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Trust Clinical Protocol Directorates of Nephrology and Pharmacy Protocol for anticoagulation of extracorporeal circuits during kidney replacement therapy or plasma exchange Author/Contact Document File Path John Sexton 2135 EQMS No. 4488 Document impact assessed Yes/No Version 2 Status Approved Publication Date January 2013 Review Date January 2015 Approved by (Executive) Peter Williams Date: Ratified by (Relevant Group) Clinical & Cost Effectiveness Group Date: Date: Distribution: Royal Liverpool and Broadgreen University Hospitals NHS Trust-intranet Please note that the Intranet version of this document is the only version that is maintained. Any printed copies must therefore be viewed as “uncontrolled” and as such, may not necessarily contain the latest updates and amendments. 1 Table of Contents Heading Page Number 1.0 Introduction 3 2.0 Objective 3 3.0 Scope of Protocol 3 4.0 Protocol 4 4.1 Patients undergoing routine haemodialysis (HD) or Haemodiafiltration (HDF) (tinzaparin) 4.1.1 HD/HDF more than three times a week 4.1.2 Monitoring and further management of HD/HDF patients 4.2 Patients undergoing haemofiltration (HF) (Standard Unfractionated Heparin) 4.2.1 Management of clots or bleeding in heparin patients 4.3 Minimal Unfractionated Heparin policy 4.4 Heparin-free therapy 4.5 Special circumstances 4.5.1 Patients with Heparin Induced Thrombocytopaenia 4.5.2 Patients having planned procedure/surgery 4.5.3 Patients having unplanned procedure/surgery 4.5.4 Patients on prophylactic anticoagulation 4.5.5 Patients on therapeutic anticoagulation 4 7 8 9 10 10 10 11 11 11 Roles and Responsibilities 11 5.1 Clinical Directorate of Nephrology 5.2 Pharmacy and Haematologists 5.3 Ward 6B and satellite dialysis units 5.4 All staff 11 11 11 12 6.0 References 12 7.0 Training and resources 12 8.0 Monitoring and audit 13 9.0 Equality and diversity 13 9.1 14 5.0 Recording and monitoring of Equality and Diversity Appendix – Quick reference guide Document history/version control 2 5 5 6 14 1.0 Introduction The purpose of this guideline is to provide guidance in managing anticoagulation of the extracorporeal circuit required by patients undergoing haemodialysis (HD), haemofiltration (HF), haemodiafiltration (HDF) or plasma exchange (PE). Clots in the dialysis membrane will reduce the efficacy of the therapy and if the whole circuit is clotted this will result in loss of blood. Chronic kidney disease (CKD) itself has also been documented to be a hypercoagulable state. The aim of therapy is to adequately anticoagulate the extracorporeal circuit without either under-treatment leading to clotting or loss of blood due to either clotting or bleeding. Anticoagulation should be tailored to the needs of patient, clinical condition and also the type of treatment the patients are receiving. The European Best Practice Guidelines 2002 (EBPG)1 recommend the use of Low Molecular weight Heparins (LMWH) over unfractionated heparin (UFH) Increasing numbers of clinical studies have confirmed that LMWH is an effective alternative to UFH with comparable efficacy and safety2,3,4,5. The most widely used LMWH is tinzaparin,6,7 offering various advantages over UFH: 1. Ease of use as it can be administered as a single fixed bolus dose, 2. Fewer bleeding episodes and thrombocytopenia, 3. Reduced thrombus formation, 4. Improved lipid profile, less hyperkalemia, 5. Greater patient and staff satisfaction, 6. Reduced staff time, drug and consumables costs8 7. Fewer calculations, dilutions, and error risks. 2.0 Objectives The objectives of this protocol are to assist the kidney unit at Royal Liverpool University Hospital Trust (RLBUHT) and its associated satellite dialysis units to: achieve adequate and safe anticoagulation of extracorporeal circuits guide health care workers in selecting the appropriate anticoagulation regime for a patient requiring therapies involving extracorporeal circuits ensure all patients receive anticoagulation in a consistent manner during therapies involving extracorporeal circuits 3.0 Scope of the Protocol This protocol applies to all patients who are receiving treatments involving extracorporeal circuits in the kidney unit at RLBUHT and its satellite dialysis units but should not replace clinical judgement. Interpretation and application of these guidelines will be the responsibility of the individual health care worker. If in doubt a senior colleague i.e. a Consultant Nephrologist or a senior Haematologist must be consulted. 