Pulmonary Embolism Medication: Tips for Nurses to Manage a Heparin Drip

• Continuous intravenous infusion, also called a heparin drip, is a pulmonary embolism (PE) medication that can cause discomfort among nurses who manage a patient’s treatment. 
• The provider orders the tests and medications, but nurses are a vital part of the collaboration that must occur for the sake of a patient’s wellbeing. 
• Learn to effectively manage a PE patient’s continuous heparin infusion using the seven rights of medication as a framework. 

Pulmonary embolism (PE) affects around 900,000 people in the United States annually, according to the American Lung Association. 

Recognition of the signs and symptoms, coupled with timely intervention, yields better outcomes. Whether you’re a nurse in an emergency department or an inpatient unit, you’re an integral participant in recognition and timely treatment of a patient who is experiencing a PE.  

The initiation of anticoagulant therapy is a vital intervention after diagnosis. As nurses, we all have that one medication that gives us just a little bit of anxiety. For some, it may be the effects of the medication itself. For others, it may be the route of administration. For others, it may be the level of monitoring required once the medication is administered.  

In relation to PE, the medication that may cause a nurse to become uncomfortable is heparin, specifically in the form of a continuous intravenous (IV) infusion (sometimes used interchangeably with the term heparin drip). In this article, I will discuss how to effectively manage a PE patient’s continuous heparin infusion using the seven rights of medication as a framework. 

Pulmonary Embolism Medication: Administration Advice 

Right PERSON:

Verify that you’re administering heparin to the correct patient by using two patient identifiers. 

Right MEDICATION:

Hespan (volume expander) can potentially be mistaken for heparin, according to the ISMP’s List of Confused Drug Names. For this reason, depending on your institution, you may see the names written with upper-case lettering to distinguish between the two (HEParin and HESpan). 

Right TIME:

The “right time” is usually used in relation to a scheduled medication dose or even the right amount of time that has transpired between administration of PRN doses. In relation to a continuous heparin infusion, we can apply “right time” to titration of the infusion. This is also known as the adjustment of the infusion rate.  

The activated partial thromboplastin time (aPTT or PTT) measures the amount of seconds it takes for blood to clot when certain reagents are added to plasma in a test tube. Based on the aPTT value, the nurse uses a nomogram as a guide to adjust the rate of the continuous heparin infusion to reach a therapeutic value. The aPTT is considered therapeutic at 1.5 to 2 times the control value. This, of course, varies from hospital to hospital. It is important to know that nomograms and the therapeutic aPTT value vary based on the reagent that is used in your institution’s laboratory. Also consider if the heparin is being administered along with thrombolytic therapy or platelet GP/IIB/IIIa antagonists. With that said, the many nomograms that can be viewed with a web search or example in a textbook are not standard to every institution. Therefore, it is important to follow the guidelines specific to your institution. 

 A baseline aPTT is drawn prior to initiation of infusion usually if there has not been a value obtained within the past 24 hours. After initiation of the infusion, redraw every six hours until two or more therapeutic values are obtained. Once two or more therapeutic values are obtained, aPTT can be assessed every 24 hours.  

In my years as a nurse and educator, a mistake I have witnessed is that after the initial aPTT draw, some nurses thought they were supposed to draw another PTT six hours later. For instance, if the aPTT was drawn at 4 p.m., the nurse was under the misconception that blood had to be drawn for subsequent aPTT at 10 p.m., 4 a.m., 10 a.m., 4 p.m., and so on. Remember that an aPTT is drawn prior to administration of the initial IV bolus and redrawn six hours after the IV bolus. Thereafter, an aPTT should be drawn six hours after any change to the infusion rate. If no change in infusion rate is required according to the nomogram, that is the only time the next aPTT is drawn six hours after the last aPTT was drawn.  

The partial thromboplastin time (PTT) is another comment test used to determine the titration of a continuous heparin infusion. It has the same purpose as aPTT. The difference is that the process for running an aPTT involves an activator being added to speed up clotting time and results. The reference range of aPTT is also narrower than PTT and is considered to be more sensitive. Regardless of which test your institution uses, it is important for the nurse to be vigilant when reading the nomogram to titrate the infusion correctly. You will get some application practice below. 

Right DOSE:

The pharmacy label on the heparin bag should match what is on the actual bag. For continuous infusion, you will generally see a 500ml bag that contains 25,000 units of heparin. The initial bolus dose and infusion rate usually is based on the patient’s weight in kilograms. Best practice is to weigh the patient prior to the provider entering an order for the infusion. In doing this, an accurate dose and rate can be calculated. Do not rely on the weight that is documented in the patient’s electronic medical record. As we know, weight can fluctuate at any time during a hospital stay. 

Before the start of the infusion, it is usually recommended to administer a bolus dose of heparin intravenously. The amount can vary. This is not administered via syringe to the port, but by programming the IV pump to administer the bolus from the heparin bag. After the bolus is finished, the heparin will be administered from the pump at the appropriate rate. Technology is a wonderful thing and, conveniently, the IV pump can calculate for us. However, manual calculation to confirm the infusion rate is the safest bet. A second nurse should also verify the dose and rate.

Right ROUTE:

Heparin should be administered intravenously through its own tubing. No secondary tubing should be attached to the line. No other infusion, including continuous normal saline fluids, should be attached to the Y-port of the tubing. 

Right REASON:

There are several reasons a continuous heparin infusion would be ordered for a patient. These conditions include, but are not limited to, unstable angina, atrial fibrillation, coronary thrombolysis, non-Q wave myocardial infarction, deep vein thrombosis, and acute venous thromboembolism. If you are the nurse who initiates the infusion, be sure to consult with the provider about the indication. If you are the nurse continuing the management of the infusion, ask the questions in shift report and research the electronic medical record for yourself. 

Ensure that you can answer the questions of the patient and/or family members when they ask why the patient is on the heparin drip. Remember that heparin does not dissolve clots that have already formed. It is meant to prevent the existing clots from becoming larger and to prevent new clots from forming. 

Right DOCUMENTATION:

As we know, timely documentation is a must. Here are a few items the nurse should document: 

• Initial bolus dose administered 
• Initial infusion rate (with verification from a second nurse) 
• Time of infusion initiation 
• Infusion rate changes (with verification from a second nurse) 
• Infusion pauses 
• SBAR communication with the provider about critical lab values   
• Adverse reactions to heparin and intervention 
• Patient/family education

The Bottom Line

The provider orders the tests and medications, but nurses are a vital part of the collaboration that must occur for the sake of a patient’s wellbeing. Nurses lay eyes on the patient the most frequently. Therefore, you are one of the greatest advocates a patient can have. Regarding the management of a heparin infusion, it is important to double-check everything and speak up if the order seems wrong or the patient is reacting adversely to the medication. The thought of what could go wrong (particularly excessive bleeding) can be daunting. However, you are well-equipped to do the job. If you feel unsure, ask questions before managing the infusion. I wish you all the best in being a vigilant nurse who carefully manages the care of patients with pulmonary embolism and beyond! 

Read More