Subject: Heparin Infusion Therapy Page 6 of 6

GOOD SHEPHERD MEDICAL CENTER POLICY

Division: Clinical Effective Date: Page 1 of 5 April 16, 2008 Department: Date/Historical File: Committee Approval/Dates: Pharmacy October 2004 MUST Committee 11/11 December 13, 2001 April 2, 2001 May 4, 2012 Subject: Heparin Therapy

Purpose: To outline the nursing management of patients receiving heparin therapy: (a.i.1) Infusion Therapy according to one of the following protocols (a.i.1.a) Pulmonary Embolism (PE) and/or Deep Vein Thrombosis (DVT) protocol (a.i.1.b) Heparin Administration Manipulation for Effective Recovery in Stroke (HAMERS) protocol or (a.i.1.c) Cardiac Heparin Infusion Adjustment Protocol CHAIN) (a.i.2) Subcutaneous Therapy (a.i.2.a) Low Molecular Weight Heparin (LMWH) (a.i.2.b) Unfractionated Heparin

Level: Dependent

Supportive Data: Infusion 1. Heparin infusions are used to interrupt the formation of stable clots and allow for natural clot dissolution. 2. Contraindications to Heparin use include: (1) known hypersensitivity to Heparin, (2) active bleeding, and (3) severe thrombocytopenia. 3. Pharmacy will send pre-mixed Heparin drips with 25,000 units of Heparin in 500 milliliters D5W (concentration equals 50 units per 1 milliliter). 4. Pharmacy will send the selected protocol with the Heparin bag. Nursing staff will utilize this protocol to adjust the Heparin infusion rate according to the patient’s Activated Partial Thromboplastin Time (aPTT) values. 5. Heparin infusions are administered via an infusion pump unless patient scheduled for Magnetic Resonance Imaging (MRI). Two RNs must verify initial Heparin bolus dosing, pump programming, and any rate changes. Correct medication administration verified according to five rights. 6. The aPTT value will be obtained from laboratory testing. Bedside PTTs will not be performed. 7. The PE/DVT and CHAIN protocols are calculated according to the patient’s weight in kilograms. The HAMERS protocol is not weight based. 8. When calculating the dosing weight for obese patients (greater than 30% above ideal body weight), use the following formula:

Dosing Weight (kg) = Ideal Body Weight (kg) + 0.4 (Total Body Weight – Ideal Body Weight) Males: Ideal Body Weight = 50.0 kilograms + (2.3 x Height in inches over

P:A.9 Subject: Heparin Infusion Therapy Page 2 of 6 5 feet) Females: Ideal Body Weight = 45.5 kilograms + (2.3 x Height in inches over 5 feet Subcutaneous: 1) Subcutaneous heparin is used to prevent and interrupt the formation of stable clots and allow for natural clot dissolution. 2) Contraindications to Heparin use include: (1) known hypersensitivity to Heparin, (2) active bleeding, and (3) severe thrombocytopenia. 3) The clinical advantages of low-molecular-weight heparin include predictability, dose- dependent plasma levels, a long half-life and less bleeding for a given antithrombotic effect. LMWH is therapeutic from the first dose which enhances therapy. 4) LMWH is weight based 5) The risk for Heparin Induced thrombocytopenia is lower with LMWH than Standard Unfractionated Heparin 6) Creatinine Clerance should be calculated for renal dose adjustment with LMWH.

7) Content: Nursing Management Assessment 1. If using the PE/DVT, CHIAN nomograms, or LMWH obtain patient’s weight in kilograms.

2. Assess the following each shift or more often as the patient’s condition warrants: Vital Signs: Temperature, Pulse, Respirations, and Blood Pressure Signs/symptoms of bleeding:  Bruising, petechiae  Bleeding gums  Black, tarry, maroon, or bright red stools  Hematuria  Coffee ground emesis  Decreased hemoglobin or hematocrit  Decreased blood pressure  Mental status changes

3. If visual inspection is questionable for bleeding, obtain an order for the appropriate test: if indicated, perform a guaiac test of stool, dipstick of urine, or Hemocult test of gastric aspirant. Notify physician if any of the above tests are positive.

