Sydney south west area health service



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SSWAHS Clinical Guidelines  

Clinical Quality Council Approval: November 2006                                                                             



SYDNEY SOUTH WEST AREA HEALTH SERVICE 

 

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                                                                             



Table of Contents  

 

 

Section 

 

 



Description 

 

Page 

1  

Intravenous Standard Heparin Protocols  



3-5 

2  

Low Molecular Weight Heparin  



1-5 

Management of Bleeding on Intravenous Stand and Low 

Molecular Weight Heparin  



Initiation of Warfarin Therapy  



1-5 

Management High INR and Bleeding During Warfarin Therapy  



1-2 

Perioperative Management of Anticoagulant Therapy in patients 

on Warfarin  

1-6  

Intravenous Standard Heparin Protocols (Syringe Driver 

Protocols)  

1-3  


SSWAHS Clinical Guidelines  

Clinical Quality Council Approval: November 2006                                                                             



Intravenous Standard Heparin Protocols 

(100 units/ml infusion) 

Note: The following protocols are for infusional devices using 25,000 

units of sodium heparin in 250 ml normal saline (0.9% sodium chloride) 

and are not suitable for infusional devices using higher concentrations

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.  

 

A. 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 


55 3300 


660 

60 



3600 

720 


65 3900 


780 

70 



4000 

840 


75 4000 


900 

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. 

 

U



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                                                                             



B. HEPARIN PROTOCOL FOR ATRIAL FIBRILLATION, 

VENOUS AND ARTERIAL THROMBOEMBOLIC DISEASE, 

PROSTHETIC HEART VALVES  

 

 

DOSAGE:

 

Concentration = 25,000 units heparin sodium in 250 normal 

 

 

saline (0.9% sodium chloride). (100 units per ml) Based on 18 

  units/kg/hour. 



 

WEIGHT 

BOLUS 

UNITS PER HOUR 

Starting rate  

mL per hour* 

50 3500 


900 

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) 

 

Based on aPTT Normal Range of 25-35  Seconds & Infusion of 25,000units in 250mL 



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                                                                             



Notes on intravenous heparin: 

 

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.  

 

Safety Issues with infusion pumps: 

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.  

 

Changing Between Intravenous Heparin and Clexane  

 

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                                                                             



Low Molecular Weight Heparin 

(Thrombo-embolism and Unstable Coronary Artery Syndromes) 

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. 

 

AVAILABILITY: 

Clexane 20mg, 40mg, 60mg, 80mg, 100mg, 120 mg, 150 mg syringes 

Fragmin 2,500 units, 5,000 units 

 

BEFORE STARTING TREATMENT: 

  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) 

 

Therapeutic dosing (twice daily): 

 

Normal or near normal renal function 

(CCR >60 ml/min) 

Clexane 1 mg/kg Q12H SCI  (no cap based on weight 

but check peak anti-Xa levels if body weight >100 kg



Moderate renal impairment 



(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                                                                             



Severe renal impairment 

(CCR<30 ml/min) 

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). 

 

PRECAUTIONS: 

  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                                                                             

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.  

 

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

.  

 

 

Reference:  



 

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                                                                             



Charts for estimating GFR: 

 

 

Normal Renal Function (Calculated Creatinine Clearance (CCR)>60 

ml/minute 

1mg/kg twice daily 

 

Moderate Renal Impairment: 

 

CCR 30-60mL/min                 

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.   

 

Severe Renal Impairment        

       


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.  

 

SERUM CREATININE <100 micromol/

L and CCR 

 

Age 

 

Sex 

 

Weight 

  

40kg 

50kg 

60kg 

70kg 

80kg 

90kg 

100kg 

50yrs M 

 

 



 

 

 



 

 

 F   

 

 

 



 

 

 



60yrs M 

 

 



 

 

 



 

 

 F   



 

 

 

 

 



 

70yrs M 

 

 



 

  

 

 



 

 F 

<30 

ml/min 

 

 

 30- 50 



ml/min 

 

 

 



 

80yrs M 

 

 

 



 

 

 



 

 F 

 

 



 

 

 



 

90yrs M 

 

 



 

 

 



 

 F 

 

 

 



 

 

 



 


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