Consensus Guidelines for Australian Clinicians for the usage of anti-coagulants during heparin-based product shortages

Appendix 3: Patient Prioritisation Schema if there is a Shortage of Heparin Based Products

Guidelines to assist with contingency planning to manage the clinical implications of a shortage of heparin based products.

Page last updated: 16 July 2008

Treatment Priority 1

Specialty

Medical Conditions and/or Procedures

Usage of LMWH should continue for these pts – high priority

Apart from the specific clinical indications listed, LMWHs should not otherwise be given unless patients require anti- coagulation and have adverse reactions to other anti-coagulants.
PaediatricsCLEXANE ONLY (no Fragmin)

Clexane is the drug of choice for outpatient anticoagulation in children

UFH may be used for inpatients, line patency and dialysis.

There is no experience in using
Clexane for dialysis in children.
Obstetrics and gynaecologyMaternal metal cardiac valves.

Women with DVT/PE during pregnancy

Women with previous DVT/PE with a proven thrombophilia during pregnancy

Women with antiphospholipid syndrome for maternal and foetal benefits during pregnancy

Treatment Priority 2

Specialty

Medical Conditions and/or Procedures

Unfractionated heparin can be substituted for Clexane/Fragmin.



Consider using fondaparinux.


Where possible, patients should be moved to oral anticoagulants.
Emergency DepartmentPulmonary embolus

Deep vein thrombosis

Acute Coronary Syndromes

Multiple trauma patients

Patients on anticoagulant therapy for thrombosis with a current history of cancer

Embolic stroke patients
PaediatricsCongenital heart disease

Scoliosis surgery

Maintenance of line patency in children
Internal MedicineAtrial Fibrillation in the absence of acute embolic stroke

Prophylaxis of pts with PHx of VTE or thrombophilic state

High Risk medical inpatients (eg cardiac failure, chest infection). No data on warfarin usage for this group.

Hyperthyroidism
Cardiothoracic surgeryCardiac valve replacement

Cardiac surgery
VascularVascular surgery

Cerebral aneurysm coiling or embolisation, embolisation of cerebral vascular malformations at risk of haemorrhage, acute upper or lower limb ischaemia with
threatened loss of limb, aortic dissection not amenable to surgical repair, acute occlusion of arteries or veins requiring urgent revascularisation not suitable for surgical intervention.

Endovascular techniques which require heparin cover to minimise risk of arterial or venous thrombosis causing significant pt morbidity eg ischaemic limb rest pain.
Orthopaedic SurgeryHip, pelvis and acetabular fractures. Single long bone fractures
Primary and secondary joint arthroplasty
General surgeryIntra-abdominal malignancy surgery

Moderate-risk urgent or semi-elective general surgery patients are those patients undergoing a non-major procedure and are between the ages of 40 and 60 years or have additional risk factors, or those
patients who are undergoing major operations and are < 40 years of age with no additional risk factors

Higher-risk urgent or semi-elective general surgery patients are those undergoing non major surgery and are > 60 years of age or have additional risk factors, or patients undergoing major surgery who are > 40 years of age or have additional risk factors.

Urgent or semi-elective general surgery patients with a high risk of bleeding
HITH (Hospital in the Home)DVT patients, not outlined above

Note: Where testing is difficult eg rural/remote patients, can use SC UFH regimen with minimal need for dose adjustment according to APTT.
RenalHaemodialysis.

Note: Anticoagulation essential for this group and warfarin NOT an alternative.
Obstetrics and gynaecologyHigh risk women and moderate risk women.

Post natal immediate thromboprophylaxis

Postpartum thromboprophylaxis:

Six week postpartum thromboprophylaxis is used in the following groups and is usually daily Clexane:
  • Women with DVT in current or previous pregnancy
  • Women with thrombophilia and previous DVT
  • Certain other high risk thrombophilias
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Treatment Priority 3

Specialty

Medical Conditions and/or Procedures

Use alternatives to heparin based products eg use other products or mechanical prophylaxis eg IPCInternal MedicineDVT prevention for medical inpatients. Use IPC or GCS.
General SurgeryLow risk general surgery, minor procedure, <40 yrs, no additional risk factors
Laparoscopic surgeryIn general laparoscopic surgery is low risk for thrombosis.

Thromboprophylaxis is not recommended apart from early mobilisation.2
Intravascular cathetersAlternative products such as normal saline may be used for maintenance of intravascular catheters.

NB However heparin Is still required for maintenance of line patency in children.
Obstetrics and GynaecologyCaesarean section. Recommend use of graduated elastic compression stockings and intermittent pneumatic compression boots.11

Available data suggest that the risk of VTE
is higher after caesarean section
(especially emergency surgery) than after vaginal delivery.12 The presence of additional risk factors for pregnancy- associated VTE (for example, prior VTE, thrombophilia, age > 35 years, obesity, prolonged bed rest, and concomitant
acute medical illness) may exacerbate this risk.

Use of GCS during and after caesarean section is recommended in patients considered to be at moderate risk of VTE, with addition of LMWH or UFH prophylaxis in those thought to be at high risk.12
However, data on benefits associated with these interventions are inconclusive.

Laparoscopic gynaecological surgery with additional risk factors for VTE, use GCS or IPC.
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Treatment Priority 4

Specialty

Medical Conditions and/or Procedures

Procedures and elective surgery which can be deferred safelyVascularElective procedures for non-life threatening but life limiting conditions requiring intra-arterial or intra-venous bolus heparin use such as performed for lower limb claudication.
General SurgeryModerate-risk elective general surgery patients.

Higher-risk elective general surgery patients.

Elective general surgery patients with a high risk of bleeding.