3 4.0 Protocol 4.1 Patients undergoing routine haemodialysis (HD) or haemodiafiltration (HDF) up to three times a week - Tinzaparin Regime Tinzaparin is preferred as it comes in 3 strengths of pre-filled syringe, is more likely to be reversed by protamine (60-85%) compared with other LMWHs9 and has minimal accumulation of Anti-factor Xa activity in patients with kidney failure10. Recommended regime (Shorter than 3 hour sessions of HD/HDF) 1. Dialysis should be attempted without using LMWH. 2. If clots are observed then tinzaparin 2500 units should be used for future dialysis sessions. 3. If clots are still observed with a dose of 2500 units then use the policy as described below. Recommended regime (3-4 hours of HD/HDF): 1. The circuit is primed with normal saline, then 2,500 units of tinzaparin injected into the venous bubble at the start of dialysis 2. The extracorporeal circuit is observed for signs of clotting; if none then continue with the dose of 2,500 units for future sessions 3. If clots are observed in the circuit then 3,500 units of tinzaparin should be injected from the next session onwards, and the circuit observed for signs of clotting; if none then continue with the dose of 3,500 units for future sessions 4. If clots are observed in the circuit then 4,500 units of tinzaparin should be injected from the next session onwards, and the circuit observed for signs of clotting; if none then continue with the dose of 4,500 units for future sessions 5. If clots continue to be found in the circuit then a Consultant should be informed as a matter of urgency. Recommended regime (More than 4 hours of HD/HDF): 1. The circuit is primed with normal saline, then 3,500 units of tinzaparin injected into the venous bubble at the start of dialysis 2. The extracorporeal circuit is observed for signs of clotting; if none then continue with the dose of 3,500 units for future sessions 3. If clots are observed in the circuit then 4,500 units of tinzaparin should be injected from the next session onwards, and the circuit observed for signs of clotting; if none then continue with the dose of 4,500 units for future sessions. 4. If clots continue to be found in the circuit then a Consultant should be informed as a matter of urgency. 4 Clotting despite 4,500 units of tinzaparin (>3 hour sessions) The maximum dose of tinzaparin in the above schedule is 4,500 units. In the very rare situations where if there are still signs of clotting at this dose, two doses of tinzaparin 2,500 units can be used. The first dose of 2,500 units should be given at the start of dialysis, and the second after 2 hours. This strategy must be adopted only after discussion and/or on clear instruction from the Consultant of that patient. This agreement must be documented in the case notes and care records, and the patient’s consent noted. 4.1.1 Patients undergoing routine haemodialysis (HD) or haemodiafiltration (HDF) more than three times a week These patients can be initiated on tinzaparin 2,500units pre-HD/HDF. Further increases above this dose can be carried out as above but the problem of tinzaparin accumulation should be considered. Some patients may require the use of standard unfractionated heparin regimes (See Section 4.2). 4.1.2 Monitoring and further management of HD/HDF patients There are three main problems associated with anticoagulation of extra corporeal circuits; they are: clotting in the extra corporeal circuit prolonged bleeding development of Heparin Induced Thrombocytopenia (HIT) - see Section 4.5.1) Management of clots in the extra corporeal circuit: Signs of clotting in the extracorporeal circuit include: 1. Visible clots in the circuit or the membrane 2. Raised venous pressure 3. Reduced arterial pressure 4. Raised trans-membrane pressure (TMP) 5. Colour of blood darkens in the circuit Signs of clotting should be responded to by increasing the tinzaparin dose as detailed above, until a maximum of 4,500 units is reached, at which point the matter should be discussed with a Consultant. Management of prolonged bleeding: If bleeding persists at