ANTICOAGULATION TREATMENT

Page by: E.J. Mayeaux, Jr., M.D.
Louisiana State University Medical Center Shreveport, Louisiana

General Treatment with Heparin

1. Baseline Study
2. Loading Dose 80U/Kg (Range = 5000-10,000U) Heparin IVPB
3. Follow immediately by constant IV infusion 1000-1500 units/hour or 18U/Kg/Hr not to exceed 1500U/Hr.
4. 4 hours later get PTT
5. Aim = 1 1/2 - 2 x control, or 15 - 30 sec over control.

• IF:
1. < 5 seconds above normal - reload with 10,000 units and increase transfusion rate by 200 units/hr.
2. 5-20 seconds above normal - reload at 5000 units (1/2 dose) and increase transfusion rate by 100 units/hr.
3. 10-15 seconds above normal - increase infusion rate by 100 units/hr.
4. 15-30 seconds above normal - maintain at same rate
5. > 30 seconds above normal -hold IV 1-1 1/2 hours (decrease PTT rise by 1/2) and restart infusion decrease by 200-300 units/hr.
• Recheck PTT in 4-6 hours!

• Notes:
1. Adjust dose according to PTT, continue until coag. rate as measured by PTT stabilizes within the desired range, then may extend interval between PTT's to 12 hours then 24 hours.
2. CBC with platelet count after 3 days of treatment and on the 7th day.

CONVERSION GUIDELINES

Heparin ---> Coumadin

Day 1 - Baseline PT ----> Begin (at 10 mg/day)

Day 2 - Draw PT ----> Give 10 mg Coumadin - if PT > 1 1/2 control or INR > 2.5 decrease by 5mg

Day 3 - Draw PT ----> Give 10 mg Coumadin - if PT > 1 1/2 control or INR > 2.5 decrease by 2.5 mg

Day 4 - Draw PT ----> Give 5mg Coumadin - if PT > 2 x control or INR > 3 decrease by 1-2 mg

Day 5 - Draw PT ----> Give 5 mg if PT > 2 x control or INR > 3 decrease 1-2 mg

Day 6 and on: Draw PT

Once a stable PT of 1 1/2 - 2 x control or INR of 2 to 3 is established, PT's may be obtained every 2 weeks, then 3 weeks, then monthly.

Notes:

1. Baseline PT taken on day 1 (after 4-5 days of Heparin) is necessary to ID a patient who is debilitated or malnourished and who as a result may have low clotting factors and prolonged PT. This patient may be sensitive to effects of Coumadin.
2. Before 2nd dose, have PT drawn to check for sensitivity.

ALTERNATIVE CONVERSIONS

Start Coumadin 15 mg/day. When PT starts to move out, give 2.5 (times number of days to move out) for daily dose.

Minidose Heparin

5000 units SQ Bid