Therapeutic anticoagulation

LMWH—given SC once daily on basis of weight (see individual products for dosage). Usually continued for 4-7 days until warfarin effect, INR>2.0.

Standard IV UFH—initial IV bolus 5000iu in 0.9% saline given over 30 mins (lower loading dose for small adult/child). Follow with 15-25iu/kg/h using a solution of 25,000iu heparin in 50mL 0.9% saline (= 500iu/mL) and a motorised pump, e.g. for 80kg adult dose is 80 x 25 = 2000iu/h. Monitor IVI with APTT ratio, aim for ratio of 1.5-2.5, check 6h after starting treatment. Adjust dose as shown opposite.

Check APTT ratio 10h after dose change; daily thereafter. Use fresh venous sample—do not take from line. Continue heparin until INR in therapeutic range for warfarin—takes ~5 days; massive ileo-femoral thrombosis and severe PE may require 7-10 days' heparin.

Contraindications—caution if renal, hepatic impairment, recent surgery, known bleeding diathesis, severe hypertension.

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