Heparin Weight Based Protocol - Patientsafetycouncil.org

Anticoagulation Orders (Therapeutic)
(Heparin Weight Based Protocol)
Patient Information Required
Instructions: Orders with boxes valid only if marked X. Orders with are activated unless a line is drawn
through the order and initialed.
Patient Weight: _________Kg Allergies:__________________________________________
Discontinue any previous anticoagulation orders [Heparin, Enoxaparin (LOVENOX®)]. Caution with use of
concurrent antiplatelet therapies – Aspirin, Clopidogrel (PLAVIX ), AGGRENOX , NSAIDs.
1. Unfractionated Heparin (Standard Concentration: Heparin 25,000 units/500 mL D5W)
Before starting heparin, obtain aPTT, CBC, patient weight. CBC every 3 days.
All calculations shall be made using actual patient body weight in kilograms (kg).
Use Heparin Dosing Nomogram below for all adjustments to infusions, regardless of indication for use
INITIAL DOSING
ACS/MI Starting Dose
A. Acute Coronary Syndrome/MI or Other: .
PT WT (Kg) Units/kg/hr
INITIAL BOLUS (Round to the nearest 500 units of heparin. Refer to BOLUS ≤ 87 Kg 12
dosing grid.)
88 – 95 Kg 11
96 – 105 Kg 10
Heparin 60 units/kg IV once (Initial bolus NOT TO EXCEED 5000 106 – 113 Kg 9
units, unless patient also receiving reteplase or alteplase, then
114 – 128 Kg 8
maximum initial bolus NOT TO EXCEED 4000 units)
129 – 146 Kg 7
147 – 170 Kg 6
Half Bolus: Heparin 30 units/kg IV once
171 – 205 Kg 5
No Bolus Dose
206 – 256 Kg 4
257 – 341 Kg 3
INITIAL INFUSION
DVT/PE/AFib Starting Dose
Heparin Continuous IV infusion. Refer to STARTING DOSE grid at
right (Starting dose 12 units/kg/hr not to exceed 1000 units/hr)
PT WT (Kg) Units/kg/hr
B. DVT/ PE/Atrial Fibrillation or Other: .
INITIAL BOLUS (Round to the nearest 500 units of heparin. Refer to BOLUS
dosing grid.)
Heparin 80 units/kg IV once (Initial bolus NOT TO EXCEED 10,000
units)
Half Bolus: Heparin 40 units/kg IV once
No Bolus Dose
≤ 126 Kg 18
127 – 133 Kg 17
134 – 142 kg 16
143 – 151 Kg 15
152 – 162 Kg 14
163 – 175 Kg 13
176 – 189 Kg 12
190 – 206 Kg 11
207 – 227 Kg 10
228 – 252 Kg 9
253 – 284 Kg 8
285 – 325 Kg 7
326 – 379 Kg 6
INITIAL INFUSION
Heparin Continuous IV infusion. Refer to STARTING DOSE grid at
right. (Starting dose 18 units/kg/hr not to exceed 2250 units/hr)
MAINTENANCE INFUSION: Use Heparin Dosing Nomogram below for all treatment indications
Alternative choice for aPTT result ≤ 64 give: No Bolus Dose or Bolus dose ____units/kg IV
Heparin Dosing Nomogram
aPTT Result (seconds) Adjustment Repeat aPTT Draw
≤ 50 Bolus with 80 units/kg IV AND increase infusion by 4 units/kg/hr 6 hours
51 -64 Bolus with 40 units/kg IV AND increase infusion by 2 units/kg/hr 6 hours
65 – 95 No change (Therapeutic Range) Next AM
96 - 105 Decrease infusion by 2 units/kg/hr 6 hours
106 - 130 Hold infusion for 30 minutes AND decrease infusion by 3 units/kg/hr 6 hours
131 - 160 Hold infusion for 60 minutes AND decrease infusion by 3 units/kg/hr 6 hours
≥ 160 Hold infusion for 60 minutes AND decrease infusion by 4 units/kg/hr 6 hours
Physician Signature Date/Time Transcriber Signature Date/Time Nurse Signature Date/Time
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M-ANTICOAG, C-ANTICOAG (October, 10) Page 1 of 4

Anticoagulation Orders (Therapeutic)
(Heparin Weight Based Protocol)
Patient Information Required
2. Warfarin (Coumadin):
Daily warfarin orders to be written by physician or clinical pharmacist
Obtain baseline INR, CBC, CMP before initiation. Daily morning PT / INR. CBC every 3 days.
INR Goal 2-3 or ___________
Nutrition consult
Warfarin (COUMADIN ® )__________ mg PO today at 1700
Physician Signature Date/Time Transcriber Signature Date/Time Nurse Signature Date/Time
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M-ANTICOAG, C-ANTICOAG (October, 10) Page 2 of 4

