Wentworth Area Health Service

HEPARIN PROTOCOL (Excluding Continuous Renal Replacement Therapy)

HEPARIN PROTOCOL For patient anticoagulation only -Excluding Continuous Renal Replacement Therapy

Drug Class: Anticoagulant Indication: Deep vein thrombosis Pulmonary embolus CVA TIA Unstable angina Myocardial infarction CVVHD/HF (Note: Different protocol for this.) Prolonged AF

Contraindications: Bleeding disorders Cerebral haemorrhage Active peptic ulceration Previous Heparin Induced Thrombosis Thrombocytopenia Syndrome (HITTS)

Incompatability: Glucose 5% is not recommended as it may decrease the bioavailability of heparin due to its alkaline pH. Administration: IV infusion by infusion pump Presentation: 5 000 units / ml, 5 000 units / 0.2ml Interval: Bolus and continuous infusion Total Daily Dose: Variable, often titrated to body weight Stability: Heparin is a colourless to slightly yellow solution, minor colour changes do not affect therapeutic efficacy. Infusion should be changed every 24 hours.

Wentworth Area Health Service

HEPARIN PROTOCOL (Excluding Continuous Renal Replacement Therapy)

Storage: At room temperature Adverse Effects: Short term: haematoma formation around venipuncture site, haemorrhage is the major risk associated with a prolonged APPT, hypersensitivity reactions, HITTS evidenced by dramatic fall in platelet count, multiple clot formation and bleeding, thrombocytopenia associated with skin necrosis, hyperkalaemia due to aldosterone deficiency. Long term: osteoporesis which is usually related to high doses (>15 000 units) and long term treatment (longer than 6 months)

Comments: In cases of severe haemorrhage consider the use of protamine sulphate. It is administered at a dose of 1 mg per 100 units of heparin. The protamine dose should be sufficient to neutralize half the estimated amount of heparin present. At high doses protamine acts as an anticoagulant hence not more than 50mg should be given at any one time Anticoagulation of the Patient: Heparin Infusion Initial Infusion Rates - Nomogram

Initial Infusion Rate Weight (kgs) Units in 24 Hours 50 55 60 65 70 75 80 85 90 95 100+ 20 400 22 400 24 480 26 520 28 560 30 600 32 640 34 680 36 720 38 760 70 800 Units per Hour 850 950 1 000 1 100 1 200 1 300 1 350 1 450 1 550 1 600 1 700 ml/hr 17 19 20 22 24 26 27 29 31 32 34

Wentworth Area Health Service

HEPARIN PROTOCOL (Excluding Continuous Renal Replacement Therapy)

Bolus Dose: Give 5 000 units heparin IV bolus, then commence an infusion Infusion: Dilute 25 000 units of heparin in 500 mls normal saline to give a final concentration of 50 units/ml. Commence the infusion according to body weight adjustment nomogram above. APTT should be measured 6 hourly until APTT is within the required range. Note that to alter the Heparin being delivered to the patient, it is the infusion rate that changes and NOT the concentration of the heparin. In general, aim to keep the APTT between 70 to 90 seconds for full anticoagulation.

Dose Adjustment as per APTT: Heparin infusion concentration 25 000 units in 500 mls Normal Saline = 50 units / ml

APPT (secs) <41 41-70 70-90 90-120 120-150 >150

Bolus Dose (Units) 40 units/kg 40 units/kg 0 0 0 0

Infusion Adjustment Increase by 4 units/kg/hour Increase by 2 units/kg/hour No Change Decrease by 2 units/kg/hour Decrease by 3 units/kg/hour Stop Heparin for 1 hour then decrease by 3 units/kg/hour

Repeat APPT 6 hours 6 hours As Requested 6 hours 6 hours 6 hours

Heparin Lock: Dilute 1 000 units heparin (0.2 ml of Heparin strength 5 000 units in 1 ml) to 2 ml Normal Saline and inject into lumen. Apply a sticker indicating the lumen has been Heparin Locked. Heparin Locks should be redone weekly. Prior to recommencing use of that lumen, withdraw 5 ml blood from the lumen to clear any residual Heparin and flush with 10 ml Normal Saline.

Wentworth Area Health Service

HEPARIN PROTOCOL (Excluding Continuous Renal Replacement Therapy)

COMPILED BY COMMITTEE RESPONSIBLE DATE REVISED DATE EFFECTIVE REVIEW DATE

Under Review ICU management committee Under Review Under Review Under Review