Monitoring patients on heparin

What is your protocol on monitoring APTTs on patients with heparin gtts?

Do you differentiate between standard nomagram and a modified nomagram.

I have seen too many people bleed or develop large hematomas because thier APTT has not been checked for more than 6 hours and it is way over limit.

Any imput would be greatly appreciated as I am trying to change our practice to make it safer.

Denise:)

[KC CHICK]

We check PTTs Q6hrs until we get 2 PTTs that are therapeutic. Then, they get checked every day. If the gtts need to be changed again...check 6 hrs after the change and ....need 2 more therapeutic PTTs until its every AM again. We have two different protocols to follow. Stroke and Cardiac. I think the therapeutic levels are different for each. Both initial gtts. are based on pt. wt.

Anne

[BadBird, BSN, RN]

We check PTT 4 hours after a bolus and drip have started, when therapeutic them just QAM, anytime you need to titrate up or down then you check PTT 6 hrs after that.

[whipping girl in 07, RN]

We do it the exact same way as KC CHICK.

[MollyMo]

We check q4 until we have 2 therapeutic, then qAM. Sometimes, if a bolus and drip increase is required for a subtherapeutic level, we don't give the bolus, we just up the drip. Nursing judgement.

[Bermuda]

We initially go by the patients weight..actual not stated and then according to that we give a bolus and start the gtt accordingly then do PTT's q6h until therapeutic then it would be qam from that point on....

[misti_z]

Originally posted by KC CHICK

We check PTTs Q6hrs until we get 2 PTTs that are therapeutic. Then, they get checked every day. If the gtts need to be changed again...check 6 hrs after the change and ....need 2 more therapeutic PTTs until its every AM again. We have two different protocols to follow. Stroke and Cardiac. I think the therapeutic levels are different for each. Both initial gtts. are based on pt. wt.

Anne

Same here. If value >150 is obtained the gtt is off for 30min and another PTT drawn p the 30min then restart per the protocol.

[Sleepyeyes]

Yup, we have a separate protocol and MAR for heparin gtt with the parameters on it. We write up the orders for the APTT draws "per heparin protocol" and can always put in a stat draw if we suspect any problems. The lab's usually real good about getting it back to us quickly too; can draw and get results within one hour.

Very important on a tele floor.

[dhogan]

We check 6 hours after bolus and starting gtt. Then we have a protocol sheet with different ranges. We check 4 hours after any changes. When it is theraputic it will be checked every am.

[louiemed5]

If someone has a minute could you please give me an example of values concerning monitoring aPTT levels on a patient receiving Heparin. I know the basics of the "normal range is between 20-45 seconds," and the "therapeutic level should be at 1.5-2.5 x the control"...but I'm having difficulty putting that into practice.

Thank you for any response. :nuke:

[BBFRN, BSN, PhD]

louiemed;

Here is a very good example of a best practice protocol sheet for weight based heparin. Check with your facility's protocol to make sure it's the same before using. I think it lays out the protocol in an easy-to-understand manner.

Does your facility use a protocol sheet? If not, they really should.

EnoxaparinWeightBasedHeparinDSO.pdf

[ghillbert, MSN, NP]

I work with VAD patients - we use a "postop" (low dose) and a "DVT" (high dose) protocol.

Heparin dosing should be very exact based on nomograms - I can't believe someone does it according to "nursing judgement"!!