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..