Heparin + Coumadin + Labs

Soooo your patient is on Coumadin and Heparin and they have all these INR’s and PTT’s or AntiXa’s to be drawn and the family wants to know right now, “WHY ARE THEY BEING STUCK SO MUCH!?”

Patients get put on a Heparin drip and bridge it to Coumadin for a variety of reasons.  Maybe they’re in afib, maybe they have a brand new mechanical heart valve, maybe they just had a femoral-popliteal bypass and will need their blood thin to maintain patency of the graft.  There are many different reasons.

Basically, Heparin quickly thins a patient’s blood to a therapeutic level (which depends on why they need their blood to be thin in the first place).  Coumadin takes longer to kick in and get to a therapeutic level.  Some patients are at such high risks for clots that they can’t wait for the Coumadin to kick in, so they need IV Heparin now.  Like, right now.

So, you get an order to start a Heparin drip.  This is one of those stop what you’re doing and do this NOW kind of things.

Note:  when you get an order for a heparin drip, always double check to see if the doc wants a bolus or not.

IV Heparin is different than subcutaneous Heparin.  It’s a much higher dose and it goes straight into their circulation.  So if they ask you if they can just do those little shots in their belly, you can tell them absolutely and unequivocally no (did you say that in a Professor Slughorn voice?  10 points for Gryffindor if you did).

When a patient is on IV Heparin, it is started at a set rate based on their weight and how aggressive they need to be.  The way we monitor if the blood is at a safe level is with either a PTT or an Anti-Xa lab.  Typically, these are drawn every 6 hours until it is stable (making dosage adjustments based on how high/low their lab is) for a few draws, then it’s drawn every 12 hours, then every day.

The patient will then have an order to get Coumadin during the day.

“Coumadin and Heparin at once?!  Isn’t that too much!?  They’re going to bleed out!” says the concerned family member.  You can tell them no, the likelihood of that is very low.  And the need to thin their blood is much greater than the bleeding risk of the medication at this point.  So calm yourself, frantic family member.. your loved one needs this medication desperately.

If a patient is receiving Coumadin, make sure they have a DAILY INR ORDERED!  The patient’s doctor will specify a therapeutic range for them.  Our goal is to get the INR within that range, near it, or consistently trending up towards it.  If the doctor rounds and an INR was not ordered and they weren’t alerted, you’ll hear about it :-)

Make sure there’s an INR resulted.  You should get this lab value in report, as it should be drawn with am labs.  The doctor will ask you what this is when they round.

So, to summarize..

Heparin = PTT’s or Anti-Xa labs

Coumadin = INR labs

Both are completely necessary and non-negotiable.  There’s no way around this; the labs must be drawn to know how to correctly dose the medications they so desperately need.

Nursey Tip:  if your Heparin drip has been therapeutic and the PTT/Anti-Xa is now a daily lab, order it at the same time as your INR so they don’t have to get stuck twice.  Also, if your PTT/Anti-Xa needs to be drawn around the time some other non-time sensitive labs are due, re-time your labs to be when your PTT/Anti-Xa is due.  That’ll save the patient a stick, if possible.  (And make sure you tell them you did that so you can get bonus points!)  Remember though, that PTT/Anti-Xa is TIMED.  It cannot be whenever is easiest.  Even if the patient was just stuck 2 hours ago for another timed lab, you cannot change the time.  You run the dangerous risk of their blood being too thick or too thin if you do this (cough-risking your license-cough-cough).

Disclaimer: this is informational only, always follow your hospital’s policies and procedures.  Surprisingly enough, saying “Nurse Eye Roll told me to” doesn’t hold up in court.  Alas, maybe one day..

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Afibbin Heart – Explanations for Patients + Family Members

If you have a patient who just flipped into uncontrolled afib, even if they can’t feel it, they probably are freaking out.. especially if they can see their heart rate on the monitor or the vitals machine next to them.  Or if there’s a nurse or tech making a big obnoxious deal about it.

The most important thing you, as their capable and confident nurse, can do is stay calm.  You need to have your Nurse Face on and act like you’ve got everything under control, even if it’s not.

Explain to them that their atria are quivering and not contracting properly (if they’re a post-op CABG patient, tell them this occurs in approximately 30% of all CABG patients).  Continue to tell them that if they quiver and don’t properly contract, blood can pool and they can have a clot form which can travel and go somewhere else in their body.  We are most concerned if it goes to their brain or lungs.  Our goal is going to be to get them back into a normal rhythm and/or have their heart rate less than 100.  .

(Are you reading that with a calm, reassuring nursey voice?  Good.  Patients love that voice.  I love that voice.  I feel so safe!)

Continue to explain that we have a lot of different and extremely effective ways to handle this.  We see this frequently and know how to deal with it.  We’re kind of a big deal (use the Ron Burgundy voice for that last one).

Use this time to tell them it’s important they are not exerting any additional energy while we’re trying to get their heart rate and rhythm controlled.  They won’t be working with therapy today and they need to stay in bed for the time being.  Also let them know that we’re going to be taking manual blood pressures frequently because sometimes your blood pressure can drop a little bit with this rhythm as well as with some of the medications we give.

Reassure them.  Let them know that yes, this is scary but we’ve got it all under control.  The doctor is aware, and we’ve got orders we are working on to get that heart back into shape.

Their doctor may want to cardiovert them.   If so, don’t give them anything to eat or drink until they’re done.  (Sometimes they puke after they get shocked.)  Typically, they give some conscious sedation as well.  Let the patient know we’re going to give them something to relax and we’re going to shock their heart back into a normal rhythm.  Ideally, your physican tells them that.  However, realistically, they’re going to want to know why you’re bringing the code cart into their room.  That usually scares people, so make sure you’re calm, comforting, and reassuring.