either the site of needling or any other site then because of the long half-life of tinzaparin, its effects need to be reversed. Protamine sulphate will neutralise up to 60-85% of the Antifactor Xa activity of tinzaparin. Protamine (1%) is supplied in 50mg in 5mL ampoules. Tinzaparin dose 2500 units 3500 units 4500 units 5000 units Protamine sulphate dose (mg) required 25 mg in 2.5 ml in 50mL of 0.9% saline/5% dextrose 35 mg in 3.5 ml in 50mL of 0.9% saline/5% dextrose 45 mg in 4.5 ml in 50mL of 0.9% saline/5% dextrose 50 mg in 5.0 ml in 50mL of 0.9% saline/5% dextrose 5 Protamine should be administered slowly, at NO MORE THAN 5mg/minute, observing for signs of hypotension, bradycardia or dyspnoea. The effect of protamine sulphate lasts for approximately 3 hours. If bleeding persists after 3 hours another dose of protamine may be given (contact Pharmacy for advice). Protamine should not be given to patients with known Protamine allergy or an allergy to fish or fish products. If bleeding still persists or the patient is allergic to protamine then the advice of the on-call Haematologist should be sought. At the next HD/HDF session: If patient was receiving 2,500 units, then dialyse with no anticoagulation If patient was receiving 3,500 units, then reduce the dose to 2,500 units o If patient was receiving 4,500 units, then reduce the dose to 3,500 units, continuing to monitor patients as usual. 4.2 Patients undergoing haemofiltration (HF)- Standard Unfractionated Heparin (UFH) Regime There are a paucity of data for use of tinzaparin in haemofiltration. In these patients UFH should be used, as described below. This regime is also suitable for patients who cannot be managed adequately on tinzaparin. Loading UFH dose: The circuit is primed with normal saline and an intravenous loading dose of heparin is given as shown: Dry Weight (Kg) Loading dose (units) Up to 45 Kg 46-55 Kg 56-65 Kg 66-75 Kg 76-85 Kg 86-95 Kg >96 Kg 1,000 units 1,500 units 2,000 units 2,500 units 3,000 units 3,500 units 4,000 units Volume (ml) of 1000 units/mL UFH 1 mL 1.5 mL 2 mL 2.5 mL 3 mL 3.5 mL 4 mL Maintenance UFH dose: 1. 5ml of 1,000 units/ml UFH is mixed with 15 ml of normal saline to produce a solution of 250 units/mL UFH 2. The extracorporeal procedure is started as well as the maintenance infusion at 6mL/hour (1,500 units UFH/hour). 3. The heparin infusion is stopped 1 hour before the end of the session. 4. Patients should be monitored for signs of clotting or bleeding; if no problems then the same dose can be continued for further sessions. 6 4.2.1 Management of clots or prolonged bleeding in UFH patients Management of clots in the extra corporeal circuit: If the patient develops any signs of clotting in the extracorporeal circuit then the activated clotting time (ACT) that forms the baseline value should be checked, and the infusion rate increased by increments of 500 units/hour (2ml/hour). An ACT target of 1.5 times the baseline value (not to exceed 220 seconds) should be aimed for, the circuit continued to be monitored for clotting, and if there is no clotting then this infusion rate can be documented and used in future sessions. Management of prolonged bleeding in patients receiving UFH: Prolonged bleeding at either the site of needling or any other site may require reversal of UFH effects, though often simple compression is sufficient because the half-life of UFH is short (30-120minutes). If bleeding does not stop then protamine can be used at a dose of 10mg for every 1000 units of UFH activity to be reversed, remembering that not all the UFH dose will require reversal. Protamine administration and monitoring is detailed in 4.1 above and Pharmacy can be contacted for advice. At the next HD/HDF/HF session: Check the access if stenosis is suspected, obtain senior advise and a Doppler scan Check ACT that forms the baseline value Use the same loading dose Reduce the infusion rate by increments of 500 units/hour (2ml/hour) Check ACT aim for a maximum of no more than 1.5 times the baseline If there is no bleeding after dialysis then document the dose to be used for future sessions 7 4.3 Minimal unfractionated UFH regimen Extracorporeal therapy in patients with Acute Kidney Injury (AKI) There are no studies published using tinzaparin in patients with AKI needing