Initiation and Maintenance
This clinical pathway is not intended for patients on ECMO, cardiac bypass pump, hemodialysis or continuous renal replacement therapy. Refer to specific guidelines for these situations.
Initiation of therapy:
-
Obtain blood for CBC, PT, aPTT.
-
Loading heparin dose: 75-100 units/kg IV over 10 minutes.
-
Loading dose may not be indicated in certain clinical situations with increased bleeding risk.
-
-
Calculate initial maintenance heparin dose based on age and weight.
-
Initial maintenance dose:
≤ 1 year 28 units/kg/hour IV
> 1 year 20 units/kg/hour IV
-
-
Obtain blood for a standard heparin level.
-
Maintain the standard heparin level at 0.3-0.7.
-
Obtain aPTT once daily if using heparin levels.
-
Use heparin level to calibrate aPTT levels.
Table 1 - Heparin Adjustment*
|
Heparin Assay-Unfractionated |
Dose Adjustment |
Repeat Heparin Assay-Unfractionated |
|
Less than 0.2 units/mL |
Consider 50 units/kg bolus and increase infusion rate by 10% |
4 hours after rate change |
|
0.2-0.29 |
Increase infusion rate by 10% |
4 hours after rate change |
|
0.3-0.7 |
Infusion rate remains the same |
Next Day |
|
0.71-0.8 |
Decrease infusion rate by 10% |
4 hours after rate change |
|
0.81-0.99 |
Hold infusion for 30 minutes and decrease infusion rate by 10% |
4 hours after rate change |
|
Greater than or equal to 1 |
Hold infusion for 60 minutes and decrease infusion rate by 15% |
4 hours after rate change |
*Adapted from Table 3 of the Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (Monagle et al., 2012)
References
David, M., et al. (2007, Jan). Heparin and LMWH in Children. Thrombosis Interest Group of Canada. Retrieved Nov 15, 2018, from http://www.tigc.org/eguidelines/heparinchild07.htm.
Lexicomp Online, Pediatric and Neonatal Lexi-Drugs. Heparin. Retrieved Nov 2018, from https:online.lexi.com.
Monagle, P., Chan, A. K. C., Goldenberg, N. A., Ichord, R. N., Journeycake, J. M., Nowak-Göttl, U., & Vesely, S. K. (2012). Antithrombotic therapy in neonates and children: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest, 141(2 Suppl), e737S-e801S. https://doi.org/10.1378/chest.11-2308
Monagle, P., Cuello, C. A., Augustine, C., Bonduel, M., Brandão, L. R., Capman, T., Chan, A. K. C., Hanson, S., Male, C., Meerpohl, J., Newall, F., O'Brien, S. H., Raffini, L., van Ommen, H., Wiernikowski, J., Williams, S., Bhatt, M., Riva, J. J., Roldan, Y., . . . Vesely, S. K. (2018). American Society of Hematology 2018 Guidelines for management of venous thromboembolism: treatment of pediatric venous thromboembolism. Blood Adv, 2(22), 3292-3316. https://doi.org/10.1182/bloodadvances.2018024786
Roach, E. S., Golomb, M. R., Adams, R., Biller, J., Daniels, S., Deveber, G., Ferriero, D., Jones, B. V., Kirkham, F. J., Scott, R. M., & Smith, E. R. (2008). Management of stroke in infants and children: a scientific statement from a Special Writing Group of the American Heart Association Stroke Council and the Council on Cardiovascular Disease in the Young. Stroke, 39(9), 2644-2691. https://doi.org/10.1161/strokeaha.108.189696
These pathways do not establish a standard of care to be followed in every case. It is recognized that each case is different, and those individuals involved in providing health care are expected to use their judgment in determining what is in the best interests of the patient based on the circumstances existing at the time. It is impossible to anticipate all possible situations that may exist and to prepare a pathway for each. Accordingly, these pathways should guide care with the understanding that departures from them may be required at times.