Unfractionated heparin

Common Indications

DVT, PE, AFIB, ACS

Bleeding Risk Factors

1. Surgery, trauma, or stroke within the previous 14 days.
2. History of peptic ulcer disease, GI bleeding or GU bleeding.
3. Platelet count less than 150K
4. Age > 70 yrs.
5. 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)

Treatment

1. Bolus - 150 u/kg for PE, and 80-100 u/kg for all other conditions.
2. Infuse - 15-25 u/kg/hr (high risk --> 15-18 u/kg/hr; low risk --> 22-25 u/kg/hr)
3. Sliding scale - PTT in 60-80 range..
   1. PTT Bolus/Hold Adjust Heparin
   2. <50 70 u/kg 0 Increase 200 u/hr
   3. 50-59 0 0 Increase 100 u/hr
   4. 60-80 0 0 No change
   5. 81-99 0 0 Decrease 100u/hr
   6. >100 0 60min Decrease 200 u/hr
      1. If 1st PTT after loading dose is > 100 sec do NOT change the infusion rate unless evidence of bleeding
4. The PTT should be checked 4-6 hrs after a new bolus or any change in the infusion dose.
5. 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)

Source

1/22/06; DONALDSON (addapted from Lampe)