Heparin drips

[moffist]

I have just started at a new hospital and was very concerned with a heparin drip we were running. It was started at 2330 and no PTT/INR was taken again. Pt. had a peripheral IV and a single PICC. They started the heparin through the PICC and then Lab refused to try blood draws as said Pt was too hard a poke!!!!

I took over 8 hrs after heparin was started. Was told to switch Heparin to peripheral IV wait an hour, flush PICC with 60mls Saline then draw labs. Now my understanding is if a heparin drip is running in a Central line you CANNOT draw PT/PTT/INR as you will get skewed results!!!

Also the peripheral IV went bad so couldn't switch the lines. In the end we got a new peripheral IV switched heparin to peripheral, waited an hour then did as advised. Result was (greater than) 150. Hmmm I'm wondering how accurate that was? As it is it was over 12 hours before I could get the PTT/INR.

Then the Charge nurse wanted to run Antibiotics concurrent with the heparin. I didn't do that but surely THAT is dangerous.

Appreciate any thoughts!!!

[Magsulfate, BSN, RN]

Also, if I have a patient w/ a suspected PE or DVT, I would rather have them OVER-anticoagulated than under until things get straightened out. I've managed tons of heparin gtts and I've never seen anybody (adult) "bleed to death."

Hope things worked out for you and your patient!

I HAVE.

[madwife2002, BSN, RN]

Not all PICC;S need flushing with heparin, for example Power Piccs are not recommended to be flushed with heparin. Secondly if the pt had a single lumen then unless you used the perhipheral line you couldnt run the ab's as heparin should not be stopped and never piggybacked.

[queenjean]

Madwife, if they are compatible, y-siting them doesn't disrupt the heparin infusion. Not piggyback.

I'm with the other posters--it's not a big deal to stop the heparin, wait, flush, waste, and draw the PTT. Have you seen documented research that says otherwise? Or are you just going on your facility's (possibly outdated) protocol? Maybe some updates are in order.

If someone's going south and it could possibly be infection related, I'd say it's pretty important to the the abx in, as well as have an accurate PTT. Why not draw the PTT from the PICC and then y-site in the abx? We do it all the time if we can't get a second site or have more than one lumen. While I'd prefer to have heparin in a dedicated line, sometimes it doesn't happen that way.

[beachbum3]

We'd just stop the heparin, flush and draw the labs. Never heard anything about labs being skewed as long as you waste the first 10mLs

[moffist]

Well I'm grateful for all the replies. I guess if hospitalmpolicy says DO NOT DRAW COAGS then I have no choice but to follow it. It may be outdated but that is the hospital policy. I will talk with our educator about this policy.

Also is hospital policy NEVER to run or y tube ANYTHING with a heparin drip EVER!!!

Guess it is an outdated rule but I will ask our educator exactly why we can't (any evidence based practice etc).

I did flush well and did draw the cooags.

[pricklypear]

It's frustrating when you cannot do you job effectively - I'm sure many of us have been in the same situation - I know I have. Sometimes all you can do is CYA.

In regard to hospital policy: Sometimes hospital policy has to be thrown out the window in favor of patient care. As I stated earlier, a Dr order can override a nursing policy - assuming you are willing to follow the order. I guess that is where professional judgment comes into play. Will the patient benefit from or possibly be harmed by adherence to a policy? Policies are black and white, real life is about 28 shades of gray.

[moffist]

Absolutely and that is what I did. Followed the dr order and drew the blood anyway!!!

Great replies everybody and thanks!!!

[Magsulfate, BSN, RN]

A lot of doctors and hospitals are getting away from using heparin as a standard and switching to NS because of the risk of getting heparin induced thrombocytopenia.

[futrarmyCRNA]

Ok the heparin was running through the PICC when it was suggested I run the antibiotic with it. No 2nd peripheral by then.

My last hospital 's protocol said NEVER draw coags from a PICC (single, double OR triple) after initiating a Heparin drip. You get skewed results.

The protocol here was checked. Labs were supposed to be drawn by the Lab (who were refusing) and we would have got the blood from the restarted IV BUT that was MANY hours later!!!

Still think 12 hrs was way too long!!!!

Thanks for the reply.

The usual PTT is 6 hours between changing of rates and when first started. If it is a within therapuetic level then can be drawn the next morning. A result will not be skewed if the drip is stopped and line flushed with the 3 time push pull method. That level is a little high but not uncommon for someone on a heparin gtt, as it is usually stopped for an hour after that and restarted at a lower rate.

[surviveslu]

I agree. It is very common practice where I work to stop the drip, flush the line well, waste the first ten mL, then draw labs. I have never seen anything in evidence based practice that would seem to indicate that this is incorrect.

Same as our hosp

[MunoRN, RN]

You shouldn't draw a ptt from a lumen infusing heparin, but there is nothing wrong with drawing a ptt from another lumen as long as the heparin is off for a few minutes and the heparin lumen is clamped. There is some (questionable) evidence that drawing a ptt from another lumen can produce a very small change in the ptt, but a statistically different result is not the same as a clinically different result; it doesn't really matter if the true ptt is 72 and the ptt you get from drawing off a central line is 74, it makes no difference in the clinical decision making.

In general, I think single lumen PICCs are stupid, particularly in the case of a heparin gtt, but if that's all you've got and the patient is a hard stick and/or you are trying to save their veins then the best option is to run the heparin gtt through a peripheral and save the single PICC for lab draws.

[3dayRN]

I realise heparin is compatable with other drugs but with an overdue PTT, a heparin drip running without being checked I was not prepared to add insult to injury especially as pt wasn't or didn't seem to be doing well

Just curious...how is hanging a compatible antibiotic "adding insult to injury". You are doing no harm hanging this if compatible, but causing potential harm NOT hanging an ordered antibiotic. Hanging this or not hanging this should have nothing to do with not being able to draw coags. Maybe I'm just reading this wrong and this is not what you meant?