DVT, PE, AFIB, ACS
Bleeding Risk Factors
- Surgery, trauma, or stroke within the previous 14 days.
- History of peptic ulcer disease, GI bleeding or GU bleeding.
- Platelet count less than 150K
- Age > 70 yrs.
- Hepatic failure, uremia, bleeding diathesis, brain metastases.
Draw extra blue top prior to starting if concerned about a hypercoaguable state (heparin will interfere with assays)
- Bolus - 150 u/kg for PE, and 80-100 u/kg for all other conditions.
- Infuse - 15-25 u/kg/hr (high risk --> 15-18 u/kg/hr; low risk --> 22-25 u/kg/hr)
- Sliding scale - PTT in 60-80 range..
- PTT Bolus/Hold Adjust Heparin
- <50 70 u/kg 0 Increase 200 u/hr
- 50-59 0 0 Increase 100 u/hr
- 60-80 0 0 No change
- 81-99 0 0 Decrease 100u/hr
- >100 0 60min Decrease 200 u/hr
- If 1st PTT after loading dose is > 100 sec do NOT change the infusion rate unless evidence of bleeding
- The PTT should be checked 4-6 hrs after a new bolus or any change in the infusion dose.
- Other LABS to check include stool GUIAC qd and CBC (platelets) qd
Duration: DVT or PE --> 5 days of heparin (even if the INR is therapeutic earlier in hospital course)
1/22/06; DONALDSON (addapted from Lampe)