From the Guidelines
Heparin IV should be stopped at least 4 hours before hemodialysis catheter installation to minimize bleeding risk, as recommended by the American College of Chest Physicians clinical practice guideline. This guideline suggests stopping UFH 4 hours before a surgery/procedure over stopping IV UFH < 4 hours before a surgery/procedure, with a conditional recommendation and very low certainty of evidence 1.
When considering the timing of heparin cessation, it's essential to weigh the risks of bleeding against the need for anticoagulation. For patients on therapeutic anticoagulation, a longer window may be necessary to ensure adequate clearance, while those on prophylactic doses may require less time.
Key considerations for heparin management include:
- Checking the activated partial thromboplastin time (aPTT) before the procedure to confirm it has returned to an acceptable range
- Administering protamine sulfate to reverse heparin's effects if the procedure is urgent and cannot wait for full heparin clearance, typically at a dose of 1 mg per 100 units of heparin received in the previous 2-3 hours
- Restarting heparin 4-6 hours post-procedure once hemostasis is confirmed, individualized based on the patient's bleeding risk and the technical difficulty of the catheter insertion.
The decision to stop heparin IV before hemodialysis catheter installation should be made with caution, prioritizing the patient's morbidity, mortality, and quality of life outcomes. The most recent and highest quality study, published in 2022 in the journal Chest, supports stopping UFH at least 4 hours before the procedure 1.
From the Research
Heparin Administration and Hemodialysis Catheter Installation
- The decision to stop heparin (unfractionated heparin) IV before hemodialysis catheter installation is crucial to prevent bleeding complications 2, 3, 4, 5.
- Studies suggest that the risk of bleeding is higher in patients with active bleeding or those at risk for hemorrhage 2, 4.
- The use of low-dose heparin (1,000 U/ml) as a catheter lock solution may reduce the risk of bleeding without compromising catheter patency 3, 5.
- The effect of heparinized catheter lock solutions on systemic anticoagulation should be considered, and the concentration of heparin used as a lock solution may impact the risk of bleeding 4, 5.
Timing of Heparin Discontinuation
- There is no specific guideline on when to stop heparin IV before hemodialysis catheter installation, but it is essential to weigh the risk of bleeding against the need for anticoagulation 2, 3, 4, 5.
- The activated partial thromboplastin time (aPTT) can be used to monitor heparin levels and adjust the timing of heparin discontinuation accordingly 2, 3, 4, 5.
- Individual patient factors, such as the risk of bleeding and the presence of active bleeding, should be considered when deciding when to stop heparin IV before hemodialysis catheter installation 2, 4.