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Protocol for systemic unfractionated heparin administration and adjustment for pediatric patients

Protocol for systemic unfractionated heparin administration and adjustment for pediatric patients
  1. UFH loading dose: 75 units/kg IV over 10 minutes.
  1. Initial maintenance dose:
    • Infants <1 year: 28 units/kg per hour
    • Children ≥1 year: 20 units/kg per hour

  1. Adjust UFH to maintain antifactor Xa activity 0.35 to 0.7 units/mL. In most children, this corresponds to a goal aPTT of 60 to 85 seconds.

    aPTT testing can be used to facilitate dose adjustments, but only after establishing that the aPTT range corresponds to the target antifactor Xa range in the individual patient.

    Initial testing is performed 4 to 6 hours after starting the infusion.
Anti-Xa
(units/mL)		 aPTT
(seconds)		 Bolus
(units/kg)		 Hold infusion
(minutes)		 Rate change Repeat
anti-Xa/aPTT
≤0.1 <50 50 0 Increase 10% 4 hours
0.11 to 0.34 50 to 59 0 0 Increase 10% 4 hours
0.35 to 0.7 60 to 85 0 0 No change 4 hours, then daily once 2 consecutive values are in range
0.71 to 0.99 86 to 95 0 0 Decrease 10% 4 hours
1.0 to 1.19 96 to 120 0 30 Decrease 10% 4 hours
≥1.2 >120 0 60 Decrease 15% 4 hours
  1. When anti-Xa/aPTT values are therapeutic, monitor anti-Xa/aPTT and CBC daily.
UFH: unfractionated heparin; IV: intravenous; aPTT: activated partial thromboplastin time; CBC: complete blood count.
* If both anti-Xa activity and aPTT are monitored and there is a disconnect between the two values such that the aPTT is >150 yet the anti-Xa level is subtherapeutic, the UFH should not be increased to achieve the desired therapeutic anti-Xa level since there are reports of bleeding complications occurring in this setting, particularly in neonates. Consultation with a pediatric hematologist is recommended in such cases.
References:
  1. Monagle P, Chan AK, Goldenberg NA, et al. Antithrombotic therapy in neonates and children: Antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2012; 141:e737S.
  2. Trucco M, Lehmann CU, Mollenkopf N, et al. Retrospective cohort study comparing activated partial thromboplastin time versus anti-factor Xa activity nomograms for therapeutic unfractionated heparin monitoring in pediatrics. J Thromb Haemost 2015; 13:788.
Original table modified for this publication. From: Michelson AD, Bovill E, Andrew M. Antithrombotic therapy in Children. Chest 1995; 108:506S. Table used with the permission of Elsevier, Inc. All rights reserved.
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