices and is not to be used for anticoagulant
therapy.

Acute coronary syndromes (off-label use): IV infusion (weight-based dosing per institutional nomogram
recommended):
STEMI: Adjunct to fibrinolysis (full-dose alteplase, reteplase, or tenecteplase): Initial bolus of 60 units/kg
(maximum: 4,000 units), then 12 units/kg/hour (maximum: 1,000 units/hour) as continuous infusion. Adjust
to target aPTT of 1.5 to 2 times control (approximately 50 to 70 seconds). Continue for a minimum of 48
hours, and preferably for the duration of hospitalization (up to 8 days) or until revascularization (if
performed) (ACCF/AHA [OGara 2013]).
NSTE-ACS: Initial bolus of 60 units/kg (maximum: 4,000 units), followed by an initial infusion of 12
units/kg/hour (maximum: 1,000 units/hour). Adjust to target aPTT of 1.5 to 2 times control (approximately
50 to 70 seconds). Recommended duration is 48 hours or until percutaneous coronary intervention (PCI) is
performed.
Note: If PCI is performed while patient on fondaparinux, 85 units/kg of heparin (60 units/kg if a GP IIb/IIIa
inhibitor [eg, abciximab, eptifibatide, tirofiban] is used) should be given immediately before PCI with
subsequent heparin dosing based on the target activated clotting time (AHA/ACC [Amsterdam 2014]).

Anticoagulation (Intermittent administration): IV: Initial: 10,000 units, then 50 to 70 units/kg (5,000 to
10,000 units) every 4 to 6 hours

Atrial fibrillation (off-label use): Guidelines pertaining to peri-cardioversion use (ACCP [You 2012]):
Patients with atrial fibrillation (for more than 48 hours or unknown duration) undergoing cardioversion: IV
heparin to maintain an aPTT prolongation that corresponds to plasma heparin levels of 0.3 to 0.7 units/mL
anti-Xa activity started at the time of transesophageal echocardiography (TEE) is recommended with
cardioversion performed within 24 hours of the TEE if no thrombus is seen.
Patients with atrial fibrillation (for 48 hours or less) undergoing cardioversion: Cardioversion may be
performed without prolonged anticoagulation. However, anticoagulation with IV heparin to maintain an
aPTT prolongation that corresponds to plasma heparin levels of 0.3 to 0.7 units/mL anti-Xa activity should
be started at presentation in patients with no contraindications to anticoagulation.
Emergency cardioversion in hemodynamically unstable patient: Cardioversion may be performed without
prolonged anticoagulation. Anticoagulation with IV heparin to maintain an aPTT prolongation that
corresponds to plasma heparin levels of 0.3 to 0.7 units/mL anti-Xa activity should be started prior to
cardioversion in patients with no contraindications to anticoagulation.

Cardiothoracic surgery (cardiopulmonary bypass): IV: Initial: 300 to 400 units/kg prior to arterial or
venous cannulation; titrate to ACT. Cardiopulmonary bypass may be initiated once ACT is at least 400
seconds; measure ACT every 30 minutes and administer additional heparin as necessary (Kincaid 2014).

Interstitial cystitis (bladder pain syndrome) (off-label use): Intravesical: Note: Various dosage regimens
of heparin (20,000 to 50,000 units) alone or with alkalinized lidocaine (1% to 4%) have been used. When
lidocaine and heparin are mixed, there is a risk of precipitation if proper alkalinization does not occur.
Lidocaine stability and pH should be determined after the components have been mixed, prior to
administration.
Single-dose regimen: Instill the combination of 50,000 units of heparin, lidocaine 200 mg, and sodium
bicarbonate 420 mg in 15 mL of sterile water into the bladder via catheter and allow to dwell for 30 minutes
before draining (Parsons 2012).
Once-weekly dosing regimen: Instill the combination of 20,000 units of heparin, lidocaine 4% (5 mL), and
sodium bicarbonate 7% (25 mL) into an empty bladder via catheter once weekly for 12 weeks and allow to
dwell for 30 minutes before draining (Nomiya 2013).
Twice-weekly dosing regimen: Instill 25,000 units of heparin (diluted with 5 mL of sterile water) into
bladder via catheter twice weekly for 3 months (Kuo 2001).

Maintenance of catheter patency (continuous infusion): Using heparin 2 unit/mL large volume IV
solutions, may administer at an infusion rate of 3 mL/hour (equivalent to 6 units/hour); however, rate of
infusion dependent upon age, weight, clinical condition of patient, and procedure being employed. Do not
use as a "catheter lock flush".

Maintenance of line patency (line flushing): When using daily flushes of heparin to maintain patency of
single and double lumen central catheters, 10 units/mL is commonly used for younger infants (eg, <10 kg)
while 100 units/mL is used for older infants, children, and adults. Capped PVC catheters and peripheral
heparin locks require flushing more frequently (eg, every 6 to 8 hours). Volume of heparin flush is usually
similar to volume of catheter (or slightly greater). Additional flushes should be given when stagnant blood is
observed in catheter, after catheter is used for drug or blood administration, and after blood withdrawal from
catheter.

Parenteral nutrition: Addition of heparin (0.5 to 3 unit/mL) to peripheral and central parenteral nutrition
has not been shown to decrease catheter-related thrombosis. The final concentration of heparin used for
TPN solutions may need to be decreased to 0.5 units/mL in small infants receiving larger amounts of
volume in order to avoid approaching therapeutic amounts. Arterial lines are heparinized with a final
concentration of 1 unit/mL.

