B JOSEPH1, H KULKARNI1
1East Metro Health Services – Armadale Health Services, Armadale, Australia
Aim: To establish an effective optimal anticoagulation dose of LMWH in HDF patients by using Modified Jannsen Scoring Scale (MJSS) and Bleeding times (BT).
Method: Maintenance HDF patients (n 46) on heparin (UH) were changed to LMWH over 8 weeks to establish an effective dose and efficacy was established over further 2 weeks on effective dose. Anticoagulation effect and bleeding times were assessed. MJSS score of 1 or less at the end of HDF session was considered effective. LMWH dose was escalated as in protocol. Bleeding and Clotting events were evaluated on UH and Effective dose of LMWH (2 weeks each). Costs, dialysis efficacy, nursing resource utilisation were monitored. Role of Body weight, Hb, antiplatelet/ anticoagulants, Blood flow rate (BFR), UF volume, vascular access were evaluated.
Results: Standard fixed dose LMWH (40 mg for >50 Kg) was effective in 27 of 46 patients (58.7%). 10 of 19 (53%) primary failures responded to stepwise LMWH dose escalation. Remaining 9 patients (19%) needed split-dosing at 0 hrs and 2 hrs in HDF to the optimal dose. Final effective absolute dose and adjusted to body weight (mg/kg) dose (Median IQR) for LMWH was 40 (40 – 80) and 0.60 (0.52 – 0.74) respectively. Primary failure was related to low LMWH dose (mg/Kg) -median IQR 0.40 (0.35-.46). Type of access, Hb, BFR, UF volume had no effect on the dose of LMWH. Costs of LMWH are significantly higher (242%) compared to UH.
Conclusion: Fixed dose Enoxaparin was effective in 59.6% and 40.4% of patients required dose optimisation for effective anticoagulation. Enoxaparin at 0.6 mg/kg (0.5 – 0.7) to the closest available prefilled syringe is suggested as appropriate initial dose.
Boby Joseph is Nurse Unit Manager and have almost qualified as Renal Nurse Practitioner. Apart from an efficient manager, he has keen interests in dialysis related research and patient centred care.