Question Re Heparin

[Danish]

I have been looking online and in my drug books and cant find an answer to this question...

On Thursday in clinical I had a pt with a DVT that was receiving a Heparin protocol. She was also receiving Gentamycin IV Q12 h. She only had a double lumen PICC. The nurse I was working with said that the Heparin should be stopped to give the Gent b/c you cannot run both through the PICC and the woman had no other IV access. I was under the impression you NEVER stop Heparin unless you have an order from the physician. My instructor called the pharmacy and they said the drugs should be compatible. The nurse, however, said that they were not and that we should stop the Heparin for an hour.

I know that I am just a student, and I didnt want to step on her toes, but I was in a tough spot because the nurse and my instructor were disagreeing. I could not find anywhere that the Gent and heparin were incompatible, but I do see what she was saying about running both through one PICC line.

Anyway, she stopped the Heparin and piggybacked the Gent with NS, then restarted the Heparin.

What should I have done in this case?

[EmmaG, RN]

Actually had the Lovenox people in house last week and they are very strongly encouraging use of Lovenox for treatment of DVT.

After all, Lovenox is a type of heparin - just a low molecular weight heparin. And like regular heparin, it inhibits the formation of thrombin.

Yeah; the prophylactic dosage I've seen is usually 40mg. For patients with DVT's it's 1mg/kg. I can't remember the last time I saw heparin used for DVT. (more often, it's been for stroke protocol)

[lsyorke, RN]

Heparin or Lovenox prevent it getting worse, does not lyse the thrombus.

Lovenox is the drug of choice in our hospital for DVT, NOT heparin. Neither heparin or lovenox will lyse a thrombosis...the body does that by itself. Heparin drips are slowly going out completely. They are labor intensive and result in massively variable PTT's , so their effectiveness is not as good as it was once thought to be.

[StephOScope]

Good learning experience you've had! There will be so many more to come...

My slightly dated Davis handbook does list Gent and Heparin as both additive and Y-site incompatible...however, a multi-lumen access device is neither. These devices are designed to permit administration incompatible substances. It should be noted though that my reference is a few years old and there may be more timely info available regarding compatibility.

I wouldn't advise stopping a Heparin infusion without the MD's knowledge. Although there is probably no immediate risk of doing so, Heparin is generally monitored with serial PTT/APTTs and titrated using a nomogram approved by your facility. Stopping the Heparin intermittently and for a significant period of time on a patient who is having q6hr labs drawn to monitor it could lead to unnecessary upward and downward titration of the drip to compensate for the interruptions in the infusion. I wouldn't consider this an egregious error--the titration will compensate for it, after all--but with every upward titration you run the risk of excessive anticoagulation and therefore increase the risk of bleeding.

On a final note, I have seen similar things in my facility. I followed up a nurse who had been stopping and flushing a peripheral Heparin drip briefly in order to push morphine at intervals. She had even indicated on the MARs a friendly little reminder to other nurses that heparin/morphine are not compatible, which actually they are. Rather than point out to her that she was 'wrong,' I showed her the compatibility information and mentioned that I was going to change the MARs so that everyone could save some time on the procedure. 'Nuff said. She could continue to stop the drip and flush the line, for all I care.

As a student, I'd say that unless you see something that blatantly jeopardizes a patient, do just what you did: ask some questions, learn from it, and base your own practice on what you've learned.

[jojotoo, RN]

Yeah; the prophylactic dosage I've seen is usually 40mg. For patients with DVT's it's 1mg/kg. I can't remember the last time I saw heparin used for DVT. (more often, it's been for stroke protocol)

IV Lovenox is now starting to be used for strokes, instead of heparin.

[EmmaG, RN]

IV Lovenox is now starting to be used for strokes, instead of heparin.

I saw that where I used to work before traveling; the last place I traveled was a neuro unit, and they still used the stroke protocol heparin drips. Haven't seen it used much elsewhere though.