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Maintenance and Monitoring

  • Once a therapeutic aPTT or heparin level is achieved obtain blood for CBC, PT, aPTT and/or heparin level at least daily.

  • Measure platelet counts daily. If platelet count decreases below 150,000/microL or drops by ≥ 50%, determine if the decrease in platelet count is related to the underlying disorder or is potentially due to heparin therapy. If likely due to heparin, discontinue heparin; initiate an alternative therapy and consult hematology. The risk for heparin-induced thrombocytopenia (HIT) is greater after 5 days of heparin.

  • Heparin therapy should be administered in an IV and must not be stopped or interrupted for any other medications. If the infusion is interrupted for more than 1 hour, re-establish the heparin maintenance infusion at the previous rate and obtain aPTT and heparin level 4-6 hours later. Once the aPTT level is available, adjust the infusion rate as indicated by Table 1.

  • Heparin should be discontinued 6 hours prior to any invasive procedures such as lumbar puncture or surgery unless the clinical situation requires an emergent intervention. For conditions necessitating more emergent intervention, utilize protamine as described in the section Heparin Antidote. Restart 12-24 hours after the procedure or surgery and when hemostasis has been achieved.

Table 1 - Heparin Adjustment

aPTT
(seconds)

Bolus
(units/kg)

Hold infusion
(minutes)

Rate change
(units/kg/hour)

Repeat PTT

< 50

50

0

↑10%

4 hours

50-59

0

0

↑ 10%

4 hours

60-85

0

0

No Change

24 hours

86-95

0

0

↓10%

4 hours

96-120

0

30

↓10%

4 hours

> 120

0

60

↓15%

4 hours

References:

David, M., et al. Heparin and LMWH in Children. Thrombosis Interest Group of Canada. January 2007. http://www.tigc.org/eguidelines/heparinchild07.htm. Accessed 11/15/08.

Lexi-Drugs Online/Pediatric Lexi-Drugs Online, Enoxaparin, http://online.lexi.com/crlsql/servlet/crlonline, Copyright © 1978-2008 Lexi-Comp, Inc, Hudson, OH 44236

Monagle P, Chan AKC, Goldenberg NA, Ichord RN, Journeycake JM, Nowak-Gottl U, Vesely SK. 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 2012; 141: e737S –e801S.

Roach ES. Golomb MR. Adams R. Biller J. Daniels S. Deveber G. Ferriero D. Jones BV. Kirkham FJ. Scott RM. Smith ER. American Heart Association Stroke Council. Council on Cardiovascular Disease in the Young. 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. [Journal Article] Stroke. 39(9):2644-91, 2008 Sep.

These guidelines 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 guidelines for each. Accordingly these guidelines should guide care with the understanding that departures from them may be required at times.