extracorporeal therapies. As most of these patients are ill and may need daily dialysis the recommendation is to use minimal UFH as described below. It is possible that depending on the clinical situation some patients may have to have their extracorporeal therapy with no UFH. See section 4.4 for details: the management plan must be discussed with either a Consultant or Specialist Registrar. Patients undergoing plasma exchange (PE) This form of therapy is typically used for (but not exclusively for): ANCA positive vasculitis with Lung and kidney involvement Anti-GBM disease Thrombotic Thrombocytopaenic Purpura Haemolytic Uraemic Syndrome Immune complex glomerulonephritis especially Kidney Transplant patients Multiple myeloma Because of the severity of these patients’ conditions, and associaterd coagulopathies, the choice of anticoagulation is again minimal UFH. Other situations requiring minimal UFH include: Patients having a planned operation within 12 hours Some patients on therapeutic warfarin The above list is to be used only as a guide and the reason for using minimal UFH policy must be documented in the patient’s care record. Dosing schedule for minimal UFH Clot formation during a session or bleeding may require dose adjustment as described or even heparin-free therapy. If the extra corporeal circuit clots during a session then the dose needs to be increased or if there’s excess bleeding then dose may have to be reduced. This should be discussed with the Consultant or the Specialist Registrar of the firm. Loading dose: The circuit is primed with normal saline and a minimal intravenous loading dose of heparin is given as shown: Dry Weight (Kg) Loading dose (units) Up to 45 Kg 46-55 Kg 56-65 Kg 66-75 Kg 76-85 Kg 86-95 Kg >96 Kg 500 units 750 units 1,000 units 1,250 units 1,500 units 1,750 units 2,000 units 8 Volume (ml) of 1000 units/mL UFH 0.5 mL 0.75 mL 1 mL 1.25 mL 1.5 mL 1.75 mL 2 mL Maintenance dose: 1) 5ml of 1,000 units/ml UFH is mixed with 15 ml of normal saline to produce a solution of 250 units/mL UFH 2) The extracorporeal procedure is started alongside the maintenance infusion at a rate depending on the patient’s dry weight: Up to 50 Kg = 500 units/hour UFH (2 ml/hour of infusion) 51 – 75 Kg = 750 units/hour UFH (3ml/hour of infusion) >76 Kg = 1,000 units/hour UFH (4ml/hour of infusion) 3) The heparin infusion is stopped 1 hour before session end. Patients should be monitored for signs of clotting or bleeding; if no problems then the same dose can be continued for further sessions If a patient receiving minimal UFH develops clots in the circuit then the infusion rate could be increased by 250 units(1ml)/hour. If there’s prolonged bleeding then the infusion rate could be reduced by 250 units(1ml)/hour. This change in management must be discussed with either the Consultant or the Specialist Registrar of that firm and documented. 4.4 Heparin-free extra-corporeal therapy No anticoagulation may be required in situations such as: 1. Post surgery or recent invasive procedures like kidney biopsy 2. Active bleeding either GI tract or elsewhere 3. Intra-cerebral bleeding 4. Pericarditis 5. Therapeutic LMWH or warfarin 6. HIT 7. Short HD/HDF sessions (initial therapy) The reason for not using heparin must be documented in the patent’s care record. Procedure for heparin-free therapy: 1. The circuit should be primed with about 1L of normal saline and the extracorporeal therapy started 2. The circuit should be flushed with about 200mls of saline every hour, observing for clots in the system. If none are observed, then the hourly flushes can be continued. 3. If clots are seen, then the circuit can be flushed with 200mL of normal saline every 30 minutes. 4. The whole amount saline that was infused must be removed from patient as part of wash back by the end of the dialysis session. Another option for such a patient is the use of Nephral or Evodial kidneys. As they are coated with heparin the required amount of saline flushes will be either small or absent. All patients in this group must be reviewed regularly and a clear reason for continuing with no anticoagulation policy must be documented. If the indication for heparin-free therapy no longer applies then the patient should be put onto one of the regular regimes depending on their clinical condition. 