Sydney south west area health service
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SSWAHS Clinical Guidelines Clinical Quality Council Approval: November 2006 1
Governing Body & Management Approved By
Originally Issued
Re-Issued
Current Version Issued
Next Review Date
Guidelines- Anticoagulation: Heparin & Warfarin SSWAHS Clinical Guidelines Clinical Quality Council Approval: November 2006 2
Description Page 1 Intravenous Standard Heparin Protocols 3-5 2 Low Molecular Weight Heparin 1-5 3 Management of Bleeding on Intravenous Stand and Low Molecular Weight Heparin
Initiation of Warfarin Therapy 1-5 5 Management High INR and Bleeding During Warfarin Therapy 1-2 6 Perioperative Management of Anticoagulant Therapy in patients on Warfarin
Intravenous Standard Heparin Protocols (Syringe Driver Protocols)
SSWAHS Clinical Guidelines Clinical Quality Council Approval: November 2006 3
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.
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.
NFRACTIONATED H EPARIN D OSAGE A DJUSTMENT P ROTOCOL F OR C ORONARY S YNDROME (S TEMI AND N ON S TEMI ) Based on aPTT Normal Range of 25-35 Seconds & Infusion of 25,000units in 250mL (100 units/ml) aPTT (seconds) Bolus Dose IV Stop Infusion IV Rate Change (mL/hr) Repeat aPTT <35 2,000 units
increase 2 mL/hr from current rate 6 hours
35-54 Nil
NO increase 1mL/hr from current rate 6 hours
55-75 T h e r a p e u t i c R a n g e - N o C h a n g e f r o m c u r r e n t r a t e 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 hrs
SSWAHS Clinical Guidelines Clinical Quality Council Approval: November 2006 4
units/kg/hour. WEIGHT BOLUS UNITS PER HOUR Starting rate mL per hour* 50 3500
900 9 55 3500 990
10 60 5000
1080 11
65 5000
1170 12
70 5000 1260
13 75
5000 1350
13 80 5000
1440 14
85 5000
1530 15
90 5000
1620 16
95 7500
1710 17
100 7500
1800 18
110 7500
1980 20
>120 7500 2100
21 *Note: Millilitres per hour has been rounded to the nearest whole number
The first APTT is taken six hours after commencing the infusion and the rate adjusted as below. IV U NFRACTIONATED H EPARIN D OSAGE A DJUSTMENT P ROTOCOL F OR AF/VTED (T ABLE 2)
aPTT (seconds) Bolus Dose IV Stop Infusion IV Rate Change (mL/hr) Repeat aPTT < 35 5,000 units NO increase 2mL/hr from current rate 6 hours
35-45 Nil
NO increase 2mL/hr from current rate 6 hours
46-54 Nil
NO increase 1mL/hr from current rate 6 hours
55-90 T h e r a p e u t i c R a n g e - N o C h a n g e f r o m c u r r e n t r a t e Daily 91-95 Nil
NO decrease 1mL/hr from current rate 6 hours
96-105 Nil
NO decrease 2mL/hr from current rate 6 hours
> 105 Nil
60 mins Restart at 2mL/h less than previous rate 6 hrs
SSWAHS Clinical Guidelines Clinical Quality Council Approval: November 2006 5
1) A baseline full blood count, PT and APTT should be performed prior to heparin therapy. A Haematologist should be consulted if there are significant baseline abnormalities. 2) Full blood count should be performed at least three times per week, to exclude heparin induced thrombocytopenia and a fall in haemoglobin to suggest bleeding. 3) The possibility of a retroperitoneal bleed should be considered in the absence of another identified cause of pain in the back, leg, or abdomen. A full blood count should be performed and reviewed as soon as possible, as well as urgent medical assessment and imaging of the abdomen. 4) Where the therapeutic intention is anticoagulation for venous thrombo- embolism, non-steroidal anti-inflammatory drugs (NSAIDs) should be ceased to reduce the risk of bleeding. 5) In patients who have just had cardiac or great vessel surgery, consideration should be given to omitting the bolus dose of heparin. This should be discussed with the Cardiothoracic Surgeon. 6) If the patient has had a recent surgical procedure, anticoagulation should be discussed with the Surgeon prior to initiation, where possible.
Care needs to be taken that pumps are operated according to hospital protocols and the manufacturer’s instructions. To reduce the risk of accidental infusion of a large volume of heparin solutions: 1. Turn off the flow occlusion device on the infusion BEFORE removing the set from the pump. 2. Set the volume to be delivered to 50 ml, to reduce the risk of accidental infusion of larger volumes.
Where a decision is made to change the patient from intravenous heparin to Clexane, the calculated dose of Clexane (see low molecular weight heparin protocol) should usually be administered as soon as the intravenous heparin is ceased, assuming the patient was not over-anticoagulated on heparin at the time.
If the patient were changed from subcutaneous Clexane to intravenous heparin, intravenous heparin would normally be commenced when the next dose of Clexane is due, assuming the patient was not over-anticoagulated at the time.
SSWAHS Clinical Guidelines Clinical Quality Council Approval: November 2006 1
Enoxaparin (Clexane) is the preferred low molecular weight heparin (LMWH) in these guidelines. Dalteparin (Fragmin) may be alternatively used where it is the preferred choice of the Attending Medical Officer. Fragmin is discussed for prophylaxis only.
