Cardiac Heparin Order Set

Mount Auburn Hospital
Cardiac Protocol
Heparin Weight Based Protocol
Physician Orders
STAMP PATIENT PLATE HERE
1. Heparin IV
IV Bolus per chart
units
Medication Orders
Weight
41 - 50 kg
51 - 60 kg
61 - 70 kg
> 70 kg
Bolus Dosing Parameters
Bolus Dose
(70 units/kg)
3,200 units
3,900 units
4,600 units
5,000 units
Required Information
(Physician must complete all blank spaces)
1. Review contraindications on reverse of form
2. Check the medications taken by this patient
that, in combination with heparin may increase
risk of bleeding:
None
Salicylates (i.e., aspirin, trilisate)
Platelet aggregation inhibitors (i.e., ticlopidine)
NSAIDS (i.e., ibuprofen, naprosyn)
Other agents (i.e., dipyridamole)
2. Begin Heparin infusion
Initial Infusion Rate
3. Indication:
Infuse per chart at:
units/hour
Weight
Infusion Rate
(15 units/Kg/hour)
Infusion Rate
in mL/hour
(see indications on reversed side)
41 - 50 kg
700 units/hour
7 mL/hour
4. Calculations according to weight:
Note: Concentration 100 units/mL
51 - 60 kg
800 units/hour
8 mL/hour
Kg (actual)
Kg (estimated)
> 61 kg
1,000 units/hour
10 mL/hour
5. Baseline PTT: (must be entered)
6. PT, PTT, and CBC stat (draw prior to bolus
dose) and Daily CBC.
7. Stat PTT 6 hours after heparin bolus.
CARDIAC PROTOCOL
NOMOGRAM FOR PTT GOAL OF 50 -80 SEC
8. Draw Stat PTT’s and adjust dosage based
on Adjustment Chart.
PTT
(Second)
< 40
40 – 49
50 – 80
81 – 95
96 – 110
111 – 149
Bolus
Unit
5000
0
0
0
0
0
Hold
min
0
0
0
0
30
60
Rate Change
(units/hr)
+ 200 units/hour
+ 100 units/hour
0
- 50 units/hour
- 100 units/hour
- 200 units/hour
CRITICAL TEST RESULT RESPONSE
Next Draw
Repeat PTT
6 hours
6 hours
Next AM
12 hours
6 hours
6 hours
9. Notify MD for PTT 110 or any signs of
bleeding.
10. If PTT is between 50-80 it may be drawn the
next AM.
Physician Signature:
≥ 150
0
HOLD
infusion.
STAT PTT
in 1 hour.
HOLD
Infusion
until PTT
back.
If PTT still
> 150 continue
to hold infusion.
Recheck PTT
in 1 hour.
Once PTT < 150,
restart infusion
at –200 units/hr
1 hour
6 hours
Print Name:
Beeper Number:
Date:
Time:
MD
FORM 533-DMR, Rev. 4/15/11, MAH
FAX Completed Form to Pharmacy