9 4.5 Special circumstances 4.5.1 Patients with Heparin Induced Thrombocytopaenia (HIT) Any patient receiving LMWH or UFH is at risk of developing the rare but serious complication of HIT. FBC must be checked just prior to and weekly for 2 weeks when starting or changing an extracorporeal therapy. A drop of more than 50% in platelet count since the patient was started on UFH/LMWH is highly suggestive of HIT. HIT is a clinical diagnosis which may be supported by testing for antibodies to heparin-PF4 complex in conjunction with advice from a Haematologist. If HIT is suspected in a haemodialysis patient, heparin/LMWH exposure should be stopped immediately and further exposure avoided. At this point an appropriate alternative anticoagulant should be initiated. Diagnosis is confirmed if platelet counts recover after withdrawing heparin/LMWH. It should be borne in mind that unexpected clotting of the dialyser circuit, or thrombotic occlusion of arterio-venous fistula/grafting despite optimal dosing of heparin/LMWH may also indicate the development of HIT.11 The platelet count should be measured immediately to exclude this bearing in mind that HIT is defined by a 50% drop in platelet count which may mean that the new result is not <150x109/L .12 The various options to anticoagulate a patient with HIT are as mentioned below, pharmacy can supply details of how individual drugs are used. Extracorporeal therapy without the use of heparin formulations . Epoprostenol (prostacycline) (Flolan Danaparoid Argatroban Further advice can be obtained from Pharmacy. 4.5.2 Patients having planned procedure/surgery Any patient who is receiving extra corporeal therapy must have their regular therapy performed with the usual dose of anticoagulation at least 12 hours prior. If the last dose of anticoagulation (even with tinzaparin) is more than 12 hours previously, then the risk of excessive bleeding with a planned procedure is extremely rare. In view of this patients should receive their usual anticoagulation. If for some unforeseen reason the extra corporeal therapy has to be performed with in 12 hours of the planned procedure then either minimal UFH (see section 4.3) or heparin-free therapy (see section 4.4) should be used. 10 4.5.3 Patients having unplanned procedure/surgery following a normal dialysis session There is no clear available guidance available in this situation. A pragmatic approach would depend on the type on anticoagulation used. If UFH was used for dialysis reversal can be performed using protamine and confirmed by checking the APTT. If LMWH was used most of the activity will be reversed by protamine but it may have to be confirmed by both APTT and Factor-Xa levels. Details of protamine use can be found in section 4.1.2. 4.5.4 In-patients on prophylactic anticoagulation In view of the multiple co-morbidities of dialysis patients most patients would qualify for Venous Thrombo-Embolism prophylaxis as recommended by NICE. There is no available evidence or guidance in such a situation. Logical guidance from haematology is: continue with normal anticoagulation on dialysis lower dose dalteparin (2500units) daily to be given on the ward in-patient team is responsible for ensuring dalteparin is prescribed appropriately. if there is prolonged bleeding then the dose of tinzaparin should be reduced, dalteparin withheld on dialysis days, or consideration given to the use of the minimal UFH regime. 4.5.5 Patients on Therapeutic anticoagulation If a dialysis patient in taking either long term warfarin, therapeutic dose of LMWH or intravenous therapeutic heparin, or a therapy such as dabigatran, then that patient initially should be dialysed with no anticoagulation but if the circuit is showing signs of clotting then patient could be dialysed with 2500 units of tinzaparin or minimal UFH. 5.0 Roles & Responsibilities 5.1 Clinical Director of Nephrology The Clinical Director ensures that the Consultant Nephrologists, junior staff, Ward 6B and satellite dialysis unit nursing staff operate this protocol and that adequate and safe systems are in place to ensure this. 5.2 Pharmacy and Haematologists Pharmacists and Haematologists assist the Nephrology Directorate by providing support as requested and ensuring that this protocol is updated at regular intervals. 