Heparin and Warfarin - Sydney South West Area Health Service

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Sydney South West Area Health Service Guideline No: SSW_GL2007_010 Date issued: November 2007 ANTICOAGULATION: HEPARIN AND WARFARIN CONTENTS 1. Intravenous Unfractionated Heparin Protocols…………………………………….............3 1.1 Heparin Protocol for Acute Coronary Syndrome 1.2 Heparin Protocol for Atrial Fibrillation, Venous and Arterial Thromembolic Disease, Prosthetic Heart Valves 1.3 Notes on Intravenous Heparin 1.4 Safety Issues with Infusion Pumps 1.5 Changing between Intravenous Heparin and Clexane 2. Low Molecular Weight Heparin (Thromboembolism and Unstable Coronary Artery Syndromes)………………………………………………………………………….....5 2.1 Products and Availability 2.2 Before Starting Treatment 2.3 Dose 2.4 Administration 2.5 Precautions 2.6 Monitoring 2.7 Charts for Estimating GFR 3. Management of Bleeding on Intravenous Standard and low Molecular Weight Heparin…………………………………..…………………………………………………….10 3.1 Intravenous Unfractionated Heparin 3.2 Low Molecular Weight (LMW) Heparin 3.3 Precautions with Protamine 4. Initiation of Warfarin Therapy………….……………………………………………………11 4.1 Pre-Treatment 4.2 Commencement of Therapy 4.3 Initiation of warfarin Algorithm 5. Rang of International Normalised Ratio (INR) Recommended for Specific Applications for Warfarin Therapy…….……………………………………………………13 6. Duration of Anticoagulation…………….……………………………………………………13 7. Managing High INR and Bleeding During Warfarin Therapy……………………………14 7.1 Blood Products 7.2 Vitamin K 8. Patient Information on Warfarin…………………………………………………………….15 9. Perioperative Management of Anticoagulent Therapy in Patients on Warfarin……….16 9.1 Thrombotic Risk ATTACHMENT 1: Perioperative Management of Anticoagulent Therapy ATTACHMENT 2: Intravenous Standard Heparin Protocols for 300 unit / mL Infusion Compliance with this guideline is recommended Page 2 of 24
Sydney South West Area Health Service Guideline No: SSW_GL2007_010 Date issued: November 2007 ANTICOAGULATION: HEPARIN AND WARFARIN 1. Intravenous Standard Heparin Protocols Note: The following protocols are ONLY for use with 100 Units/mL solutions of Heparin (wherever possible this should be in the form of commercially prepared bags of 25,000 Units of Heparin Sodium in 250mL 0.9% Sodium Chloride). These protocols are NOT suitable for higher concentrations infused at Liverpool Hospital. Therapy is usually initiated with a bolus intravenous dose of heparin calculated by body weight, and then a heparin infusion commenced at the rate indicated below. The initial bolus dose is usually omitted following cardiothoracic surgery. It will often be appropriate to omit the bolus dose in the early postoperative period where there is a high risk of bleeding. If in doubt, discuss this with the surgeon responsible for the patient. 1.1 Heparin Protocol for Acute Coronary Syndrome (STEMI, non-STEMI and Unstable Angina): DOSAGE: Concentration = 25,000 units heparin sodium in 250ml normal saline (0.9% sodium chloride). (=100 units per mL). Based on 12 units/kg/hr MAX:1000units/hr WEIGHT (kg) BOLUS (units) UNITS PER HOUR Starting rate mL per hour* 50 3000 600 6 55 3300 660 7 60 3600 720 7 65 3900 780 8 70 4000 840 8 75 4000 900 9 80 4000 960 10 >80 4000 1000 10 • Note: millilitres per hour have been rounded to the nearest whole number. The first aPTT is taken six hours after commencing the infusion and the rate adjusted as below. Unfractionated Heparin Dosage Adjustment Protocol For Acute Coronary Syndrome (Stemi, non-Stemi and Unstable Angina) Based on aPTT Normal Range of 25-37 Seconds and Infusion of Heparin 100 Units m/L (25,000 units in 250mL) aPTT (seconds) Bolus Dose IV Stop Infusion IV Rate Change (mL/hr) Repeat aPTT < 37 2,000 units NO increase 2 mL/hr from current 6 hours rate 37-54 Nil NO increase 1mL/hr from current 6 hours rate 55-75 Therapeutic Range - No Change from current rate Daily 76-90 Nil NO Reduce 1mL/hr from current rate 6 hours 91-105 Nil NO Reduce 2mL/hr from current rate 6 hours 105 Nil 60 mins Restart at 2mL/h less than previous rate 6 hours Compliance with this guideline is recommended Page 3 of 24
Page 1: Guideline Anticoagulation: Heparin
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Page 21 and 22: THE DAY OF SURGERY: Last Clexane to
Page 23 and 24: Attachment 2 Intravenous Standard H

Heparin and Warfarin - Sydney South West Area Health Service

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