Guidelines for the Therapeutic Dosing of Heparin

Guidelines developed by the UWHC Center for Drug Policy

Revised by: Wendy Horton, PharmD, BCPS

Reviewed by: Lisa Gryttenholm, PharmD; Dan Hendrickson, RPh; Jonathan Keevil, MD; Scott Mead, MD;
Justin Sattin, MD; Susan Schroeder, RN; William Tanke, RPh; Michelle Thoma, PharmD; Philip Trapskin,
PharmD; Eliot Williams, MD; Kenneth Wood, DO

Coordination: Lee Vermeulen, RPh, MS, FCCP Director, Center for Drug Policy

Approved by P&T: January 2004

Last Review Date: April 2009
Next Scheduled Review: April 2011

A. The prescriber will initiate the heparin protocol by writing an order to begin heparin per protocol.
The order must specify the intended dosing regimen and if an initial bolus is desired.

Low Intensity Regimen acute MI treated with alteplase, tenecteplase or

abciximab/eptifibatide/tirofiban
(note: no bolus is recommended if less than 6 hours from arterial sheath removal)

Medium Intensity Regimen non-ST segment myocardial infarction, mechanical valve

High Intensity Regimen established deep vein thrombosis, pulmonary embolism,

ventricular/atrial thrombus

B. Once the prescriber orders the heparin protocol, the nurse takes the following steps:

1.0 Review initial order for desired dosing regimen (low, medium, high intensity) and whether a bolus
is indicated.

Maximum Initial
Bolus Dose Maximum Bolus Initial Infusion
Regimen Infusion Rate
(units/kg) (units) (units/kg/hr)
(units/hr)
Low 60 4000 12 1000
Medium 70 7000 15 1400
High 80 10,000 18 2000

2.0 Obtain actual body weight. Use best estimate of true weight if unable to weigh patient. Record
weight in HealthLink. Make calculations using actual body weight.

3.0 Order labs

3.1 Stat baseline aPTT and INR/PT.
3.2 Hematocrit and platelet count every other day until day 14, beginning the day that
heparin is initiated.
3.3 Stat aPTT 6 hours after initiation of heparin. Repeat stat aPTT 6 hours after each dose
adjustment
(see #7).

4.0 Heparin is a high-alert medication. An additional double-check is required as specified in Hospital

Administrative Policy 8.33 must be performed on all boluses, when IV pump programming is

outside of the established IV pump decision support software (Alaris Guardrails ) limits, and
when a new bag of heparin is hung.

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 5.0 Prepare and administer the initial heparin bolus, if one is ordered. If no bolus is ordered, proceed
to step 6.
5.1 Document bolus in HealthLink
5.2 Use heparin 1000 units/mL vial for bolus from floor stock.

6.0 Initiate heparin infusion.

6.1 Document infusion rate in HealthLink in mL/hr
6.2 Use heparin 25,000 units/500 mL D5W premixed bags.

7.0 Titration of heparin therapy

7.1 Stat aPTT 6 hours after initiation and 6 hours after any dose change. Adjust heparin
infusion as indicated in the dosing adjustment table until aPTT is therapeutic. Use
supplemental bolus if ordered.
7.2 Record each heparin rate adjustment on the heparin flow sheet.
7.3 Once three consecutive aPTTs (drawn every 6 hours) are therapeutic, order routine
aPTT only every 24 hours. If dose adjustment again becomes necessary, recheck aPTT
in six hours and repeat the process.

8.0 If heparin is being used therapeutically, no modification of these protocol orders is

allowed. While discouraged, if patient circumstances require heparin dosing that differs
from established protocols, specific orders must be written. Separate heparin order sets
are available for patients on ECMO or ventricular assist devices.

Low and Medium Intensity (Arterial Thrombosis) Heparin Anticoagulation Dose Adjustments
aPTT (seconds) Bolus/Hold Infusion
<34 Give supplemental bolus if ordered & inform 100 units/hr = 2 mL/hr
MD
34-37 Give supplemental bolus if ordered & 100 units/hr = 2 mL/hr
inform MD
38-44 0 50 units/hr = 1 mL/hr
45-54 0 NO CHANGE
55-64 0 50 units/hr = 1 mL/hr
65-84 0 100 units/hr = 2 mL/hr
85-100 Hold infusion 1 hour & inform MD 150 units/hr = 3 mL/hr
101-125 Hold infusion 1 hour & inform MD 200 units/hr = 4 mL/hr
>125 Hold infusion 1 hour & inform MD 200 units/hr = 4 mL/hr

High Intensity (Venous Thromboembolism) Heparin Anticoagulation Dose Adjustments

aPTT (seconds) Bolus/Hold Infusion
<34 Give supplemental bolus if ordered & inform 100 units/hr = 2 mL/hr
MD
34-44 Give supplemental bolus if ordered & 100 units/hr = 2 mL/hr
inform MD
45-54 0 50 units/hr = 1 mL/hr
55-70 0 NO CHANGE
71-85 0 100 units/hr = 2 mL/hr
86-100 Hold infusion 1 hour & inform MD 150 units/hr = 3 mL/hr
101-125 Hold infusion 1 hour & inform MD 200 units/hr = 4 mL/hr
>125 Hold infusion 1 hour & inform MD 200 units/hr = 4 mL/hr

If two consecutive aPTTs are greater than 125 seconds, patient should not be maintained on the heparin
protocol. Recommend consultation with Pharmacy and/or Hematology for assistance with dosing.

If two consecutive aPTTs are subtherapeutic, a consultation with Pharmacy or Hematology is

recommended for assistance with dosing.

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 9.0 Monitoring
9.1 Every eight hours: Inspect line/surgical/wound sites for bleeding and check patient for
symptoms indicating bleeding such as hematomas, bruising, and respiratory symptoms.
Contact MD for any signs of bleeding.
9.2 Provider should be notified if:
9.2.1 Baseline aPTT > 34 seconds or baseline INR > 1.2
9.2.2 Hemoglobin decreases by > 2 g/dL from baseline or platelets <100,000/microliter
or platelets decrease by greater than 1/3 of baseline value
9.2.3 aPTT is less than 38 seconds or greater than 84 seconds if patient is on low or
medium intensity regimen
9.2.4 aPTT is less than 45 seconds or greater than 85 seconds if patient is on high
intensity regimen
9.2.5 Patient has any deterioration in neurologic status

10.0 Relative Contraindications and Precautions

10.1 Hypersensitivity to heparin.
10.2 Increased risk for hemorrhagic complications.
10.3 Patients who are actively bleeding.
10.4 Thrombocytopenia.
10.5 Less than 72 hours post-op.
10.6 Recent hemorrhagic stroke.

Reference:
Antithrombotic and thrombolytic therapy: American College of Chest Physicians Evidence-Based Clinical
th
Practice Guidelines (8 Edition). Chest. 2008;133(6 Suppl):67S-887S.

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