What is the management for a patient on heparin (unfractionated heparin) drip with prolonged partial thromboplastin time (PTT)?

From the Guidelines

When managing a patient on a heparin drip with prolonged partial thromboplastin time (PTT), the most appropriate action is to administer IV protamine sulfate to reverse heparin, dosing it according to the dose of heparin infused over the preceding 2–3 hours, at 1 mg for every 100 units of heparin given, with a maximum single dose of 50 mg 1. This approach is based on the strongest recommendation with moderate to high-quality evidence from the guideline for reversal of antithrombotics in intracranial hemorrhage 1. The key considerations in managing such a patient include:

• Urgently reversing anticoagulation in patients when intracranial hemorrhage develops during full-dose heparin infusion, as recommended by Frontera et al 1.
• Considering the dose and timing of heparin administration to guide protamine dosing, as the recommendation suggests dosing protamine according to the dose of heparin infused over the preceding 2–3 hours 1.
• Monitoring for signs of bleeding and adjusting the anticoagulation strategy as needed, given that the elevated PTT indicates excessive anticoagulation and increases bleeding risk.
• Being aware that if the aPTT remains elevated, repeat administration of protamine at a dose of 0.5 mg protamine per 100 units of unfractionated heparin may be considered, although this is based on lower quality evidence 1. The management strategy should prioritize minimizing the risk of further bleeding while also considering the need for anticoagulation, and thus, a careful and evidence-based approach to reversing heparin's effects is crucial, guided by the latest clinical guidelines and recommendations 1.

From the FDA Drug Label

Careful monitoring of partial thromboplastin time and adjustment of heparin dosage are recommended during coadministration of heparin and intravenous nitroglycerin.

The management for a patient on heparin (unfractionated heparin) drip with prolonged partial thromboplastin time (PTT) is to carefully monitor the PTT and adjust the heparin dosage as needed.

• Monitor the patient's PTT closely
• Adjust the heparin dose to maintain a therapeutic PTT range 2 2

From the Research

Management of Prolonged Partial Thromboplastin Time (PTT) in Patients on Heparin Drip

• The management of prolonged PTT in patients on heparin drip is crucial to prevent bleeding complications 3.
• The first step is to risk-stratify the patient based on hemodynamic instability, source of bleeding, and degree of blood loss 3.
• If the patient is experiencing major bleeding, transfusion of blood products and use of specific antidotes may be necessary 3.
• Protamine sulfate can be used to reverse the effects of unfractionated heparin completely and of low-molecular-weight heparin (LMWH) partially 3.
• The degree of anticoagulation and its effect on the frequency of complications after successful percutaneous transluminal coronary angioplasty have been studied, and it was found that patients with PTT greater than or equal to 3 times the control value had a significant reduction in the incidence of abrupt coronary artery closure 4.
• Fresh frozen plasma may be used to "normalize" the heparin-ACT dose-response curve in heparin-resistant patients and to lessen total heparin requirements during cardiopulmonary bypass 5.

Monitoring and Adjustment of Heparin Drip

• The PTT should be monitored regularly to adjust the heparin drip and prevent bleeding complications 6, 4.
• The International Society for Thrombosis and Haemostasis (ISTH) DIC scoring system provides objective measurement of DIC, and the scoring system correlates with key clinical observations and outcomes 6.
• In patients with DIC, the cornerstone of treatment is treatment of the underlying condition, and transfusion of platelets or plasma should not primarily be based on laboratory results and should in general be reserved for patients who present with bleeding 6.

Reversal of Anticoagulation

• The residual effects of each anticoagulant may be monitored with distinct coagulation assay, and specific antidotes may be used to reverse the effects of anticoagulants 3.
• Protamine sulfate is a specific antidote that can be used to reverse the effects of unfractionated heparin and LMWH 3.
• Idarucizumab has recently been approved for dabigatran reversal, and andexanet alfa is expected to get approved for reversal of oral factor Xa inhibitors 3.