Unique Plan Description: argatroban for Heparin Induced Thrombocytopenia
Plan Selection Display: argatroban for Heparin Induced Thrombocytopenia
PlanType: Medical                                 
Version: 1          
Begin Effective Date: 2012-03-27 13:29:21
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2022-09-01 15:14:09
Available at all facilities: Yes

argatroban for Heparin Induced Thrombocytopenia
Laboratory
		A hemogram, protime and PTT should be ordered if not already obtained in the last 24 hours(NOTE)*
	INR - MH/WH/JE
		T;N, Stat, spec type = Blood
	PTT - MH/WH/JE
		T;N, Stat, spec type = Blood
		T;N+240, Routine, spec type = Blood
	Hepatic Function Panel
		T;N, Stat, spec type = Blood
	CBC with Diff
		T;N, Stat, spec type = Blood
			Comment: Do not need to redraw if already obtained in the past 24 hours
		T+1;0400, Routine, Q24H, spec type = Blood
	Order Lab
		T;N, PTT 4 hours after initiation of argatroban and 2 hours after every rate change. Goal is PTT between 50-85 seconds.
		T;N, Daily PTT once in therapeutic range (PTT 50-85 seconds)
IV Solutions
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	argatroban 50 mg/NS 50 mL Premix
		50 mL, IV
			Comment: Hepatic Dosing (moderate hepatic impairment or AST/ALT > 3x upper limit of normal or Child-Pugh score > 6(Class B)*): 0.5 mcg/kg/min. If PTT less than 50, increase drip by 0.25 mcg/kg/min. If PTT 50-85, continue same rate. If PTT > 85, decrease drip by 0.25 mcg/kg/min.  (if PTT > or equal to 100, stop infusion and consult with MD for instructions on WHEN to restart).  Max dose 10 mcg/kg/min. Calculations should be based on total body weight. Renal Dosing adjustment is not required.
		50 mg, EVERY BAG, 0.5 mcg/kg/min
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		50 mL, IV
			Comment: Normal Dose: 2 mcg/kg/min. If PTT less than 50, increase drip by 0.5 mcg/kg/min. If PTT 50-85, continue same rate. If PTT >85, decrease drip by 0.5 mcg/kg/min (if PTT > or equal to 100, stop infusion and consult with MD for instructions on WHEN to restart).  Max dose 10 mcg/kg/min. Calculations should be based on total body weight. Renal Dosing adjustment is not required. Pharmacy to hepatic dose.
		50 mg, EVERY BAG, 2 mcg/kg/min
Medications
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	Vitamin K (MH/WH)
		2.5 mg, INT, IVPB, Once, NOW
		5 mg, INT, IVPB, Once, NOW
Patient Care
	No IM Injections
		T;N, Avoid all intramuscular injections.
	Discontinue Medication
		T;N, Discontinue all heparin, heparin flushes and low molecular weight heparin
		T;N, For patients started on warfarin, stop argatroban when daily INR >/=4, and enter orders for INR in 4 hours. If 4 hour INR <2, restart argatroban at prior rate and continue daily INR. Repeat this step until argatroban infusion is discontinued.
		T;N, For patients started on warfarin, stop argatroban when daily INR >/=4, and enter orders for INR in 4 hours. If 4 hour INR >/=2 and patient HAS received at least 5 days of therapy with both argatroban and warfarin, DC argatroban and continue daily
			Comment: warfarin with daily INR monitoring.
		T;N, For patients started on warfarin, stop argatroban when daily INR >/=4, and enter orders for INR in 4 hours. If 4 hour INR >/= 2 and patient HAS NOT received at least 5 days of therapy with both argatroban and warfarin, continue argatroban, warfarin
			Comment: and daily INR monitoring until patient has received 5 days of overlap therapy and INR is in therapeutic range (INR >/=2).
	Notify MD of Lab results
		T;N, if PTT greater than or equal to 100 seconds, and discontinue drip.  Consult with MD for instructions on when to restart infusion., Constant Indicator
	Notify MD
		T;N, if signs of bleeding ie. GI, bruising, etc. while on argatroban or coumadin
		T;N, if invasive procedure planned
		T;N, for warfarin dose when platelet counts increase for three consecutive days and there is no evidence of continuing thromboembolism
Consults/Follow-up
	Pharmacy Consult
		T;N, For hepatic dosing if evedence of hepatic disease

*Report Legend:
DEF - This order sentence is the default for the selected order
GOAL - This component is a goal
IND - This component is an indicator
INT - This component is an intervention
IVS - This component is an IV Set
NOTE - This component is a note
Rx - This component is a prescription
SUB - This component is a sub phase