Heparin Protocol questions

[qaqueen]

My facility uses a weight based heparinprotocol. Recently, I had a (new to me) experience that left mequestioning myself and my RNM.

My patient had been off the drip for a few hours for imagining studies. Whenthe patient came back, the aptt was in the 50's. Per the procedure, I wasaccompanied by a second nurse to witness the increase in dose and bolusper protocol.

The thing that threw me for a loop was the bolus dose. The patient isobese, greater than 225kg. The bolus order is 80 units/kg. I have nevergiven a heparin bolus of such magnitude (>18000 units). The witnessingnurse verified the order, the math, and the set up. She then said that she hadnever given such a large dose either.

I went to the RNM who rechecked the order, my math, and the set up. Shetold me not to chart anything yet (whaaaa???) and walked away. Asshe did not return within 30 minutes, I charted exactly what I had done,including a comment with the calculation.

Shortly before the end of the shift, she told me to go ahead and chart thebolus.

It came as no surprise to me that the patient's aptt came back criticallyhigh. Fortunately, I was handing off to a seasoned nurse that I have alot of confidence in.

I know that I followed the protocol as written. But, is this a normal bolusdose for an obese patient? Do other facilities have a separate protocolfor patients with a very high bmi?

Thanks in advance for your time.

[commonsense]

My facility uses a weight based heparinprotocol. Recently, I had a (new to me) experience that left mequestioning myself and my RNM.

My patient had been off the drip for a few hours for imagining studies. Whenthe patient came back, the aptt was in the 50's. Per the procedure, I wasaccompanied by a second nurse to witness the increase in dose and bolusper protocol.

The thing that threw me for a loop was the bolus dose. The patient isobese, greater than 225kg. The bolus order is 80 units/kg. I have nevergiven a heparin bolus of such magnitude (>18000 units). The witnessingnurse verified the order, the math, and the set up. She then said that she hadnever given such a large dose either.

I went to the RNM who rechecked the order, my math, and the set up. Shetold me not to chart anything yet (whaaaa???) and walked away. Asshe did not return within 30 minutes, I charted exactly what I had done,including a comment with the calculation.

Shortly before the end of the shift, she told me to go ahead and chart thebolus.

It came as no surprise to me that the patient’s aptt came back criticallyhigh. Fortunately, I was handing off to a seasoned nurse that I have alot of confidence in.

I know that I followed the protocol as written. But, is this a normal bolusdose for an obese patient? Do other facilities have a separate protocolfor patients with a very high bmi?

Thanks in advance for your time.

We have a maximum weight at our facility. The protocol dosages are increased until the patient is greater than 90 kg. All patients weighing greater than 90 kgs receive the same doses.

[RNpatterson]

Our facility uses weight-based protocol but pharmacy uses the weight to determine a starting rate and bolus dose - that's the only time weight is factored into our use. The order set then shows the protocol for rate changes and bolus amount based on ptt, independent of weight.

It sounds like your protocol is much different but just as anything else in critical care, when you are doing something out of the norm and you have that little voice in your head saying "is this right?," ALWAYS double-check. I'm not sure what a RNM is but I assume it's either your charge RN or manager which is a great place to start, but in this case, since it involves medication administration, my double-check would have been with a pharmacist and/or the physician.

The problem with universal protocols is not everyone fits into the one-size-fits-all model and exceptions need to be made. It wouldn't be a bad idea to bring up a suggestion to your manager or the appropriate committee to add a BMI or weight range for your protocol.

To answer your question, I couldn't tell you what we do at my current hospital does as I have not cared for a very heavy pt here, but the last hospital I worked at capped all weight-based infusions at 100kg, no matter how large the pt was.

[qaqueen]

Thank you so much! Both of these responses are terrific.

Musician's Wife, you are correct. RNM = RN manager.

I would have called the MD, but (sadly) that is very frowned on after 10pm.

I agree that I should have contacted the pharmacy as well.

I absolutely agree with the idea of a maximum weight for weight based meds. I will be bringing that up as soon as I get back to work.

Again, thank you both very much!

Best Regards

[MunoRN, RN]

We uses the same bolus dose (80 units/kg) but we cap the bolus at 8,000 units. We also use a sort of sliding scale for both rates and boluses based on weight, the more you weigh the less units/kg you get.

In general it's best to avoid stopping a heparin drip since they'll become sub-therapeutic usually in 30-45 minutes and have a normal ptt/xa after a couple of hours. The need to re-bolus then makes finding a therapeutic rate more difficult.

In most places, pharmacy is going to be your go-to person for this. Most docs will just tell you to ask pharmacy if you do ask them. They order the heparin drip and sometimes the dose goal (low vs high) and sometimes whether or not to bolus but they leave pretty much everything else up to pharmacy.

[marilynbaker]

my hospital has the same protocol.