Inadequacy of intravenous heparin therapy in the initial management of venous thromboembolism

To determine the adequacy of initial anticoagulation by intravenous heparin for patients who have deep venous thrombosis (DVT), and the factors that influence delayed anticoagulation, independent, duplicate chart review of 63 consecutive patients who had venography-proven DVT was conducted. Adequate heparinization (AH) was defined as an activated partial thromboplastin time (PTT) of more than 1.5 times the normal laboratory control. The proportions of patients achieving AH within 24 hours and 48 hours of initial heparin bolus were 46% and 62%, respectively. Patients who weighed more were less likely to achieve AH (p<0.05), while patients receiving care from the thromboembolism service were more likely to achieve AH (p<0.05). Low initial infusion rate was strongly but not significantly predictive of inadequate anti-coagulation (p=0.06). The mean heparin bolus and initial infusion rates were significantly lower than those suggested in the literature (p<0.01). The AH rates were comparable to historical controls but suboptimal compared with the rates of 66% at 24 hours and 81% at 48 hours reported in association with heparin nomogram use (p<0.05). A heparin nomogram is likely to achieve consistently higher rates of adequate heparinization.