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Heparin (unfractionated) Nursing Considerations | Bioavailable

Compound database
Heparins
Heparin (unfractionated)

Heparin (unfractionated)Nursing considerations

Known brand names include No current brand name; marketed as generic heparin sodium injection.

An injectable blood thinner given IV or under the skin, mostly in the hospital. It prevents and treats blood clots and works within minutes when given IV.

Nursing implications

Hold parameters

Stop if platelets fall below 100,000/mm³ or new thrombosis develops, and evaluate for HIT
Stop promptly if coagulation tests are excessively prolonged or bleeding occurs
Investigate an unexplained drop in hematocrit or blood pressure for hidden bleeding
Do not give with a history of HIT
Avoid after andexanet alfa

Sources: [1][2][3][4][5][6]

Administration

High-alert: confirm the vial strength every time. Vials range up to 10,000 units/mL, and mix-ups with catheter lock flush products have been fatal
Routes: intermittent IV, continuous IV infusion, or deep subcutaneous injection into fat above the iliac crest or abdomen, using a 25- to 26-gauge needle. Never IM
Use a different subcutaneous site each time to prevent hematoma
After adding to an IV bag, invert it at least 6 times so heparin does not pool
Use preservative-free heparin in neonates and infants
Incompatible in solution with several drugs, including alteplase, gentamicin, tobramycin, and ciprofloxacin

Sources: [1][2][3][4][5]

Assess and report

Side effects by what to assess

Bleeding

Bleeding and bruising
Major or fatal hemorrhage, including adrenal and retroperitoneal bleeding (serious)

Labs

Thrombocytopenia (reported up to 30%), usually 2 to 20 days after starting
HIT and HIT with thrombosis (DVT, PE, stroke, limb gangrene), possibly weeks after stopping (serious)
Hyperkalemia from aldosterone suppression (serious)

Skin and allergy

Injection site irritation; skin necrosis at subcutaneous sites
Generalized hypersensitivity (serious)

Liver

Elevated liver enzymes

Respiratory

Gasping syndrome in neonates from benzyl alcohol preservative (serious)

Sources: [1][2][3][4][5][6]

Labs and vitals

aPTT (partial thromboplastin time)

Why: Therapeutic anticoagulation with full-dose heparin
When: Baseline, then about every 4 hours when starting an infusion; before each intermittent IV dose at first; 4 to 6 hours after a subcutaneous dose
Act on: Target 1.5 to 2 times normal. Stop if excessively prolonged or bleeding occurs
Normal: 25 to 35 seconds when not on a blood thinner.

Sources: [1][2][3]

INR (prothrombin time)

Why: Baseline coagulation and warfarin overlap
When: Baseline; during warfarin overlap, at least 5 hours after the last IV dose or 24 hours after a subcutaneous dose
Act on: Stop heparin once INR is stable in range on warfarin
Normal: INR 0.8 to 1.1 when not on a blood thinner. On warfarin, the usual target is 2.0 to 3.0.

Sources: [1][2][3][4]

Platelet count

Why: Thrombocytopenia and HIT
When: Baseline and periodically throughout, with hematocrit and stool occult blood
Act on: Below 100,000/mm³ or new clots: stop heparin and evaluate for HIT
Normal: 150,000 to 400,000 per microliter.

Sources: [1][2][3]

Potassium

Why: Hyperkalemia
When: Before starting in at-risk patients; periodically in anyone treated more than 5 days
Normal: 3.7 to 5.2 mEq/L.

Sources: [1][2]

Safety

High-alert status

High-alert medication. Unfractionated heparin is named on the ISMP acute care high-alert list under anticoagulants.

Sources: [1]

Narrow therapeutic index

The label does not describe a narrow therapeutic index or direct dosing by measured blood levels of the drug.

Sources: [1]

Boxed warning

None on the current label. Fatal medication errors from vial strength mix-ups are a labeled warning.

Sources: [1]

Antidote or reversal

Protamine sulfate. About 1 mg neutralizes 100 units of heparin; give by slow infusion, no more than 50 mg in any 10 minutes. Less is needed as time passes because heparin is cleared quickly. Protamine can cause anaphylaxis-like reactions, so have resuscitation ready.

Sources: [1]

Patient teaching

Bleeding may take longer to stop, and bruising is easier; report unusual bleeding or bruising
Tell physicians and dentists before any surgery
HIT can appear up to several weeks after heparin stops; report new clots or symptoms
Report allergic reactions or skin changes at injection sites
Do not take aspirin, NSAIDs, or other drugs that affect bleeding without approval

Sources: [1]

Sound-alike and look-alike names

heparin and Hespan

Sources: [1]

Dosing

Doses come from the FDA label. Study tool, not for clinical decisions.

Adult dose

Full-dose, continuous IV: 5,000 units IV bolus, then 20,000 to 40,000 units per 24 hours, adjusted by aPTT. Label doses assume a 68 kg patient.
Full-dose, intermittent IV: 10,000 units, then 5,000 to 10,000 units every 4 to 6 hours.
Full-dose, deep subcutaneous: 333 units/kg, then 250 units/kg every 12 hours.
Postoperative VTE prophylaxis: 5,000 units subcutaneously 2 hours before surgery, then every 8 to 12 hours for 7 days or until fully ambulatory.
Open-heart surgery and dialysis: Total body perfusion: at least 150 units/kg. Dialysis: 25 to 30 units/kg, then 1,500 to 2,000 units/hour if no device guidance.

Sources: [1][2][3][4]

Renal adjustment

No fixed renal dose change; titrate by coagulation tests. Severe renal disease raises bleeding risk, and chronic renal failure raises hyperkalemia risk.

Sources: [1][2]

Hepatic adjustment

No fixed hepatic dose change; titrate by coagulation tests. Liver disease with impaired hemostasis raises bleeding risk.

Sources: [1]

How it works

Mechanism

Binds antithrombin III and greatly speeds its inactivation of clotting factors, especially factor Xa and thrombin (IIa). It also blocks fibrin stabilization. It does not break down existing clots. IV half-life is about 30 minutes for reversal dosing.

Sources: [1][2]