Anticoagulation Orders (Therapeutic)
(Heparin Weight Based Protocol)
Patient Information Required
NURSING FLOW SHEET - Scan flow sheet to pharmacy for Heparin boluses needed
Place form in physicians order section of the chart with the pre-formatted orders
Bolus doses will be rounded to the nearest 500 units of Heparin (Refer to BOLUS grid)
Initial Patient Weight: _________Kg
Baseline Lab Results (must be within the last 24 hrs.):
aPTT: ______ H/H: __________ Platelets: _______
Notify physician if aPTT ≥ 50 seconds on initiation or if platelets drop by more than 50% from baseline or drop
to

Anticoagulation Orders
(Therapeutic)
WEIGHT BASED HEPARIN
BOLUS GRID
Use the Heparin Dosing Nomogram for guidance on
which weight-based dose to use.
Round to the nearest 500 units of heparin.
PT WT
(Kg)
80 Units/Kg
(units)
60 Units/Kg
(units)
40 Units/Kg
(units)
PT WT
(Kg)
80 Units/Kg
(units)
60 Units/Kg
(units)
40 Units/Kg
(units)
45 Kg 3,500 2,500 2,000 86 Kg 7,000 5,000* 3,500
46 Kg 3,500 3,000 2,000 87 Kg 7,000 5,000* 3,500
47 Kg 4,000 3,000 2,000 88 Kg 7,000 5,000* 3,500
48 Kg 4,000 3,000 2,000 89 Kg 7,000 5,000* 3,500
49 Kg 4,000 3,000 2,000 90 Kg 7,000 5,000* 3,500
50 Kg 4,000 3,000 2,000 91 Kg 7,500 5,000* 3,500
51 Kg 4,000 3,000 2,000 92 Kg 7,500 5,000* 3,500
52 Kg 4,000 3,000 2,000 93 Kg 7,500 5,000* 4,000
53 Kg 4,000 3,000 2,000 94 Kg 7,500 5,000* 4,000
54 Kg 4,500 3,000 2,000 95 Kg 7,500 5,000* 4,000
55 Kg 4,500 3,500 2,000 96 Kg 7,500 5,000* 4,000
56 Kg 4,500 3,500 2,500 97 Kg 8,000 5,000* 4,000
57 Kg 4,500 3,500 2,500 98 Kg 8,000 5,000* 4,000
58 Kg 4,500 3,500 2,500 99 Kg 8,000 5,000* 4,000
59 Kg 4,500 3,500 2,500 100 Kg 8,000 5,000* 4,000
60 Kg 5,000 3,500 2,500 101 Kg 8,000 5,000* 4,000
61 Kg 5,000 3,500 2,500 102 Kg 8,000 5,000* 4,000
62 Kg 5,000 3,500 2,500 103 Kg 8,000 5,000* 4,000
63 Kg 5,000 4,000 2,500 104 Kg 8,500 5,000* 4,000
64 Kg 5,000 4,000 2,500 105 Kg 8,500 5,000* 4,000
65 Kg 5,000 4,000 2,500 106 Kg 8,500 5,000* 4,000
66 Kg 5,500 4,000 2,500 107 Kg 8,500 5,000* 4,500
67 Kg 5,500 4,000 2,500 108 Kg 8,500 5,000* 4,500
68 Kg 5,500 4,000 2,500 109 Kg 8,500 5,000* 4,500
69 Kg 5,500 4,000 3,000 110 Kg 9,000 5,000* 4,500
70 Kg 5,500 4,000 3,000 111 Kg 9,000 5,000* 4,500
71 Kg 5,500 4,500* 3,000 112 Kg 9,000 5,000* 4,500
72 Kg 6,000 4,500* 3,000 113 Kg 9,000 5,000* 4,500
73 Kg 6,000 4,500* 3,000 114 Kg 9,000 5,000* 4,500
74 Kg 6,000 4,500* 3,000 115 Kg 9,000 5,000* 4,500
75 Kg 6,000 4,500* 3,000 116 Kg 9,500 5,000* 4,500
76 Kg 6,000 4,500* 3,000 117 Kg 9,500 5,000* 4,500
77 Kg 6,000 4,500* 3,000 118 Kg 9,500 5,000* 4,500
78 Kg 6,500 4,500* 3,000 119 Kg 9,500 5,000* 4,500
79 Kg 6,500 4,500* 3,000 120 Kg 9,500 5,000* 5,000
80 Kg 6,500 5,000* 3,000 121 Kg 10,000 5,000* 5,000
81 Kg 6,500 5,000* 3,500 122 Kg 10,000 5,000* 5,000
82 Kg 6,500 5,000* 3,500 123 Kg 10,000 5,000* 5,000
83 Kg 6,500 5,000* 3,500 124 Kg 10,000 5,000* 5,000
84 Kg 7,000 5,000* 3,500 ≥ 125 Kg 10,000 5,000* 5,000
85 Kg 7,000 5,000* 3,500
*Maximum initial bolus is 4,000 units for acute
coronary syndrome/MI if the patient is also receiving
reteplase or alteplase