4. Assess the Heparin infusion each shift or more often for: a. Correct concentration of Heparin b. Correct rate of infusion

1. The following laboratory testing will be completed for all Laboratory Testing patients receiving Heparin infusion therapy a. Complete Blood Count (CBC):  Prior to initiation of therapy unless within last 24 hours  Daily while receiving Heparin infusion P:A.9 Subject: Heparin Infusion Therapy Page 3 of 6

CAUTION: Monitor platelet count closely. If count 50,000 or less or drops more than 50% from baseline, notify physician as this may indicate development of Heparin Induced Thrombocytopenia.

b. Activated Partial Thromboplastin Time (aPTT):  Obtain baseline prior to initiation of intravenous therapy  Every 6 hours for first 24 hours or until within therapeutic range on 1 check  6 hours after any rate change adjustment  Daily if no rate change adjustments made

2. Antifactor-Xa activity in blood is used to monitor anticoagulation efficacy with LMWH therapy. It is not recommended routinely but in special considerations:  renal failure  obesity or underweight patient  prolonged use  patients at high risk for bleeding or thrombosis

3. When ordering aPTTs in Meditech, include “On Aggressive Therapy Heparin Protocol” in comments

Pharmacy 1. Order the Heparin infusion from Pharmacy and provide the following information: a. Type of protocol ordered: PE/DVT, HAMERS, or CHAIN b. Patient’s weight in kilograms and height (if using PE/DVT or CHIAN protocol)

Initial Dose 1. The following table outlines initial Heparin bolus dosing and infusion rate instructions:

1. Administer Heparin by infusion pump using standard tubing. 2. Two RNs must verify initial bolus dosing and pump programming. Correct medication administration verified according to the five rights.

PE/DVT HAMERS CHAINN 1. Bolus: 1. Bolus: 80 units Heparin per NO BOLUS 70 units per kilogram kilogram IV push unless patient obese

CAUTION: Do not CAUTION: Do not give bolus if patient give bolus if patient has received has received  Any form of Heparin  Any form of Heparin P:A.9 Subject: Heparin Infusion Therapy Page 4 of 6 within the last 2 within the last 2 hours hours  Antiplatelet agents  Antiplatelet agents  Glycoprotein IIb/IIIa  Glycoprotein IIb/IIIa inhibitor within last inhibitor within last 24 hours 24 hours

2. Initial Infusion: 2. Initial Infusion: 2. Initial Infusion: Start at 18 units Start at 1000 units Start at 15 units Heparin per kilogram Heparin per hour Heparin per kilogram per hour per hour

Rate Adjustments 1. Adjust Heparin infusion and administer bolus doses based upon the patient’s aPTT value according to the protocol provided by Pharmacy. 2. Two RNs must verify infusion rate adjustments.

Order for Infusion 1. Write an order on the Physician’s Order Sheet for the rate Rate Changes change and next Laboratory aPTT as indicated in the selected protocol. Write the order as follows: "Lab aPTT ______Heparin Infusion adjusted to ______units/kg/hr per PE/DVT, HAMERS, or CHAIN protocol.”

Transport to Magnetic 1. Discontinue infusion pump. The infusion pump is magnetic Resonance Imaging and interferes with the test. (MRI) 2. Use a Dial-A-Flow attachment to adjust infusion to appropriate rate.

LMWH Administration 1. Administered by deep SubQ injection to the left or right anterolateral and left or right posterolateral abdominal wall 2. Do not expel the air bubble from the syringe prior to injection 3. In order to minimize bruising, do not rub injection site Anticoagulant a.i.1.a.i.1. Apply pressure to venous access sites for 5 minutes Precautions and arterial access sites for 15 minutes. a.i.1.a.i.2. Place an “Anticoagulant Therapy” sign above the head of the bed.

Drug Interactions 1. The following medications may increase the effects of Heparin therapy: a. Thrombolytics b. NSAIDS c. IIb/IIIa antagonists P:A.9 Subject: Heparin Infusion Therapy Page 5 of 6

d. Aspirin e. Ticlopidine (Ticlid) f. Clopidogrel (Plavix) g. Warfarin (Coumadin)

Patient Teaching 1. Instruct the patient and/or caregiver on the following as applicable: a. Purpose of the medication b. When to report signs and symptoms of bleeding Potential for ADR’s and drug interactions c. How to examine feces, urine, and emesis for evidence of bleeding d. Use of an electric razor instead of standard razors Importance of compliance and follow-up monitoring

Documentation 1. Document assessment data in the daily patient care record. 2. Document Heparin infusion administration on Medication Administration Record. 3. Document patient education in the Plan of Care or Clinical Path.

References: Hirsch, J. & Raschke, R. (2004). Heparin and Low Molecular Weight Heparin: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest (126). 188S-203S. Martel N, Lee J, Wells PS. Risk of heparin induced thrombocytopenia with unfractionated and low molecular weight heparin thromboprophylaxis: a meta-analysis. Blood. Prepublished on June 28, 2005, as DOI 10.1182/blood-2005-04-1546

Related Policies:  Clinical Nursing Management of Patients on Anti-Thrombotic Therapy  Coumadin Therapy  Use & Management of Glycoprotein IIa/IIIb Inhibitors

P:A.9 Subject: Heparin Infusion Therapy Page 6 of 6

Revised & Updated by:

Stacy Calloway, MS PharmD, Pharmacy Clinical Director 11/11