Vanderbilt Pediatric Hematology Anticoagulation Guidance Protocol
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Vanderbilt Pediatric Hematology Anticoagulation Guidance Protocol . 4 / 11 / 12. Robert F. Sidonio, Jr. MD, MSc . . Enoxaparin Dosing Goal anti- Xa levels are 0.6 – 1 units/ mL.

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Vanderbilt Pediatric Hematology Anticoagulation Guidance Protocol

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Vanderbilt pediatric hematology anticoagulation guidance protocol

Vanderbilt Pediatric Hematology Anticoagulation Guidance Protocol

4/11/12

Robert F. Sidonio, Jr. MD, MSc.

  • Enoxaparin

  • Dosing

  • Goal anti-Xa levels are 0.6 – 1 units/mL.

  • Certain patient populations (i.e. pregnancy, Berlin heart, etc.) may require higher anti-Xa levels. The pharmacist should be contacted if higher anti-Xa levels are needed in these patients.

  • Doses to achieve therapeutic anticoagulation are highest in infants because of altered heparin pharmacokinetics, larger volume of distribution and physiologically low antithrombin activity.

  • Consider additional monitoring at least once during acute illness requiring hospitalization, all inpatient cardiac patients and any acute renal impairment.

  • Monitoring once at admission and again weekly is a reasonable monitoring plan while hospitalized for illness.

  • Enoxaparin Dosing

  • Monitoring and Considerations

  • Administration is via injection into subcutaneous tissue.

  • Consider topical lidocaine or EMLA cream 20 minutes prior to dosing to reduce discomfort in children.

  • Monitoring should begin after the second dose is administered.

  • Check an anti-Factor Xa level 4-5 hours after an AM dose. Dosing will be given at 0800/2000 while inpatient to ensure appropriate lab turnaround time.

  • Please consult the Pharmacy Enoxaparin monitoring service for help in dosage adjustment while inpatient.

  • Pharmacy enoxaparin monitoring service will be paged when new orders for enoxaparin are ordered in WIZ/HEO. The anticoagulation dashboard will also be utilized.

  • If patient is sent home on enoxaparin then consult Pediatric Hematology thrombosis nurse for parent education in administration.

  • If patient is transitioned to generic enoxaparin, patients will have anti-Xa level drawn initially to ensure no deviation. Levels will then be followed via nomogram.

  • Administration with an Insuflon catheter should be avoided since difficult to obtain outpatient

  • Dosage titration nomogram

  • For patients < 10 kg, all doses will be rounded to the nearest 0.5 milligram to aid in ease of dosing administration upon discharge. For patients ≥ 10 kg, doses will be rounded to the nearest whole milligram.

  • Conversion from UFH to Enoxaparin

  • Give 1st dose of Enoxparin at the same time the UFH drip is stopped.

  • Conversion from Enoxaparin to UFH

  • If > 12 hours since last enoxaparin dose, give standard bolus followed by maintenance continuous UFH drip.

  • If 8-12 hours since last enoxaparin dose, give only the standard maintenance continuous UFH drip, skipping the bolus.

  • Procedures

  • For cardiac catheterization hold only the AM dose prior to procedure.

  • For invasive or surgical procedures hold a total of two doses thus the PM dose and the AM dose.

  • Restarting enoxaparin is per discretion of the surgeon or cardiologist, typically within 12-24 hours.

  • Heparin

  • Dosing and monitoring

  • Obtain a baseline CBC, PT, aPTT, Fibrinogen and correct coagulopathies as needed.

  • Initial Loading dose: 75 Units/kg over 10 minutes (Maximum 5000 units)

  • Initial Maintenance dose

  • Infusion begins after initial bolus is complete

    • < 1 year: 28 units/kg/hr

    • ≥ 1 year: 20 units/kg/hr (Maximum initial rate 1000 units/hour)

  • Obtain blood for aPTT 4 hours after loading dose and adjust based on nomogram below.

  • Follow adjustment guidelines below to maintain aPTT between 65 – 100 seconds (assuming this reflects anti-factor Xa of 0.35 – 0.7 units/mL)

  • Patients with prolonged baseline aPTT, infants, perceived difficulty managing therapeutic aPTT, excessive bleeding with therapeutic aPTT, or progression of thrombus with therapeutic aPTTmay be monitored predominantly with anti-Factor Xa levels but encourage daily PTT (drawn at same time as anti-FXa) surveillance. Please discuss with hematology service.

  • Please page the clinical pharmacist on the patient’s service when planning transition to enoxaparin or warfarin.

  • Obtain blood for aPTT/anti-FXa 4 hours after each dose adjustment and readjust as needed.

  • Maintain fibrinogen >100 mg/dL and platelet count >50k while on UFH.

  • When aPTT/anti-FXa is therapeutic on 2 consecutive samples, obtain blood for CBC, aPTT and anti-FXa level daily x 5 days.

  • Thereafter can check CBC every other day or twice a week if limited blood draws are needed.

  • Discrepancies may arise between anti-FXa and aPTT. Use clinical judgement, would recommend utilizing anti-FXa as it correlates more closely with Heparin levels.

  • Reversal of Enoxaparin

  • There is no proven method for neutralizing LMWH and protamine leads to incomplete reversal.

  • Consultation with hematology is recommended prior to administration.

  • Protamine is rarely indicated as the preferred strategy over observation.

  • If LMWH was given within 8 hours, protamine sulfate should be administered in a dose of 1 mg per 100 anti-Xa units of LMWH (maximum dose 50 mg). 1 mg enoxaparin equals approximately 100 anti-Xaunits.

  • A second dose of 0.5 mg protamine sulfate per 100 anti-Xa units should be administered if bleeding continues.


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