The Effectiveness of Implementing the Weight-Based Heparin Nomogram as a Practice Guideline

Raschke, Robert; Gollihare, Bea; Peirce, John C.

doi:10.1001/archinte.1996.00440140067006

Cited by 95 publications

(25 citation statements)

References 36 publications

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“…The proportion of patients achieving a therapeutic PTT within 24 hours is less, however, than the 77% to 99% proportion reported by a number of hospitals following the introduction of dosing nomograms. 8,10,[13][14][15][16] One other study showed that use of a nomogram allowed achievement of this goal in 66% of patients, but this was a marked improvement over the 38% of patients who reached the goal prior to the nomogram. 9 None of the hospitals in the study was routinely using a dosing nomogram by the end of 1992; therefore, such protocols likely represent one way to improve heparin dosing practices.…”

Section: Discussionmentioning

confidence: 99%

“…Exceptions have been studies of hospitals where heparin dosing nomograms have been used to guide therapy and the proportion of patients achieving adequate anticoagulation within 24 hours of the initiation of heparin has been significantly higher. 8,10,[13][14][15][16] Each of these studies, however, reflects practice in one or only a few hospitals. Further, none has examined other important features of heparin dosing, such as the frequency with which platelet counts are monitored, or the extent to which early initiation of warfarin therapy has been adopted in the community.…”

Section: Discussionmentioning

confidence: 99%

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Anticoagulation therapy in patients with venous thromboembolic disease

Whittle

Johnson

1998

J Gen Intern Med

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OBJECTIVE:To determine, in a representative sample of patients drawn from a variety of hospitals, the degree of adherence to consensus recommendations for anticoagulation among patients with deep vein thrombosis or pulmonary embolism. DESIGN:Cross-sectional review of a population-based random sample.SETTING: Twenty-one randomly selected Pennsylvania hospitals. PATIENTS:Of 357 randomly selected Medicare beneficiaries discharged from study hospitals with a diagnosis of deep venous thrombosis or pulmonary embolism during 1992, 43 charts were not reviewed for administrative reasons, 31 were miscoded or not treated with intravenous administration of heparin, and 13 were excluded for other reasons, leaving 270 in the final sample. MEASUREMENTS AND MAIN RESULTS:Overall, 179 patients (66%, 95% confidence interval [CI] 59%, 72%) received therapeutic anticoagulation (two consecutive partial thromboplastin times more than 1.5 times control) within 24 hours of starting heparin. Platelet counts were checked at least once during the first week of heparin therapy in 66% (95% CI 58%, 74%). At least 5 days of heparin therapy was given to 84% (95% CI 79%, 87%). Among 266 (99%) of the patients receiving warfarin, 193 (72%; 95% CI 63%, 80%) received heparin until the prothrombin time ratio or International Normalized Ratio was therapeutic. Patients who were started on warfarin therapy within 2 days of heparin had decreased length of stay (geometric mean 8.2 vs 9.7 days, p ‫؍‬ .003). Compliance varied among hospitals. CONCLUSIONS:In a wide variety of hospitals, we found fair, but variable, compliance with consensus recommendations for anticoagulation of patients with venous thromboembolic disease. Simple interventions to improve compliance with these recommendations might improve quality of care and reduce costs. The most dreaded complication, pulmonary embolism, has a high mortality rate in this population, and most deaths occur before the pulmonary embolism is treated. 2 The standard approach to treatment is acute anticoagulation with carefully administered and monitored intravenous (IV) heparin, followed by a period of oral anticoagulation with warfarin. 3 Since 1985, the National Heart Lung and Blood Institute (NHLBI) and/or the American College of Chest Physicians (ACCP) have convened four consensus conferences on anticoagulation therapy, which have provided guidance for anticoagulant use in this setting. 3-6 At these conferences, experts in anticoagulation therapy generate consensus recommendations for therapy, based on a thorough review of the literature using strict rules of evidence. 7 These conferences have suggested that early achievement of therapeutic levels of anticoagulation might decrease recurrences; routine monitoring of platelet counts is indicated because of heparin-induced thrombocytopenia; heparin should be administered for at least 5 days in patients with DVT or pulmonary embolism, and until therapeutic anticoagulation with warfarin has been achieved and maintained for 2 days; and warfarin therapy can be insti...

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Anticoagulation therapy in patients with venous thromboembolic disease

Whittle

Johnson

1998

J Gen Intern Med

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“…Controversy exists whether subtherapeutic aPTT increases the risk of recurrent thromboembolic events (4)(5)(6)23,38,39). Although it is reasonable to believe that a greater delay to reach threshold anticoagulation should lead to a greater number of adverse arterial and venous thrombotic events, the limited number of patients in this study does not permit to evaluate such clinical end points.…”

Section: Obesitymentioning

confidence: 91%

Delayed efficient anticoagulation with heparin in patients with a weight of 110 kg and more treated for acute coronary syndrome

Joncas

Poirier

Ardilouze

et al. 2013

Obesity

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Objective: The use of a weight-based nomogram is considered as standard care for prescribing appropriate doses of unfractionated heparin (UFH). Because of the need for multiple other medications that may affect bleeding and that clinical data have relied on similar dosing algorithms, maximum initial bolus and infusion rates have been suggested (capped initial dose). Whether these weight-based heparin nomograms properly address therapeutic dosing in obese patients remains questionable. Design and Methods: Thirty patients treated for acute coronary syndrome and weighing !110 kg were retrospectively compared with 90 controls (three groups of 30 patients, weighting 50-69.9, 70-89.9, or 90-109.9 kg), all treated with UFH, July 2008 to April 2009. The primary end point was the time required to obtain a threshold activated partial thromboplastin time (aPTT). Results: Mean time to achieve threshold aPTT was longer for obese patients weighing !110 kg than for controls (31.47 vs. 12.89 hours; P < 0.0001). At 24 hours, 63% of obese patients weighing !110 kg had not reached threshold aPTT vs. 7% of controls (P < 0.0001). However, threshold infusion rate did not differ between weight categories (13.0 vs. 13.1 U/kg/h; P ¼ NS) and approximated the initial infusion rate recommended by nomograms without applying the dose cap (12 U/kg/h). Conclusions: Adequate anticoagulation time doubled in patients weighing !110 kg, suggesting that these patients were not receiving appropriate heparin doses initially to achieve threshold aPTT rapidly. Using initial infusion rate recommended by a nomogram without capping for total body weight is suggested as acceptable in this study. This approach should be further evaluated in a prospective study.

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“…41 Therapy in acute PE is usually started with 80 units/kg of UFH as bolus followed by 18 units/kg/hour by continuous IV infusion with monitoring of activated partial thromboplastine time (aPTT between 1.5 to 2.5 times control). 50 However, the dose of UFH should not be increased > 40,000 units/day despite aPTT ratio being in the subtherapeutic range, if the antifactor Xa heparin level is > 0.35 IU/mL (51). UFH is also preferred over LMWHs in patients with severe renal impairment with creatinine clearance < 30 ml/min and in those at high-risk of bleeding.…”

Section: Heparinsmentioning

confidence: 99%