5.3 Ward 6B and Satellite Dialysis Unit Nursing Staff Nursing staff on 6PDU work to this protocol and the patient Group Direction that accompanies it. Any circumstances that mean that the PGD is not-applicable require therapy to be formally prescribed by medical staff. 11 5.4 All staff All RLBUHT staff are required to manage anticoagulation for extracorporeal procedures in the Nephrology and Renal Transplant Directorates in accordance with this protocol. Consultant staff may deviate from it with appropriate justification. 6.0 References 1. European Renal Association. European Best Practice Guidelines Expert Group on Hemodialysis. SectionV. Chronic intermittent hemodialysis and prevention of clotting in the extracorporeal system. Nephrol Dail Transplant 2002;17(Supple. 7):63-71. 2. Bramham K, Varrier M, Asgari E, Makanjuola D. Comparison of Tinzaparin and unfractionated heparin as anticoagulation on haemodialysis: equal safety, efficacy and economical parity. Nephron Clin Pract 2008;110:c107-13 3. Lim W, Cook DJ, Crowther MA. Safety and efficacy of low molecular weight heparins for hemodialysis in patients with endstage renal failure: a meta-analysis of randomized trails. J Am Soc Nephrol 2004;15:3192-206. 4. Lord H, Jean N, Dumont M, Kassis J, Leblanc M. Comparison between tinzaparin and standard heparin for chronic hemodialysis in a Canadian centre. Am J Nephrol 2002;22:58-66 5. Beijering RJR, ten Cate H, Stevens P, Vanholder R, Van Dorp WT, van Olden RW, et al. Randomised long-term comparison of tinzaparin and dalteparin in haemodialysis. Clin Drug Invest 2003;23:85-97 6. Davenport A. low-molecular weight heparin for routine hemodialysis. Hemodial Int 2008;12(suppl. 2):S34-7. 7. Davenport A, Makanjoula D, Mitra S, Donovan K, Ball S, Pritchard N, Waldron M. Practical use of Low-molecular weight heparin in haemodialysis patients. 8. Audit at Arrowe Park Hospital (personal communication) 9. SPC Innohep, Leo Laboratories Limited, February 2008 10. Mahe I et al Tinzaparin and enoxaparin given at prophylactic dose for eight days in medical elderly patients with impaired renal function. Thromb Haemost 2007; 97: 581-586 11. Takefumi M and Wanaka K. Heparin-Induced Thrombocytopenia and Haemodialysis. J Blood Disord Transfus 2011, S2. 12. Dutt T and Schulz M. Heparin induced thrombocytopaenia- an overview for nephrologists. Clin Kidney J 2013; 6:563–567. 7.0 Training & Resources Junior medical and 6PDU nursing staff will need training in the operation of this policy. 12 8.0 Monitoring and Audit No audit is needed but incidences of bleeding, clotting, or need to go outside the protocol should be reported to a Consultant. Any unusual problems should be notified to the Clinical Director of Nephrology or his assigned deputy, or raised at the monthly clinical governance meeting. 9.0 Equality and Diversity Trust is committed to an environment that promotes equality and embraces diversity in its performance as an employer and service provider. It will adhere to legal and performance requirements and will mainstream equality and diversity principles through its policies, procedures and processes. This policy should be implemented with due regard to this commitment. To ensure that the implementation of this policy does not have an adverse impact in response to the requirements of the Race Relations (Amendment Act) the Disability Discrimination Act 2005, and the Equality Act 2006 this policy has been screened for relevance during the policy development process and a full impact assessment conducted where necessary prior to consultation. The Trust will take remedial action when necessary to address any unexpected or unwarranted disparities and monitor practice to ensure that this policy is fairly implemented. This policy and procedure can be made available in alternative formats on request including large print, Braille, moon, audio, and different languages. To arrange this please refer to the Trust translation and interpretation policy in the first instance. The Trust will endeavour to make reasonable adjustments to accommodate any employee/patient with particular equality and diversity requirements in implementing this policy and procedure. This may include accessibility of meeting/appointment venues, providing translation, arranging an interpreter to attend appointments/meetings, extending policy timeframes to enable translation to be undertaken, or assistance with formulating any written statements. 