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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