N14 — The Anticoagulated Patient at the Chair

When: every treatment for a patient on apixaban (Eliquis), warfarin (Coumadin), rivaroxaban (Xarelto), or another blood thinner. The written order and your unit protocol govern.

Do this

1. Confirm the drug, the dose, and the last dose every treatment (“Did you take your blood thinner last night and this morning?”). Apixaban dose: per your nephrologist’s order / unit protocol.
2. Heparin: per your nephrologist’s order / unit protocol. Don’t assume the standard bolus and infusion apply; if the order doesn’t address the blood thinner, ask before you start.
3. If a heparin-free run is ordered, watch for dark streaks in the dialyzer, clot in the venous chamber, or rising venous or transmembrane pressure [3].
4. Needle sites: firm pressure without stopping flow (you should still feel the thrill). Time it and write down the minutes every session [12].
5. Warfarin: draw the INR with pre-dialysis labs as ordered. Call when the INR is outside the range in the patient’s order [8].
6. Ask every week: black or tarry stools, blood in stool or urine, vomiting blood, nosebleeds, new bruising, any fall, any bump to the head [2][9].
7. Apixaban on dialysis days: usual times — no hold before treatment, no extra dose after [5][6]. Missed dose: the label says take it as soon as possible that day; never double [7].
8. Before a procedure or catheter change: tell the nephrologist the drug and the last dose. Cannulation needs no hold.
9. Before the patient leaves: steady, not lightheaded (N5: Intradialytic Hypotension: Chair-Side Response).

Call the nephrologist when

• Now (and follow your unit emergency plan, N12: Chair-Side Emergencies): a fall with a head strike; new headache, confusion, vomiting, weakness, slurred speech, or vision change; vomiting blood; black or bloody stools; bleeding that won’t stop with firm pressure; a fast-growing access hematoma.
• Same day: the INR is outside the range in the patient’s order — now if the patient is bleeding.
• Same day: the circuit clotted on a heparin-free run; blood in the urine; an unexplained hemoglobin drop (N10: Anemia Protocol: ESA and Iron Hold/Report Rules).
• Same day: new aspirin, clopidogrel, prasugrel, ticagrelor, NSAID, “-azole” antifungal, ritonavir, rifampin, carbamazepine, phenytoin, or St. John’s wort [7]; taking both warfarin and apixaban; a dose that doesn’t match the order; the drug stopped or unaffordable.
• At rounds: needle-site bleeding longer than the patient’s usual for three sessions in a row [12]; a fall without a head strike.
• AF patients: see N1: Potassium Bath Selection for potassium call rules.

Don’t

• Don’t give a heparin bolus to a patient on a blood thinner unless it is ordered.
• Don’t stop, skip, hold, or double a dose on your own — or tell the patient to [7].
• Don’t blame all prolonged needle-site bleeding on the drug. Three sessions in a row can mean the access is narrowing (Examining and Cannulating the AVF and AVG).
• Don’t give vitamin K or a reversal drug without an order.
• Don’t let a patient leave after a head strike without talking to the nephrologist.
• Don’t treat a fall as a reason to stop the blood thinner — report it; the physician decides [10].