Weight-based Heparin Protocol for Deep Vein Thrombosis mvn or Pulmonary Embolism tPEl

-
Body Weight Initial IV Bolus Pure Heparin Body Weight Initial IV Bolus Pure ffipa,tn.
hnf_l
Initial Bolus: (ka) (units) (ml) lka) (units}
40 6000 1.2
3200 0.65 75
30 units/kg 45 3600 0.7 80 6400 1.3 -
(max 8000 units) 50 4000 0.8 85 6800 1.4
55 4400 0.9 7200 1.45
90
60 4800 0.95 95 7600 1.5
65 5200 1.0 100 8000 1.6
70 5600 1.1
Subsequently, start on heparin infusion according to the starting infusion rate based on body weight.

~tonitor APTT every 4 - 6 hours and adjust infusion rate based on the APTT range. . .
Example : For a 40kg patient, if repeated APTT is <50 sec, give another IV bolus of 3200 units then increase the 1nfusIon rate by
0.3ml/hr.

If APTT falls within therapeutic range, may repeat APTT the next morning.
Dilution of Heparin : 25000 units of pure heparilllo 50ml NS -> 5011.Y!L~]
Body
Weiaht Infusion Rate APTT(sec) IV Bolus Dose Hold Infusion Rate Cliange (m6111'i

< 50 3200 units +0.3

0
(0.65ml of pure heparin)
1600 units + 0.1
1.4 ml/hr 50-64 0
40 kg (0.30ml of pure heparin)
(starting rate) 65-100 No Change
0 0
(therapeutic)
101-110 0 0 - 0.1
> 110 0 60 minutes - 0.2

£Jody Infusion Rate APTT(sec) IV Bolus Dose " ' Hold Infusion
.
Rate Cbfnge (mblht)
- Weiaht
3600 units +0.4
< 50 0
(0.70ml of oure heparin)
1800 units +0.2
50-64 0
1.6 mUhr (0.35ml of pure heparin)
45 kg No Change
(starting rate) 65-100 0
0
(therapeutic)
101-110 0 0 -0.2
> 110 0 60 minutes - 0.3

Body . Infusion Rate APTT(sec) IV Bolus Dose Hold Infusion Rate Change (mlAlr)
Wei ht
4000 units + 0.4
< 50 0
0.80ml of ure he arin
2000 units +0.2
50-64 0
1.8 mUhr 0.40ml of ure he arin
50 kg 65-100 No Change
(starting rate) 0 0
thera eutic
101-110 0 0 -0.2
> 110 0 60 minutes - 0.3
i

Body IV Bolus Dose Hold Infusion Rate Change (ml.Jhr)

Infusion Rate APTT(sec)
Weight
4400 units 0 +0.4
< 50 (0.90ml of pure heParin)
2200 units 0 +0.2
50-64 (0.45ml of pure heparin)
2.0 mUhr No Change
55 kg (starting rate) 65-100 0
0
(therapeutic) - 0.2
0 0
101-110 -0.3
0 60 minutes
> 110
 Body
We_!ght Infusion Rate -
APTT(sec) Hold Infusion Rate Change (mLJbrJ
IV Bolus Dose
<: 50 4800 units
j 0.95mL of pure h8(.laril!.)
0 + 0.5
-
60 kg 2.2 ml/hr 2400 units
(starting rate)
50-64
65-100
(0.50ml ofJ)ure heparinJ 0 + 0.3
-
No Change
__{therapeutic)
101 -110
0 0
- 0.3
-
0 0
> 110 0 60 minutes - 0.4
Body
Wei ht Infusion Rate
APTT(sec) IV Bolus Dose Hold Infusion Rate Change (ml.lhr)
<:50 5200 units + 0.5
1.0ml of ure he arin 0
65 kg 2.4 ml/hr 50-64 2600 units + 0.3
0.55ml of ure he arin 0
(starting rate)
65-100 No Change
thera eutic 0 0
101 -110 0 -0.3
0
> 110 0 60 minutes - 0.4
Body
Wei ht Infusion Rate
APTT (sec) IV Bolus Dose Rate Change (rrii.Jhi)
Hold Infusion
<: 50 5600 units
1.10ml of ure he arin 0 + 0.6
2.5 mUhr 50-64 2800 units
70 kg 0 + 0.3
(starting rate) 0.60ml of ure he arin
65-100
0 No Change
thera eutic 0
101-110 0 0 -0.3
> 110 0 60 minutes -0.4
Body
Weight Infusion Rate APTT (sec) IV Bolus Dose Hold Infusion Rate Change (niL/hr)
<: 50 6000 units
_(.1.20mL of_pure heparin) 0 + 0.6
50-64 3000 units
75 kg 2.7 mUhr 0 +0.3
(0.60ml of2ure h8(.larin_)
(starting rate) 65-100
_(theraJ)eulic) 0 0 No Change
101-110 0 0 - 0.3
> 110 0 60 minutes -0.5
Body
Weight ·Infusion Rate APTT(sec) IV Bolus Dose Hold Infusion Rate Change (ml/hr)
<: 50 6400 units
(1.30ml of pure heparin) 0 +0.6
50-64 3200 units
BO kg 2.9 mUhr (0.65ml of pure heparin) 0 +0.3
(starting rate) 65-100
jtherapeutic) 0 0 No Change
101-110 0 0
> 110
- 0.3
0 60 minutes - 0.5
Body
Weight Infusion Rate APTT(sec) IV Bolus Dose Hold Infusion Rate Change (ml/hr)
<: 50 6800 units
(1.40ml of pure heparin) 0 + 0.7
50-64 3400 units
3.0 mUhr (0.70ml of pure h~arin) 0 + 0.4
85 kg
(starting rate) 65-100
0 0 No Change
(therapeuti~
101-110 0 0 -0.4
> 110 0 60 minutes - 0.5
 .I
I Body - Rate c11ange (miJhr) _
-

Weight Infusion Rate Hold Infusion

APTT(sec) IV Bolus Dose
+0.7

- < 50
7200 units 0
(1.45ml of oure henarin)
+0.4
50-64 3600 units 0
90 kg 3.0 mUhr
(starting rate) - (0.70ml of oure heoarin) No Change
65-100 0
- (therapeutic) 0
• 0.4
- 101-110 0 0
60 minutes
- 0.5
> 110 0
Body Rate Change (mUhr)
Wei ht Infusion Rate APTT(sec) IV Bolus Dose Hold Infusion

7600 units + 0.8

< 50 0
1.50ml of ure he arin
3800 units +0.4
50-64 0
95 kg 3.0 mUhr 0.75ml of ure he arin No Change
(starting rate) 65-100
0 0
thera eutic -0.4
101-110 0 0
- 0.6
> 110 0 60 minutes

Body Rate Change (mUhr)

Wei ht Infusion Rate APTT(sec) IV Bolus Dose Hold Infusion
8000 units + 0.8
< 50 0
1.60ml of ure he arin
4000 units 0 +0.4
3.0 mUhr 50-64
100 kg 0.80ml of ure he arin
(starting rate) No Change
65-100 0
0
thera eutic
0 - 0.4
101-110 0
60 minutes -0.6
> 110 0

Reference :
1· 0 uick Guide to Heparin Use (For Adult). Pharmaceutical Services Division Ministry of Health Malaysia (Updated 2010)
2 0 rug 1n1ormat,on Handbook ' ·
3. Micromedex

Prepared by:
Lau Yee Sian
Phannacist U«