Indications
Contraindications
1. Suspected myocardial infarction 1. Thrombocytopenia or other blood dyscrasias
2. Unstable angina 2. Recent (within 14 days) major surgical procedure
3. Atrial fibrillation 3. Active or recent GI bleed or active peptic ulcer
4. Intracardiac thrombus 4. Prophylactic anticoagulation prior to any major orthopedic
surgery/procedure
5. Anticoagulation for a thromboembolic CNS event, CVA
6. Possible brain metastases in patient with pre-existing CA
7. Abnormal baseline PTT (> than 36 seconds)
Conversion of Pounds to Kilograms
Pounds
Kilograms
60
27.21
61
27.66
62
28.22
63
28.57
64
29.03
65
29.48
66
29.93
67
30.39
68
30.84
69
31.29
Pounds
Kilograms
70
31.75
71
32.2
72
32.65
73
33.11
74
33.56
75
34.02
76
34.47
77
34.92
78
35.38
79
35.83
Pounds
Kilograms
80
36.28
81
36.74
82
37.19
83
37.64
84
38.1
85
38.55
86
39
87
39.46
88
39.93
89
40.37
Pounds
Kilograms
90
40.82
91
41.27
92
41.73
93
42.18
94
42.63
95
43.09
96
43.54
97
43.99
98
44.45
99
44.9
Pounds
Kilograms
100
45.36
101
45.81
102
46.26
103
46.72
104
47.17
105
47.62
106
48.08
107
48.53
108
48.98
109
49.44
Pounds
Kilograms
110
49.89
111
50.34
112
50.8
113
51.25
114
51.71
115
52.16
116
52.61
117
53.07
118
53.52
119
53.97
Pounds
Kilograms
120
54.43
121
54.88
122
55.33
123
55.79
124
56.24
125
56.7
126
57.15
127
57.6
128
58.06
129
58.51
Pounds
Kilograms
130
58.96
131
59.42
132
59.87
133
60.32
134
60.78
135
61.23
136
61.68
137
62.14
138
62.59
139
63.05
Pounds
Kilograms
140
63.5
141
63.95
142
64.41
143
64.86
144
65.31
145
65.77
146
66.22
147
66.67
148
67.13
149
67.58
Pounds
Kilograms
150
68.04
151
68.49
152
68.94
153
69.4
154
69.85
155
70.3
156
70.76
157
71.21
158
71.66
159
72.12
Pounds
Kilograms
160
72.57
161
73.02
162
73.48
163
73.93
164
74.39
165
74.84
166
75.29
167
75.75
168
76.2
169
76.65
Pounds
Kilograms
170
77.11
171
77.56
172
78.01
173
78.47
174
78.92
175
79.38
176
79.83
177
80.28
178
80.74
179
81.19
Pounds
Kilograms
180
81.64
181
82.1
182
82.55
183
83
184
83.46
185
83.91
186
84.36
187
84.82
188
85.27
189
85.73
Pounds
Kilograms
190
86.18
191
86.68
192
87.09
193
87.54
194
87.99
195
88.45
196
88.9
197
89.35
198
89.81
199
90.26
Pounds
Kilograms
200
90.72
201
91.17
202
91.62
203
92.08
204
92.53
205
92.98
206
93.44
207
93.89
208
94.34
209
94.8
Pounds
Kilograms
210
95.45
211
95.91
212
96.36
213
96.82
214
97.27
215
97.73
216
98.18
217
98.64
218
99.09
219
99.55
Pounds
Kilograms
220
100
221
100.45
222
100.91
223
101.36
224
101.82
225
102.27
226
102.73
227
103.18
228
103.64
229
104.09
Pounds
Kilograms
230
104.55
231
105
232
105.45
233
105.91
234
106.36
235
106.82
236
107.27
237
107.73
238
108.18
239
108.64
Pounds
Kilograms
240
109.09
241
109.55
242
110
243
110.45
244
110.91
245
111.36
246
111.82
247
112.27
248
112.73
249
113.18
Pounds
Kilograms
250
113.64
251
114.09
252
114.55
253
115
254
115.45
255
115.91
256
116.36
257
116.82
258
117.27
259
117.73

Baseline PTT_____________ Baseline PLT____________
Initial Bolus: Units
Date: Time:
Initial Infusion: Units/Hour
Date: Time:
Next PTT Due:
Date: Time:
Nurse Signature:
Co-Signature:
Status
Current
Heparin
Rate
Units/hour
PTT
Drawn
PTT
Value
Action
Time
Date: _________
Time: _________
AM/PM
_______ AM/PM
Date: _________
Time: _________
_______ AM/PM
AM/PM
Date: _________
Time: _________
_______ AM/PM
AM/PM
Date: _________
Time: _________
AM/PM
Date: _________
Time: _________
AM/PM
_______ AM/PM
_______ AM/PM
Date: _________
Time: _________
AM/PM
Date: _________
Time: _________
AM/PM
Form 533(a)-DMR, Rev. 2/06, MAH
_______ AM/PM
_______ AM/PM
PTT
(Second)
< 40
40 – 49
50 – 80
81 – 95
96 – 110
110 – 149
CARDIAC PROTOCOL
NOMOGRAM FOR PTT GOAL OF 50 -80 SEC
Bolus
Unit
5000
0
0
0
0
0
Hold
min
0
0
0
0
30
60
Rate Change
(units/hr)
+ 200 units/hour
+ 100 units/hour
0
- 50 units/hour
- 100 units/hour
- 200 units/hour
CRITICAL TEST RESULT RESPONSE
HOLD
infusion.
STAT PTT
in 1 hour.
HOLD
Infusion
until PTT
back.
If PTT still
> 150 continue
to hold infusion.
Recheck PTT
in 1 hour.
Next Draw
Repeat PTT
6 hours
6 hours
Next AM
12 hours
6 hours
6 hours
> 150 0
1 hour
Once PTT < 150,
restart infusion
at –200 units/hr
6 hours
Next Draw
Bolus
(Units)
Hold
(min)
Rate
Change
(Units/hr)
New Rate
(Units/hr)
No Rate
Change
(Check Box)
Next PTT
Due
Date: _________
Time: _________
AM/PM
Date: _________
Time: _________
AM/PM
Date: _________
Time: _________
AM/PM
Date: _________
Time: _________
AM/PM
Date: _________
Time: _________
AM/PM
Date: _________
Time: _________
AM/PM
Date: _________
Time: _________
AM/PM
Ordered
Y/ N
STAMP PATIENT PLATE HERE
Nurse Signature/
Co-Signature