The results of this study suggest that the 2006 standard and lower-target weight-based heparin protocols used at the authors’ institution were equally efficacious in achieving therapeutic PTT levels early in therapy, with comparable low incidences of adverse events. These protocols compared favourably to the original 1996 weight-based heparin protocol, which was evaluated previously.1 Achieving anticoagulation early (within the first 24 h) after a thromboembolic event is critical to the optimization of patient outcomes. Although the current protocols could not be compared by statistical testing with the 1996 protocol, there appeared to be greater percentages of patients with PTT values above the lower limit of the target range within 24 h in both the standard and lower-targetprotocol groups than in the 1996 analysis. As well, the time to achieve therapeutic anticoagulation for both of the 2006 protocols appeared shorter than for the 1996 protocol. With respect to safety, there was only 1 episode of major bleeding, which was induced by a fall. The rate of major bleeding in the current study (1%) was much lower than in the original study (10%) and was comparable to rates observed in recent clinical trials of patients treated with IV heparin for venous thrombo­embolism (less than 3%).”

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In both of the 2006 protocol groups, there was no statistical difference in the median time to achieve PTT above the lower limit of the target range between patients who received a full bolus dose and those who did not receive a full bolus (standard protocol 6.0 h [4.0-24.0 h] versus 6.0 h [4.0-40.8 h], p = 0.41; lower-target protocol 6.0 h [4.5-14.3 h] versus 6.9 h [4.8-39.5 h], p = 0.12). Similar results were observed for the median time to achieve PTT within the therapeutic range (standard protocol 13.8 h [4.0-36.3 h] versus 21.5 h [5.5-55.0 h], p = 0.20; lower-target protocol 14.4 h [4.5-24.5 h] versus 14.1 h [4.8-36.8 h], p = 0.39). Notably, the administration of a full bolus dose of heparin did not affect initial supratherapeutic PTTs (standard protocol 122 s [55-200 s] with bolus dose versus 132 s [46-200 s] with no bolus dose, p = 0.72; lower- target protocol 103 s [43-200 s] with bolus dose versus 80 s [52-200 s] with no bolus dose, p = 0.17).

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Charts were reviewed for a total of 153 consecutive patients who had a prescription for heparin infusion. Fifty- three patients were excluded for the following reasons: total infusion time less than 24 h (n = 23), heparin protocol not used (n = 9), older version of protocol used (n = 5), heparin infusion started at another hospital (n = 4), protocol modified by physician (n = 4), incorrect initial infusion rate (n = 2), switch in protocols during therapy (n = 2), interruption in heparin therapy before first PTT sample was drawn (n = 1), and inadvertent exclusion (n = 3). This left a total of 100 patients with 50 patients in each group.

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A retrospective, open-label observational study was conducted over a period of 5 months (September 2006 to January 2007). Approval to conduct this study was obtained from the University of British Columbia Clinical Research Ethics Board and the Vancouver Coastal Health Research Institute. The 2 current protocols were implemented in August 2006. The decision as to which protocol would be appropriate for an individual patient was left to the discretion of the physician, on the basis of the clinical indication. Patients to be included in the study were identified from a drug report generated daily by the pharmacy computer system. The goal was to enrol a convenience sample of 50 patients for whom the standard protocol (Appendix 1) was used and 50 patients for whom the lower-target protocol (Appendix 2) was used, inde­pendent of indication. Patients were excluded if they had received heparin for less than 24 h or if there had been any deliberate, documented changes in the heparin protocols, other than omitting the bolus dose (e.g., changes in target PTT range specified in writing by the physician).

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