When Will Hospitals Learn How To Use Heparin?
Heparin is one of the most basic medicines commonly used worldwide. It is the primary anticoagulant used by hospitals and is part of the World Health Organization’s List of Essential Medicines. Anticoagulants carry extreme volatility that make a patient 10 times more likely to develop intracerebral hemorrhage, thus — Heparin (unfractionated heparin UFH) and Coumadin (Warfarin) — must be used with the utmost caution in accordance with standard of care.
Medical negligence unfortunately is still quite common with administration of heparin related to the measuring and following of PTT levels after the initial bolus is administered to insure therapeutic levels.
The amount of heparin given is typically based upon a nomogram in which the patient’s initial heparin dose is calculated on weight. But that’s just to start the heparin. The cardiovascular system is dynamic and constantly changing in response to medical conditions such as surgery and reactions to medication. The American College of Chest Physicians state that because anticoagulant response to heparin varies among patients, it is standard of care to monitor heparin and to adjust the dose based on the results of coagulation testing. PTT and INR are the most common lab values used, although antifactor Xa is also now used by hospitals nationwide.
Once on heparin, the patient must be continually monitored to ensure levels remain safely therapeutic – too low, heparin is ineffective while too high increases bleeding risks to patients. PTT should be measured 6 hours after the loading bolus dose of heparin, and the continuous IV dose should be adjusted according to the result, and PTT and INR need to be meticulously monitored thereafter.
High Risk Patients
Patients experiencing or at risk of deep vein thrombosis, pulmonary embolism, atrial fibrillation or other conditions may be given blood thinners to prevent blood clots that could lead to heart attack or stroke. Anticlotting drugs are also given to patients who have already had a heart attack or stroke to reduce the risk of further damage or recurrence. Others are used during certain medical procedures or treatments to prevent clotting in the medical equipment tubing, such as during bypass surgery or kidney dialysis.
While intended to treat or prevent potentially life-threatening health problems, anticoagulants themselves can be very dangerous. Many blood thinners have very narrow margins of error—even the slightest error in strength or dosage can have devastating consequences.
Some populations are particularly susceptible to overdose and must be treated with extreme caution and monitored carefully when on anticoagulants; these populations include the elderly, infants, and patients with certain health conditions or those on specific medications.
Patient Overdose
In the vast majority of overdose cases, practitioner error is the cause. Sometimes, the cause of the overdose is tragically omission. Often, a nurse or doctor misreads the medication label and administers a higher or lower strength dose of the blood thinner and overdoses or under-doses the patient.
In other instances, the practitioner may fail to properly inform the patient that certain medications, supplements, or dietary choices may exacerbate the effects of the anticoagulant, thereby leading to an overdose even when the strength and dosage would have otherwise been appropriate. In all of these instances, the harm could have been avoided were it not for the practitioner’s failure to meet the standard of care in administering these medications which are well known to be lethal if not dispensed and managed with extreme caution.
Failure to Monitor Malpractice Claims
In other instances, the practitioner may fail to properly inform the patient that certain medications, supplements, or dietary choices may exacerbate the effects of the anticoagulant, thereby leading to an overdose even when the strength and dosage would have otherwise been appropriate. In all of these instances, the harm could have been avoided were it not for the practitioner’s failure to meet the standard of care in administering these medications which are well known to be lethal if not dispensed and managed with extreme caution.
Failure to Monitor Malpractice Claims
In many cases, negligence occurs in the practitioner’s failure to monitor the patient for signs and symptoms of an adverse reaction or overdose. Depending upon the type of blood thinner employed and the patient’s health, it may be necessary to obtain certain blood tests at regular intervals to ensure the patient’s clotting level is still within a safe and therapeutic range.
With or without follow-up blood tests, patients must be informed they can experience an overdose that is clinically manifested by outward symptoms of increased or abnormal bruising; excessive bleeding from even minor cuts and scrapes; nose bleeds; or blood in the stool, urine or vomit. Patients may also report a headache, chest pain, stomach pain, dizziness or sudden weakness among other symptoms. Serious injury or death may be avoided with prompt recognition of signs of an overdose and rapid, adequate treatment; however, when left unchecked, patients may suffer severe consequences including gastrointestinal bleeding, hemorrhagic stroke or death.
BRIDGING THERAPY
Patients taking anticoagulants in a clinical setting of a surgical procedure walk a fine line – You don’t want to bleed too much… or too little. Doctors have to walk this fine line by making reasonable judgments.
Generally, the standard of care requires surgical patients to be taken off of Coumadin before surgery to let the INR fall in the therapeutic range of 2.0-3.0 for atrial fibrillation or 2.5-3.5 for prosthetic heart valves to <1.5.
For those patients at greatest risk of developing a thromboembolism, bridging therapy with an anticoagulant may be required. Treatment resumes as soon as prudent after the surgical procedure and continued until the INR reaches the desired therapeutic level. In patients whose risk is only moderate, it is generally safe to stop Coumadin and let the INR sink to a level <1.5 without bridging therapy.
The New England Journal of Medicine addresses “Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation”.
PHYSICIAN LIABILITY
Studies by the American College of Cardiology support that prescribing certain medications such as anticoagulants set off liability alarm bells since improper medication management accounts for the fifth most common allegation. The use of warfarin often places cardiologists between a rock and a hard place. Anticoagulant’s narrow therapeutic window can create liability problems for physicians who need to decrease a patient’s stroke risk, but may end up causing severe bleeding.
Kathleen A. Mary, RNC, Legal Nurse Consultant Certified is an honored medical expert and lifetime clinical scholar valued immeasurably by her plaintiff and defense attorney-clients as a time/cost-efficient asset to medical malpractice, personal injury and product liability claims. Kathleen provides flawless investigative navigation of meritorious complexities, meticulous comprehensive medical record reviews, locates trusted preeminent experts, is a recognized medical researcher and lifetime standard of care clinical consultant. For over 25 years, 100% of Kathleen’s cases (hundreds) have been positively settled without trial. Please contact Kathleen for your next medical-legal case.