Heparin bolus administration

[RDH-RN]

When giving a Heparin bolus, and the vial is 10,000 units/10mL (1000units/mL concentration), and the bolus is to be for 4000units, would you not draw 4mL into a syringe and give it IVP? (This is the bolus that precedes an infusion with a bag that is of a 100unit/mL concentration.)

My preceptor told me that I was supposed to use a tuberculin/Heparin syringe and draw up 4 "units" and inject it subQ for the bolus.

???

[Gabby-RN]

Where I work the order usually states to give the bolus IVP.

I would draw up the bolus and give it IV or program the bolus into the pump. Our heparin is 5000 units/mL for the bolus.

With the concentrations you have given 4000 units would not be equal to 4 units on an insulin syringe. The insulin syringes we use are 100 units = 1 mL. Based on what you said, 4mL would be the correct amount to draw up and I would not give SQ unless the order was written to do so. All med orders should be written with the route.

[SierraBravo]

I do the bolus right from the bag. Heparin obviously runs on guardrails, so I can program the bolus on the pump to run right from the bag and then resume the ordered rate. I'm not familiar with giving a bolus of heparin separately from the bag. Our heparin bags are also 100units/mL and come in a 250mL bag.

[suanna]

Your perceptor is nuts- unless there is some silly hospital policy that says you cannot give a hep bolus- and if that's the case- the policy is nuts as well. I almost always give the bolus off the bag- ie: 25,000units in 250cc= 100units/cc. 10cc=1000units, 4000units is 40cc- run in as secondary rate over 5-10 min.

[RDH-RN]

Thanks so much for the responses...I thought she was nuts, too! I'm a newbie on a med-surg floor, and even though "we rarely ever get Heparin drips" I've had two to deal with in the 3 months I've been there...everyone else seems as confused and nervous to deal with them as I do. I didn't even know you could program the bolus into the pump!! I have requested a one-on-one session with one of the pharmacists on staff to help me; hopefully they'll be willing to do so.

@suanna--No, no policy to not give boluses; the opposite! (Give a certain bolus as determined by pharmacy, run the drip, PTT 6hrs after start time, adjust settings and re-bolus if need be, PTT 6hrs later, so on and so forth.) Soooo, since giving a bolus is main player in the game, I'd like to be shown/told how to do it correctly!

Thank you for your help...if any of you could explain how to program both the bolus and the drip rate into the pump, I would be most appreciative!!

[suanna]

I'ts very much dependent on the make and model of pump you are using. We use 3 or 4 different models in this hospital and they are all different in how you program. For the most part- set it up like you were running a piggyback. The only difference is you have no piggyback up. Be sure to reduce the "amount left to be infused" in the main fluid volume by the CCs of the bolus or your bag will be dry before you expect it. You end up programming 200cc/hr(or so)for a 40cc amount on the secondary program in the pump. Set the primary rate to the ordered heparin rate after the ordered bolus. Keep in mind- heparin has a very short half life. If you over shoot for some reason- it will correct with a fairly short pause in the drip. If you have to stop the drip for some reason, you are likely to loose ALL the theraputic effects of the drug and have to start playing around with boluses and titration again.

[Esme12, ASN, BSN, RN]

RDH-RN said:

Thanks so much for the responses...I thought she was nuts, too! I'm a newbie on a med-surg floor, and even though "we rarely ever get Heparin drips" I've had two to deal with in the 3 months I've been there...everyone else seems as confused and nervous to deal with them as I do. I didn't even know you could program the bolus into the pump!! I have requested a one-on-one session with one of the pharmacists on staff to help me; hopefully they'll be willing to do so.

@suanna--No, no policy to not give boluses; the opposite! (Give a certain bolus as determined by pharmacy, run the drip, PTT 6hrs after start time, adjust settings and re-bolus if need be, PTT 6hrs later, so on and so forth.) Soooo, since giving a bolus is main player in the game, I'd like to be shown/told how to do it correctly!

Thank you for your help...if any of you could explain how to program both the bolus and the drip rate into the pump, I would be most appreciative!!

Your preceptor is WRONG!

The process to bolus with the pump varies machine to machine. IN theory if you have a Heparin gtt 25,000units in 500mls that is 50units/ml.....so you would program the pump to deliver 4,000units [80ml] over a very short period of time.

For example...you would program for VTBI(volume to be infused) for 80mls @ 999mls/min. The pump would stop at the 80mls and you would need to reprogram the pump for the new rate/min [units/hour] and a new VTBI. Many facilities...unless they have dose mode pumps with a bolus function don't condone this practice as it sets up a scenario for a HUGE ERROR!

Your preceptor can not be more wrong if she tried...a TB syringe? Uhmmmm...NO!

If you have heparin 10,000units/10ml you have 1,000units/ml...you need 4,000units of heparin so you need to give 4mls to the patient.....IV bolus. NOT subq. If she meant TB syringes they have a 1ml total volume...so... you would be giving 4 total subq injections (4 full TB syringes) ...doesn't make sense...right? Certainly not when you are starting an IV drip.

I think you need to speak to your educator and manager with this question and this nurses response.... for if this is what she is doing in practice...she is wrong

[Here.I.Stand, BSN, RN]

This is someone on a heparin drip, right? I too give the bolus right from the pump; the pumps we use have a bolus mode. Actually the vials of heparin that we do use for sub q say on them "Not for IV administration."

[RDH-RN]

Oh, no, not four syringes--4 "units" of Heparin, as in, pull in enough Heparin into the syringe so that it hits the "4unit" mark on the syringe. I asked her to show me the math on how she was getting 4 and not 4000...she kept going back to the 100units/mL concentration (of the BAG!) not the 1000units/mL of the vial.

Also, while she may have said "TB syringe," I think she meant 'insulin syringe.' Not that it matters terribly, since it's still not right...just wanted to report the story correctly.

I did ask my unit supervisor if he could set up something with myself and one of the pharmacists...it's a delicate situation. I'm new, she's recently been promoted and quite honestly, used to being right and doesn't take constructive criticism well at all. She isn't a bad nurse, she just doesn't know everything, and for some reason, didn't want to admit she either didn't know about the drip or was telling me wrong intentionally. Bleh!

[Lev, MSN, RN, NP]

Here.I.Stand said:

This is someone on a heparin drip, right? I too give the bolus right from the pump; the pumps we use have a bolus mode. Actually the vials of heparin that we do use for sub q say on them "Not for IV administration."

Our sub q vials of heparin say the same thing. According to your preceptor, I'm giving boluses of heparin to many of my post op patients q8h. Dangerous! Bolus = IV.

[Clovery]

The way I learned to give a heparin bolus was similar to what the OP is describing. If I need to give 4300 units bolus, I grab one of the 5000 units per 1 mL single dose vials that we typically use for sub q heparin. I do the math and calculate I need to give 0.86 mL. I then draw up this amount into a TB syringe for accurate measurement, then inject it into a luer lock syringe so I can give it IV. The heparin vials we use say for SQ or IV use and "not for lock flush".

[tech1000]

I draw the bolus. We use the 1000units/1ml for our boluses. And we literally do give them IVP prior to beginning the actual infusion (which is, I believe, 25,000units in 500cc). I'm not sure why you'd give a "bolus" subq? That seems really strange.