Heparin drip nomogram for VTE

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University of Michigan Health System Anticoagulation Program

Guideline for Managing Unfractionated Heparin for Treatment of Venous Thromboembolism in Adult Patients Based upon Anti-Factor Xa Levels

Initial Dosing and Dosage Adjustments

Heparin should be dosed based upon actual body weight (kg): ____

1. Bolus doses (round to nearest 10 units) – Maximum bolus dose = 10,000 units

• Initial bolus dose 80 units/kg
• Other initial bolus: _______ units/kg
• No initial bolus
• No bolus EVER

2. Continuous infusion rate (round to nearest 10 units) – Maximum initial rate = 1,800 units/hour

• Initiate infusion at 18 units/kg/h
• Other initial infusion rate : _________ units/kg/h
• Non-weight based initial infusion rate : _________ units/h

3. Monitoring

• Draw INR/PT, CBC with platelet count and aPTT prior to starting heparin
• Draw STAT anti-factor Xa 6 hours after starting heparin
• Monitor anti-factor Xa and adjust per Weight-Adjusted Heparin Nomogram (target anti-factor Xa 0.3-0.7 units/mL)
• Platelet count should be monitored daily for a minimum of 2 weeks and hemoglobin/hematocrit at least weekly

 

Weight-Adjusted Heparin Nomogram

Anti-Xa (units/mL)	Repeat Heparin Bolus Dose	Hold Infusion (minutes)	Rate Change	Repeat Anti-Xa level
Less than 0.2*	80 units/kg†	0	Increase 1.5 units/kg/h	6 hours
0.2-0.29	40 units/kg†	0	Increase 1 units/kg/h	6 hours
0.3-0.7	None	0	No change	6 hours**
0.71-0.8	None	0	Decrease 1 units/kg/h	6 hours
0.81-0.99	None	30 min	Decrease 1.5 units/kg/h	6 hours
Greater than or equal to 1*	None	60 min	Decrease 3 units/kg/h	6 hours

*Notify physician if 2 consecutive Anti-Xa values are in this range

**When 2 consecutive Anti-Xa values are in therapeutic range (0.3-0.7 units/mL), obtain Anti-Xa assay the next morning and every 24 hours thereafter

 

† Please ensure physician has not selected “No bolus ever” option above