Clexane 20mg, 40mg, 60mg, 80mg, 100mg, 120 mg, 150 mg syringes Fragmin 2,500 units, 5,000 units
• Baseline full blood count, PT, APTT, electrolytes, urea and creatinine. A Haematologist should be consulted if there are significant baseline abnormalities of full blood count, PT and/or APTT. • Estimate the calculated creatinine clearance (CCR, see attached table). The eGFR is automatically calculated by many Pathology Laboratories (see
http://www.kidney.org.au & Med J Aust 2005; 183:138-141) but may not be accurate at extremes of body weight, children, or with acute changes in kidney function. If in doubt CCR should be calculated. • For patients with venous thrombo-embolism, cease antiplatelet agents unless it is specifically intended to continue these, and the benefit outweighs the risk. DOSE: Prophylaxis: Clexane 20 mg daily SCI (low risk prophylaxis or body weight <50 kg) and 40 mg daily SCI (high risk prophylaxis). Care in patients of lower body weight (<50 kg) and impaired renal function (see below) OR
Fragmin 2,500 units daily SCI (low risk prophylaxis or body weight <50 kg) and 5,000 units daily SCI (high risk prophylaxis)
Clexane 1 mg/kg Q12H SCI (no cap based on weight but check peak anti-Xa levels if body weight >100 kg )
(CCR= 30-60 ml/min) Clexane 1 mg/kg Q12H SCI (maximum 100 mg initial dose), with daily or second daily monitoring of anti-Xa levels (see below) until a stable level is achieved, with less frequent monitoring in situations where long term therapy is employed.
SSWAHS Clinical Guidelines Clinical Quality Council Approval: November 2006 2
Avoid in most circumstances, unless in close consultation with a Renal Physician and/or Haematologist. If used, Clexane 1 mg/kg/day with daily or second daily monitoring of anti-Xa levels (see below) until a stable level is achieved. .
Therapeutic dosing (once daily – not suitable for coronary artery syndromes): Normal renal function (CCR > 60 ml/min) Clexane 1.5 mg/kg daily (maximum 150 mg dose). If the patient’s weight is >100 kg, twice daily 1 mg/kg is recommended, as above. ADMINISTRATION: • Clean skin with an alcohol swab. • Inject whole length of needle vertically into a skin fold (usually the lower abdomen), holding skin fold throughout injection. • The very small air bubble commonly found in the syringe does not need to be expelled. • Depress plunger to recommended dose. • Exert pressure with a swab for 1-2 minutes to reduce bruising (do not rub).
• Clexane is renally excreted and accumulates in renal failure. Care is required particularly in the elderly, patients on antiplatelet drugs, and in the presence of impaired renal function. • Calculated creatinine clearance rate (CCR) may overestimate renal function in very obese or oedematous patients. Formal assessment of renal function is recommended in these patients. • APTT is insensitive to Clexane and cannot be used for monitoring – anti-Xa levels are required (see below). • If the patient has had a recent surgical procedure, the Surgeon involved should be consulted before the commencement of therapeutic dose LMWH. • Ideally enoxaparin at therapeutic dose should not be given <24 hours prior to invasive procedures. • Vascular access sheaths should remain in situ for 6-8 hours after the administration of Clexane and doses withheld for 6-8 hours after removal. • Extreme care in the use of Clexane in patients receiving neuroaxial anaesthesia because of the risk of bleeding (consult with an Anaesthetist). • Heparin related thrombocytopenia and thrombosis is an uncommon but potentially serious complication of heparin therapy, requiring urgent review of anticoagulation therapy and consultation with Senior SSWAHS Clinical Guidelines Clinical Quality Council Approval: November 2006 3 Medical Staff (see below). MONITORING: • Blood should be taken 4 hours (3-5 hours) after a dose of Clexane for anti-Xa levels. • For twice daily dosing, the therapeutic range is 0.6-1.0 IU/ml. • For once daily dosing, the peak anti-Xa level should be 1-2 IU/ml (there is less literature on once daily dosing compared to twice daily dosing). • A full blood count should be checked second daily on inpatients on LMWH therapy, to exclude heparin thrombocytopenia and a fall in haemoglobin to suggest bleeding. In patients receiving extended LMHW heparin therapy as an outpatient (e.g. anticoagulation during pregnancy), it is reasonable to check a full blood count weekly for three weeks and then monthly. • The possibility of a retroperitoneal bleed should be considered in the absence of another identified cause of pain in the back, leg, or abdomen. A full blood count should be performed and reviewed as soon as possible, as well as urgent medical assessment and imaging of the abdomen. •
embolism, non-steroidal anti-inflammatory drugs (NSAIDs) should be ceased to reduce the risk of bleeding .
Hirsh J & Raschke R. The Seventh ACCP Conference on antithrombotic and thrombolytic therapy. Chest. 2004;126:188S-203S The Australasian Creatinine Consensus Working Group. Chronic kidney disease and automatic reporting of estimated glomerular filtration rate: a position statement. Med J Aust 2005; 183: 138-141. SSWAHS Clinical Guidelines Clinical Quality Council Approval: November 2006 4
1mg/kg twice daily
1mg/kg twice daily. Check peak (4 hours after a dose) anti-Xa level day 2 & day 3 of therapy, and every second day after that until stable.
CCR < 30mL/min 1mg/kg daily. Check peak (4 hours after a dose) anti-Xa level day 2 & day 3 of therapy, and every second day after that until stable.
60yrs M
70yrs M
F <30 ml/min
30- 50 ml/min
80yrs M
F
90yrs M
F
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