Trying to educate myself - Reversing Heparin

[widi96]

We recently had an incident at work (I was not involved) where a Heparin bag was infused instead of an antibiotic. Pt was on a Heparin gtt, the pump was programmed incorrectly though - so they got the Heparin at the antibiotic speed. My question is - I know they hung a bag of medication to reverse the effects of the Heparin, and by the end of the night the patient was back on her titrating Heparin gtt. I was wondering if anyone knew what this drug might have been, as I'm curious and want to look it up.

[RN1989]

Protamine

[suanna]

Protamine would be the reversal agent but unless the patient was showing active bleeding somewhere I can't imagine why they wouldn't just let the heparin wear off. It has a fairly short half life and if you start trying to correct your aPTT with protamine and then resume the heparin drip you are going to have a very difficult time getting to a stable drip rate. They would have been better off holding the drip for 30min and restarting at 1/2 the prior rate- recheck the aPTT.

[GrumpyRN63, ADN, RN]

Protamine would be the reversal agent but unless the patient was showing active bleeding somewhere I can't imagine why they wouldn't just let the heparin wear off. It has a fairly short half life and if you start trying to correct your aPTT with protamine and then resume the heparin drip you are going to have a very difficult time getting to a stable drip rate. They would have been better off holding the drip for 30min and restarting at 1/2 the prior rate- recheck the aPTT.

I don't think that would be feasible if the pt received 25,000units of heparin, sounds like they got the whole bag??

[suanna]

"I don't think that would be feasible if the pt received 25,000units of heparin..."

Yep, even if they got the whole bag a normal bolus is 5000-10000 units to bump up to theraputic range, so at most he got 5x a normal low end loading bolus. Hold the drip for 30min to an hour and I bet the aPTT is just about where you want it. If not hold it for another-30min to an hour. If you reverse the heparin you risk reacting to the protamine, protamine rebound, going sub-theraputic and clotting off what you were trying to keep open, having to balance your protamine dose& heparin dose& and half life..

Unless there is a hole in the patient somewhere you don't want one that is likely to start leaking it won't hurt nearly as much to be anticoagulated for a while than to clot somewhere you don't want.

[oramar]

We recently had an incident at work (I was not involved) where a Heparin bag was infused instead of an antibiotic. Pt was on a Heparin gtt, the pump was programmed incorrectly though - so they got the Heparin at the antibiotic speed.

This is happening way to often. The last two places I worked were so proud of their bar code scanners, bragging to the news media about the safety. They had NOT set up their systems to include scanning bags of IV fluid. I thought that ommision was insane!

[GrumpyRN63, ADN, RN]

I guess it depends on how your facility dispenses Heparin, the OP stated the Heparin gtt was mistaken for a bag Atbx dose and infused at that rate, our Hep gtts come in 250cc bags and if THAT ( @ 100u/ml) is infused over an hour or so, a 25,000 unit bolus would be a bit of a problem one could not just turn a pump off for 30 minutes, one could have serious problems. I guess if the amount the pt received was known, we would know if the rx was appropriate, yeh 5k bolus was different that a 25K bolus IMO

[GilaRRT]

You need to be very careful when giving Protamine Sulfate. Many cases of anaphylaxis and other reactions have been reported with this medication. You should always try to give a small test dose prior to initiating a full infusion to see how the patient tolerates the medication.

[ava'smomRN]

how about if it was given sq? would protamine still work?

[RN1989]

Yes, it can be used for IV unfractionated heparin as well as low molecular weight heparin.

As far as the other discussions to give/not give - I've given it just a handful of times over the years and always due to a pt's ptt still being too high when they could not put off surgery any longer. Have never had a pt bleed out because of heparin "o.d". Sounds like there was a whole systemwide mess going on for this to happen. All I can ask is why nurses no longer put labels on the pumps as well as several labels on the IV lines near each injection port? If this had been done, there should not have been a problem with the pump being reprogrammed. This was an entirely preventable error.