Stopping heparin infusion during dialysis due to hypertension

[Titanium888]

Here's the scenario: Patient's vitals signs pre-dialysis was fine and normotensive. So, charted bolus heparin was given. Upon putting the pt on the machine, BP was still normotensive so heparin infusion was started. After 2 hrs, patient's BP went to 200/180, asymptomatic, relaxed. Pt was known to have hypertension during dialysis always. I am fairly new to hemodialysis compared to the techs and nurses in my unit who are in this field for more than 7 years. Now there are 2 school of thoughts in our unit. The first (the one I was trained in) believes that stopping/clamping the heparin infusion of the hypertensive patient during dialysis will benefit the pt. It is to prevent cerebral hemorrhage in case the pt will have stroke. The second believes that since bolus has been given, there's no point of stopping the heparin infusion since it's already in the plasma regardless of the half life.

I cannot find a protocol in our unit. But if we follw the right intervention based on rationale, which do you think is right?

How about your practice or protocol in your unit. Replies in this topic is much appreciated.

[LiverpoolJane]

First of all I would re-check that BP with a manual sphyg as I personally have never seen a BP like that. If the dyastolic was indeed that high I would be getting him urgent medical attention, I have had pts whos' BP increases during HD and they have had anti-hypertensives pre HD and that has sorted the problem.

However to answer the question of giving heparin with HTN per say - I have worked in renal since 1992 and I must admit have not seen a protocol on omitting in HTN. You don't say if the patient completed HD without the circuit clotting, if he / she completed HD without problems I would use this info as a guide for reducing the heparin dose future sessions. You could try doing heparin free / minimal heparin if you are worried in the future and again there is probably little in the way of guidance on this. The way I have done it in the past is by regular saline flushes - about 100 - 200mls of saline every half to one hour, checking for any signs of clotting when the saline clears the circuit. Of course you have then got to account for this in the total UF. At my last place of work we had a way of measuring the activated clotting times and would use this to allow minimal heparinisation.

I wouldn't continue with the heparin if I was concerned, it has a half life of between 20 - 60 mins so there would be every point in omitting further bolus or stopping the infusion.

[madwife2002, BSN, RN]

In acute care we rarely use heparin but we do have lots of problems with the system clotting off. I do flush the system every 15 mins with 50 mls N/S. I am now trying 100mls q 30 mins but still have problems with clotting. The doctors are really adverse to heparin even with the chronic people. i would love to read all research on this

[LiverpoolJane]

In acute care we rarely use heparin but we do have lots of problems with the system clotting off. I do flush the system every 15 mins with 50 mls N/S. I am now trying 100mls q 30 mins but still have problems with clotting. The doctors are really adverse to heparin even with the chronic people. i would love to read all research on this

Kay, the only real success I have had doing heparin free HD was by using the AN69 dialyser but they are more expensive. In my last place I was able to get "approval" to use them, the doctors (as you say) will just come along and state they want the therapy heparin free, with no consideration of the problems. I was able to do this by adding up the cost of the packs we threw, sometimes two in a session, not to mention the impact on the patients HB. It works out cheaper using the more expensive AN69 than 2 - 3 cheaper ones. The powers that be of course just won't get it in most cases.

I was going to do heparin free RRT for my dissertation but thinking of looking at prescribing acute RRT instead as there is a complete lack of best practice guidelines on this. I know ADQI are looking at this but at the moment they are looking at continuous ITU CVVHD/F, not intermittant.

Anyway, watch this space.:)

[Lacie, BSN, RN]

As a previous poster stated check the b/p manually to ensure as I agree that b/p doesnt appear an accurate reading. We never cut our heparin off due to b/p but if hypertension continues in lieu of fluid removal we have standing orders for Clonidine which we can give up to 2x's during tx if needed. I have had pts b/p increase on dialysis due to the stress it has on the body but they tend to level out once we increase the uf. If anything I would turn off the sodium if on then recheck. I have never heard of heparin being turned off due to b/p.