The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA.
Am J Health Syst Pharm. 2013 Jun 1;70(11):980-7. doi: 10.2146/ajhp120246.
A simplified dosing nomogram to assist nurses in adjusting the rate of i.v. bivalirudin administration in cases of heparin-induced thrombocytopenia (HIT) is described.
To facilitate the availability of bivalirudin [corrected] as an alternative direct thrombin inhibitor (DTI) for patients with HIT at The Ohio State University Wexner Medical Center (OSUWMC), a team of clinical pharmacists developed a nomogram designed to simplify infusion dosage adjustments by nurses. In contrast to bivalirudin nomograms requiring patient-specific, percentage-based dose adjustments, the nomogram developed at OSUWMC specifies fixed adjustments (0.005 or 0.01 mg/kg/hr) according to the current activated partial thromboplastin time (aPTT) value relative to aPTT goals. During pilot testing over three years, the nomogram was used to guide dosage adjustments in 65 adult patients receiving continuous infusions of bivalirudin for suspected or confirmed HIT in intensive care units. Overall, the use of the nomogram resulted in adequate anticoagulation, with 53.7% of all measured aPTT values in the target range; 30.5% of aPTT values were below target, and 15.8% of values were above target. The median time to steady state was 11.0 hours (range, 5.0-31.8 hours), and bleeding rates were consistent with those reported in the literature. Nurse adherence to the nomogram was 100%, and no dosing errors occurred during a total of 487 dosage changes. Based on the pilot study results, the nomogram was refined to improve initial dosing for patients with creatinine clearance values of >30 mL/min; other refinements were made to enhance the safety of bivalirudin therapy for HIT in patients with severe renal impairment.
A nurse-driven, sliding-scale nomogram for bivalirudin therapy in patients with HIT provided a simple dosing protocol and resulted in a high rate of adherence by nurses.
描述一种简化的剂量图示，以帮助护士调整肝素诱导的血小板减少症（HIT）患者静脉内注射比伐卢定的输注速率。
为了方便俄亥俄州立大学韦克斯纳医学中心（OSUWMC）的 HIT 患者使用比伐卢定[纠正]作为替代直接凝血酶抑制剂（DTI），一组临床药师开发了一种图示，旨在通过护士简化输注剂量调整。与需要根据患者特定的、基于百分比的剂量调整的比伐卢定图示相比，OSUWMC 开发的图示根据当前激活的部分凝血活酶时间（aPTT）值相对于 aPTT 目标相对固定调整（0.005 或 0.01mg/kg/hr）。在三年的试点测试中，该图示用于指导 65 名在重症监护病房接受比伐卢定连续输注的疑似或确诊 HIT 成人患者的剂量调整。总体而言，该图示的使用导致了充分的抗凝作用，所有测量的 aPTT 值中有 53.7%处于目标范围内；30.5%的 aPTT 值低于目标，15.8%的值高于目标。达到稳定状态的中位数时间为 11.0 小时（范围为 5.0-31.8 小时），出血率与文献报道的一致。护士对图示的依从性为 100%，在总共 487 次剂量调整中没有发生剂量错误。基于试点研究结果，对图示进行了改进，以改善肌酐清除率>30mL/min 的患者的初始剂量；对图示进行了其他改进，以提高严重肾功能损害患者的 HIT 比伐卢定治疗的安全性。
一种用于 HIT 患者的比伐卢定治疗的基于护士的滑动比例图示提供了一种简单的给药方案，并导致护士高度遵守。