Percutaneous coronary intervention (off-label use; Levine 2011): IV:

No prior anticoagulant therapy:
If no GPIIb/IIIa inhibitor use planned: Initial bolus of 70 to 100 units/kg (target ACT 250 to 300 seconds
for HemoTec, 300 to 350 seconds for Hemochron)
or
If planning GPIIb/IIIa inhibitor use: Initial bolus of 50 to 70 units/kg (target ACT 200 to 250 seconds
regardless of device)
Prior anticoagulant therapy:
If no GPIIb/IIIa inhibitor use planned: Additional heparin as needed (eg, 2,000 to 5,000 units) (target ACT
250 to 300 seconds for HemoTec, 300 to 350 seconds for Hemochron)
or
If planning GPIIb/IIIa inhibitor use: Additional heparin as needed (eg, 2,000 to 5,000 units) (target ACT
200 to 250 seconds regardless of device)

Thromboprophylaxis (low-dose heparin): SubQ: 5,000 units every 8 to 12 hours. Note: The American
College of Chest Physicians recommends a minimum of 10 to 14 days for patients undergoing total hip
arthroplasty, total knee arthroplasty, or hip fracture surgery (Guyatt 2012).

Venous thromboembolism (treatment): Note: Start warfarin on the first or second treatment day and
continue heparin until INR is 2 for at least 24 hours (usually 5 to 7 days) (Guyatt, 2012).
DVT/PE (off-label dosing): IV: 80 units/kg (or alternatively 5,000 units) IV push followed by an initial
continuous infusion of 18 units/kg/hour (or alternatively 1,000 units/hour) (Guyatt 2012)
or
DVT/PE (off-label dosing): SubQ: Unmonitored dosing regimen: Initial: 333 units/kg then 250 units/kg
every 12 hours (Guyatt 2012; Kearon 2006)

Dosing: Geriatric
Patients >60 years of age may have higher serum levels and clinical response (longer aPTTs) as compared
to younger patients receiving similar dosages. Lower dosages may be required.
Dosing: Pediatric
Note: Many concentrations of heparin are available ranging from 1 unit/mL to 20,000 units/mL. Carefully
examine each prefilled syringe or vial prior to use ensuring that the correct concentration is chosen. Heparin
lock flush solution is intended only to maintain patency of IV devices and is not to be used for anticoagulant
therapy.

Thrombosis, treatment: Systemic heparinization:

Infants: IV: Initial loading dose: 75 units/kg over 10 minutes; then initial continuous maintenance infusion
at: 28 units/kg/hour; adjust dose to maintain an anti-Xa activity of 0.35 to 0.7 units/mL or an aPTT range
that correlates to this anti-Xa range or a protamine titration range of 0.2 to 0.4 units/mL (ACCP [Monagle
2012])
Children and Adolescents: IV: Initial loading dose: 75 units/kg over 10 minutes, then initial continuous
maintenance infusion at: 20 units/kg/hour; adjust dose to maintain an anti-Xa activity of 0.35 to 0.7
units/mL or an aPTT range that correlates to this anti-Xa range or a protamine titration range of 0.2 to 0.4
units/mL (ACCP [Monagle 2012])
Note: Because of variation among hospitals with reagents (lot numbers) and corresponding control of aPTT
values, individual institutions should establish unique, institution-specific nomograms. Due to extensive
variability within reagents and anti-Xa levels with corresponding aPTTs, a specific nomogram has not been
provided; refer to guidelines for a specific nomogram (ACCP [Monagle 2012]).

Dosing: Renal Impairment

No dosage adjustment required; adjust therapeutic heparin according to aPTT or anti-Xa activity.

Dosing: Hepatic Impairment

No dosage adjustment required; adjust therapeutic heparin according to aPTT or anti-Xa activity.

Administration
SubQ: Inject in subcutaneous tissue only (not muscle tissue). Injection sites should be rotated (usually left
and right portions of the abdomen, above iliac crest).
IM: Do not administer IM due to pain, irritation, and hematoma formation.
Continuous IV infusion: Infuse via infusion pump. If preparing solution, mix thoroughly prior to
administration.
Heparin lock: Inject via injection cap using positive pressure flushing technique. Heparin lock flush solution
is intended only to maintain patency of IV devices and is not to be used for anticoagulant therapy.
Central venous catheters: Must be flushed with heparin solution when newly inserted, daily (at the time of
tubing change), after blood withdrawal or transfusion, and after an intermittent infusion through an
injectable cap. A volume of at least 10 mL of blood should be removed and discarded from a heparinized
line before blood samples are sent for coagulation testing.
Intravesical (off-label use): Various dosage regimens of heparin (20,000 to 50,000 units) alone or with
alkalinized lidocaine (1% to 4%) have been instilled into the bladder.

Compatibility
See Trissels IV Compatibility Database

Storage
Heparin solutions are colorless to slightly yellow. Minor color variations do not affect therapeutic efficacy.
Heparin should be stored at room temperature. Protect from freezing and temperatures >40C.
Stability at room temperature and refrigeration:
Prepared bag: 24 to 72 hours (specific to solution, concentration, and/or study conditions)
Premixed bag: After seal is broken, 4 days. Out of overwrap stability: 30 days.