Have family/visitors go to the waiting room while you do your synchronized cardioversion.  You’ll never do that alone; a doctor or midlevel provider should be with you as well as another nurse (preferably your charge nurse).

If they use medications the described in my previous post, you can print off informational sheets for them or their family, as they will probably go home on oral versions of them.

I’ve had dozens and dozens of patients flip into afib.  It scares patients and families, especially if it’s after a huge heart surgery, like a CABG.  They’re typically emotionally exhausted at that point.  The best thing you can do for these patients and families is to be confident, remain calm, and try to make them feel as safe as possible.

Explain things to them in a reassuring voice and don’t freak out (even if you’re freaking out on the inside).  If you get concerned, ask a fellow nurse, but don’t do it in front of them.

This can also be discouraging to a patient and/or family.  Let them know it’s a bump in the road to recovery, but we’re still getting there.  Be positive, confident, and hopeful with them.  Even if they don’t act down, they may be good at hiding it.  Be encouraging to them and their family.

(Use your judgement though; if it is a case of someone with a very poor prognosis, don’t change the tone that’s already been set.)

Disclaimer: this is informational only, always follow your hospital’s policies and procedures.  Surprisingly enough, saying “Nurse Eye Roll told me to” doesn’t hold up in court.  Alas, maybe one day..

A-Fibbin Heart – When to be Concerned About Afib

Basic afib definition: their atria are quivering and not fully contracting

Why does this matter?  Blood can pool in the atria and then clot.  This clot can move.  You’re most concerned if it moves to their lungs or brain, causing a stroke.  Your risk for having a stroke significantly increases if you’re in afib.

As a busy floor nurse, when should I freak out about afib?

There are a few levels of concern here.  Keep this in mind:

Controlled afib = a heart rate less than 100 (not as concerning)

Uncontrolled afib = a heart rate over 100 (concerning)

If you’re getting report, heard they were in normal sinus rhythm (NSR) with a rate of 80 and you look at the monitor and see an irregular rhythm without P waves, they’re in a fib.

If they are in controlled afib, take note, assess and call.  That is a minimal freak-out situation.  They need to know about it, but it’s not an emergency by any means.  Also, look back at their telemetry and try to find a time of when they flipped; they will ask you when they flipped.

If they are in uncontrolled afib, this is now your priority.  Whatever you were doing before can wait.  Go look at your patient, see if they’re diaphoretic, sweaty, nauseated, etc.   Get a blood pressure immediately.

Note: those BP machines do not read afib correctly.  If your patient flips into afib, go get a MANUAL BLOOD PRESSURE.

Once you have a fresh set of vitals (ideally, your tech got those), have their latest labs/meds available to you, and call your NP/PA/doctor and let them know.  Be ready for a bunch of new orders.

Depending on their preference, the patient’s history, comorbitities, etc., the surgeon may do a synchronized cardioversion (I LOVE to push the shock button), a chemical cardioversion (adenosine), or utilize amiodarone or cardizem to convert them.

Chances are, they’ll want Cardizem or Amiodarone.  Both should have an order set, so when you’re entering the order (if the physician hasn’t done so themselves) look under order sets, not individual orders.  And these orders need to be put in STAT.

This would be a great time for some TEAMWORK.  See if your charge nurse can grab an IV pump to prime your drip while you get your bolus, or vice versa.  Time is a factor here, you don’t want them stroking out on you!

Both drips come with a bolus.  Cardizem is an IV push (usually 10 mg), followed by a titratable drip.  The order set will have your specific titrations on it.  If you have your bolus in hand but not your drip, wait to push it until you have your drip ready to go.

Amiodarone is a little different.  It does have a bolus, but it’s an IV drip that goes in over 10 minutes.  This is followed by another IV bag that goes in over 6 hours, and a final bag which infuses over 18 hours.  Typically, you don’t titrate Amiodarone unless you’re in a higher level of care of have specific orders to do so.

Make sure your patient is in bed and tell physical and occupational therapy that they’ll need to wait to see your patient until tomorrow.  You’re going to use your awesome nursey judgement and put them on bed rest for the time.  (No, don’t call the doctor for an order, just tell them they can’t get out of bed until their heart rate is better.)

Sooo… I started my drip and my patient’s heart rate is still 140.  When do I call again?

Goal = normal sinus rhythm OR afib with a rate less than 100.

If it has been over an hour and their heart rate is not consistently less than 120 and coming down (and your Cardizem is maxed out), you will need to call for further orders.  If they flipped into normal sinus rhythm, YAY YOU FIXED THEM!  Good job!

Alright, new scenario:  Let’s say you’re in report and you heard this all went down yesterday and their on their final bag of Amiodarone and now in NSR with a HR of 94.

Something you need to look for is their conversion to PO!  If you’re getting report and they don’t have PO Amiodarone on their MAR, one of your priorities will be to get them switched to PO.  This is missed frequently because the doctor’s initial priority is to get them converted.

Take a peek and see how much time is left on that drip and make sure you have an order to give them their PO Amio 2 hours before it’s dry.  Or else, they’re going to flip back and you’ll have to start all over!

The same goes with Cardizem.  Get that PO Cardizem in them 2 hours before turning the drip off.   If they’ve been on a drip for two days, that should be a red flag to you.  When the doctor rounds, ask if we can get them off the drip and on PO.  And if they are purposefully leaving them on, ask them why for your own learning.

My next post will be on explaining all of this to their family member that’s freaking out, asking you 900 questions while you’re trying to start their drip..

Disclaimer: this is informational only, always follow your hospital’s policies and procedures.  Surprisingly enough, saying “Nurse Eye Roll told me to” doesn’t hold up in court.  Alas, maybe one day..