9.1 Recording and Monitoring of Equality & Diversity The Trust understands the business case for equality and diversity and will make sure that this is translated into practice. Accordingly, all policies and procedures will be monitored to ensure their effectiveness. Monitoring information will be collated, analysed and published on an annual basis as part of our Single Equality and Human Rights scheme. The monitoring will cover all strands of equality legislation and will meet 13 statutory employment duties under race, gender and disability. Where adverse impact is identified through the monitoring process the Trust will investigate and take corrective action to mitigate and prevent any negative impact. The information collected for monitoring and reporting purposes will be treated as confidential and it will not be used for any other purpose. .Document History Version Date 0.1 29/3/11 0.2 1 2 26/5/11 7/6/11 10/1/13 3 19/11/13 Comments Released from Directorate to MMG Revision by Pharmacy Comments from Dr Martlew Revison with comments from Dr Martlew and Anijeet Suggestions from Dr Dutt at MMG Author H Anijeet J Sexton H Anijeet/J Sexton J Sexton J Sexton Review Process Prior to Ratification: Name of Group/Department/Specialist Committee Internal consultation on revision Medicines Management Group Clinical & Cost Effectiveness Group 14 Date Autumn 2014 15/11/13 Summary of the anticoagulation of extracorporeal circuits Directorate of Nephrology (2014) C=CLOTTING START HD/HDF TINZAPARIN REGIME < 3 hours up to 3 x week NO TINZAPARIN 3-4 hours up to 3 x week C TINZAPARIN 2,500u TINZAPARIN 2,500u C C >4 hours up to 3 x week HD/HDF > 3 x WEEKLY TINZAPARIN 3,500u TINZAPARIN 3,500u TINZAPARIN 3,500u TINZAPARIN 2,500u C C C C TINZAPARIN 4,500u TINZAPARIN 4,500u TINZAPARIN 4,500u C C C CLOTS: DISCUSS WITH CONS Consider 2 x 2,500u doses 2 hours apart DISCUSS WITH CONS Prolonged Bleeding: apply pressure, PROTAMINE (See policy), step down dose at next session START HF HEPARIN UFH REGIME MINIMAL UFH REGIME SEE POLICY FOR USES HEPARIN FREE HEPARIN (UFH) LOADING DOSE 1,000-4,000 units (1-4mL of 1000u/mL) according to weight HEPARIN (UFH) LOADING DOSE 500-2,000 units (0.5-2mL of 1000u/mL) according to weight HEPARIN (UFH) 5mL of 1000u/mL made up to THEN 20mL with saline (=250units/mL) N MAINTENANCE DOSE until 1 hr before end of session 6mL(1,500units)/hour C CLOTS: Exclude HIT, check baseline ACT, (aim for 1.5 x baseline, not exceeding 220seconds): then INCREASE MAINTENANCE DOSE by 500u (2mL)/hour BLEEDS: Check baseline ACT, (aim for 1.5 x baseline, not exceeding 220seconds): then pressure, PROTAMINE (See policy), REDUCE MAINTENANCE DOSE by 500u (2mL)/hour HEPARIN (UFH) 5mL of 1000u/mL made up to THEN 20mL with saline (=250units/mL) MAINTENANCE DOSE until 1 hr before end of session 2mL(500units)/hour (<50kg) 3mL(750units)/hour (51-75kg) 4mL(1,000units)/hour (>75kg) C CLOTS: Exclude HIT, discuss with Consultant; possibly CONSIDER INCREASING MAINTENANCE DOSE by 250units(1mL)/hour from next session C SALINE PRIME, HOURLY 200mL FLUSH 15 BLEEDS: Discuss with Consultant; possibly pressure, PROTAMINE (See policy), CONSIDER REDUCING MAINTENANCE DOSE by 250u (1mL)/hour FLUSH every 30 minutes REMOVE EXTRA FLUID ON MACHINE Loading doses of unfractionated heparin (using 1,000u/mL UFH) Dry Weight <45kg 46-55kg 56-65kg 66-75kg 76-85kg 86-95kg >96kg Normal UFH Regime Minimal UFH Regime 1,000units (1mL) 500units (0.5mL) 1,500units (1.5mL) 750units (0.75mL) 2,000units (2mL) 1,000units (1mL) 2,500units (2.5mL) 1,250units (1.25mL) 3,000units (3.0mL) 1,500units (1.5mL) 3,500units (3.5mL) 1,750 units (1.75mL) 4,000units (4mL) 2,000units (2mL) Protamine rescue doses (if needed) add required dose to 50mL of saline or dextrose administer at MAXIMUM 5mg/min watch patient for allergic reactions Anticoagulant dose 2,500units tinzaparin 3,500units tinzaparin 4,500units tinzapatin 5,000units tinzaparin Unfractionated heparin Protamine rescue dose (diluted to 50mL) 25mg (2.5mL) 35mg (3.5mL) 45mg (4.5mL) 50mg (5.0mL) GIVE 10mg for every 1,000units of heparin to be reversed; this will not be the full session UFH dose due to the short half-life of UFH