New Lab Value for Heparin Drips
We will shortly be starting two separate protocols for Heparin drips. One for Acute Coronary Syndrome (ACS) and one for Deep Vein Thrombosis (DVT). There are some slight differences between the two. The ACS protocol is lower, in that the bolus is 60 units/kg and the continuous drip begins at 12 units/kg/hrand the DVT protocol calls for 80 unit/kg bolus and 15 units/kg/hr continuous drip.
The new lab value for Heparin drips is called the Anti FactorXa “Anti factor ten a”
The PTT coagulation result can be elevated for several other reasons than just the Heparin infusion. For this reason, we are changing to the Anti F Xa for the protocol at SBMC. The Anti F Xa is also called the Heparin factor, as it directly reflects the amount of Heparin in the patient bloodstream.
Though we are using the Anti F Xa, the protocol is essentially the same. There is a goal range of 0.30-0.70. Just like with the PTT, if the range is high the protocol has the Heparin held and restarted at a lower rate. If low the patient is bolused and the drip rate is increased.
The importance of anticoagulation is in keeping the patient from forming blood clots that will impede circulation and decrease oxygenation to tissues and cause tissue necrosis.
(See next page)
Adult Heparin Reference Text - DVT
1. D/C IM Injections. No IM injections while on heparin; no Lovenox or Fragmin within 12 hrs.
2. Laboratory Orders:
a)STAT Labs: aPTT, PT, CBC with platelet count. DO NOT begin drip until all Lab results received
b)UA and stool occult blood if possible on initiation or within 24 hours
c)CBC with platelet count at least every 3 days
d)Measure Anti F Xa (Anti Factor Xa stated “Anti factor 10a also called the Heparin Factor) 6 hours after any dose increase or decrease.
e)Repeat Anti F Xa in 6 hours if Anti F Xa is therapeutic
f)Change Anti F Xa to every 24 hours if two consecutive Anti F Xa values are within therapeutic range (Anti F Xa 0.30 – 0.70).
g)Readjust heparin drip as needed per protocol.
h)Discontinue the above Lab orders when heparin is D/C’d.
3. Heparin Drip (25,000 units/250mL) Use Actual Weight ______Kg (Maximum: 125 Kg).
Heparin Bolus IVP (Use 1000 units/1 mL) / 80 units/kg x ______kg = ______units (Maximum: 10,000 units)(dose per kg) (bolus dose)
DO NOT bolus if aPTT > 50. Start initial drip as calculated below
Heparin Drip (Conc: 100 units/mL) / 15 units/kg/hr x ______kg = ______units/hr 100 = ______ml/hr (Max: 2000 units/hr)
(dose per kg/hr) (infusion rate)
- Adjust heparin infusion rate within 1 hour of last blood draw.
- Adjustments are based on the following sliding scale table. (Round-off doses to the nearest 1 mL).
- Goal is to maintain Anti F Xa within therapeutic range 0.30 to 0.70 units/mL.
- For IVP bolus dose, useHeparin 1000 unit/mL.
Anti F Xa (units/ml) / Re-Bolus Dose / Infusion Rate Adjustment / Order Anti F XaLabAgain
ROUND BOLUS TO THE NEAREST 100 UNITS / ROUND DRIP TO THE NEAREST 1 ml
Anti F Xa less than 0.20 / 60 units x Wt =
______units
(Max: 10,000 units) / Increase rate by 4 units/kg/hr / 6 hours after bolus
Anti F Xa 0.20 to 0.24 / NONE / Increase rate by 3 units/kg/hr / 6 hours after rate change
Anti F Xa 0.25 to 0.29 / NONE / Increase rate by 2 units/kg/hr / 6 hours after rate change
Anti F Xa 0.30 to 0.70 / NONE /
Anti F Xa in therapeutic range
/ In the morning and QAM (if 2 consecutive values within this range)Anti F Xa 0.71 to 0.80 / NONE / Decrease rate by 1 units/kg/hr / 6 hours after rate change
Anti F Xa 0.81 to 1 / NONE /
Decrease rate by 2 units/kg/hr
/ 6 hours after rate changeAnti F Xa above 1 / NONE /
HOLD DRIP FOR 1 HR, Decrease rate by 3 units/kg/hr
/ 6 hours after rate changeAdult Heparin Reference Text - ACS
1. D/C IM Injections. No IM injections while on heparin; no Lovenox or Fragmin within 12 hrs.
2. Laboratory Orders:
i)STAT Labs: aPTT, PT, CBC with platelet count. DO NOT begin drip until all Lab results received
j)UA and stool occult blood if possible on initiation or within 24 hours
k)CBC with platelet count at least every 3 days
l)Measure Anti F Xa(Anti Factor Xa stated “Anti factor 10a also called the Heparin Factor) 6 hours after any dose increase or decrease.
m)Repeat Anti F Xa in 6 hours if Anti F Xa is therapeutic
n)Change Anti F Xa to every 24 hours if two consecutive Anti F Xa values are within therapeutic range (Anti F Xa 0.30 – 0.70).
o)Readjust heparin drip as needed per protocol.
p)Discontinue the above Lab orders when heparin is D/C’d.
3. Heparin Drip (25,000 units/250mL) Use Actual Weight ______Kg (Maximum: 125 Kg).
Heparin Bolus IVP (Use 1000 units/mL) / 60 units/kg x ______kg = ______units (Maximum: 5,000 units)(dose per kg) (bolus dose)
DO NOT bolus if aPTT > 50. Start initial drip as calculated below
Heparin Drip (Conc: 100 units/mL) / 12 units/kg/hr x ______kg = ______units/hr 100 = ______ml/hr (Max: 1000 units/hr)
(dose per kg/hr) (infusion rate)
- Adjust heparin infusion rate within 1 hour of last blood draw.
- Adjustments are based on the following sliding scale table. (Round-off doses to the nearest 1 mL).
- Goal is to maintain Anti F Xa within therapeutic range 0.30 to 0.70 units/mL.
- For IVP bolus dose, use Heparin 1000 unit/mL.
Anti F Xa (units/ml) / Re-Bolus Dose / Infusion Rate Adjustment / Order Anti F XaLabAgain
ROUND BOLUS TO THE NEAREST 100 UNITS / ROUND DRIP TO THE NEAREST 1 ml
Anti F Xa less than 0.20 / 60 units x Wt =
______units
(Max: 5,000 units) / Increase rate by 4 units/kg/hr / 6 hours after bolus
Anti F Xa 0.20 to 0.24 / NONE / Increase rate by 3 units/kg/hr / 6 hours after rate change
Anti F Xa 0.25 to 0.29 / NONE / Increase rate by 2 units/kg/hr / 6 hours after rate change
Anti F Xa 0.30 to 0.70 / NONE /
Anti F Xa in therapeutic range
/ In the morning and QAM (if 2 consecutive values within this range)Anti F Xa 0.71 to 0.80 / NONE / Decrease rate by 1 units/kg/hr / 6 hours after rate change
Anti F Xa 0.81 to 1 / NONE /
Decrease rate by 2 units/kg/hr
/ 6 hours after rate changeAnti F Xa above 1 / NONE /