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Note.Heparin solution at concentrations of 80 units/mL for children 10 kg or less or 40 units/mL for children greater than 10 kg.

aHold the dose 30 minutes.

Note.Heparin solution at concentrations of 80 units/mL for children 10 kg or less or 40 units/mL for children greater than 10 kg.

aHold the dose 30 minutes.

• When the patient's APTT achieves a therapeutic level, repeat APTT, CBC with platelet count daily.

• The heparin level should be monitored during the first 48 hours. Heparin level should be 0.2-0.4 units/mL.

• The heparin level is expected to be 0.35-0.70 units/mL by an anti-factor Xa assay.

• When heparin is interrupted for more than 1 hour, reestablish the heparin maintenance infusion at the previous rate until the APTT result is available. After that, administer heparin in accordance with the APTT results.

• When the platelet count is 100,000/mm3 or less, consider discontinuing heparin therapy and instituting alternative therapy, because the risk of heparin-induced thrombocytopenia is greater after 5 days of therapy.

Duration of heparin therapy

• Deep-venous thrombosis: A minimum of 5-7 days; maintenance warfarin therapy can be instituted on day 1 or 2 of heparin therapy.

• Pulmonary embolus: 7-14 days; start warfarin therapy on day 5.

• Neonates may be treated for 10-14 days without warfarin.

Avoid acetylsalicylic acid (ASA; aspirin) or other antiplatelet drugs during heparin therapy when possible.

Heparin antidote

• If heparin needs to be discontinued, termination of the heparin infusion will be sufficient (because of the rapid clearance of heparin).

• If an immediate effect is required, protamine sulfate administration may be indicated.

• Following administration of IV protamine sulfate, neutralization occurs within 5 minutes.

Disorders of Coagulation 353 The dose of protamine sulfate required to neutralize heparin is as follows:

Last dose of heparin

Protamine dosea (per 100 mg heparin)

<30 minutes

1 mg

30 minutes

0.5 mg

1 hour

0.75 mg

>1 hour

0.375 mg

>2 hours

0.25 mg

"Maximum dose of protamine sulfate, 50 mg, to be administered in a concentration of 10 mg/mL at a rate not to exceed 5 mg/min. If administered faster, it may cause cardiovascular collapse. Patients with known hypersensitivity reactions to fish and those who have received protamine-containing insulin or previous protamine therapy may be at risk for hypersensitivity reactions to protamine sulfate. Repeat APTT 15 minutes after the administration of protamine sulfate.

"Maximum dose of protamine sulfate, 50 mg, to be administered in a concentration of 10 mg/mL at a rate not to exceed 5 mg/min. If administered faster, it may cause cardiovascular collapse. Patients with known hypersensitivity reactions to fish and those who have received protamine-containing insulin or previous protamine therapy may be at risk for hypersensitivity reactions to protamine sulfate. Repeat APTT 15 minutes after the administration of protamine sulfate.

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