Actions in response to elevated INRs

[pinkyrx]

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For those of you who have experience working/rotating in anticoagulation clinics (both hospital or clinic based)...

At what point do you send a patient with an elevated INR to the emergency room? Let's say they're not actually bleeding and have no signs/symptoms. Do you send them to the ER if INR is >5.0?

If you're in a clinic do you send them to the ER or do you administer Vitamin K on site? Does it make a difference if your working in a clinic vs. working in a hospital/VA type environment where the ER is almost next door?

Also, how closely do your physicians/pharmacists follow the CHEST guidelines on administration of Vitamin K? Do you see people using IM/IV Vitamin K very often in situations where PO is obviously a better choice?

 

[Aznfarmerboi]

For those of you who have experience working/rotating in anticoagulation clinics (both hospital or clinic based)...

At what point do you send a patient with an elevated INR to the emergency room? Let's say they're not actually bleeding and have no signs/symptoms. Do you send them to the ER if INR is >5.0?

If you're in a clinic do you send them to the ER or do you administer Vitamin K on site? Does it make a difference if your working in a clinic vs. working in a hospital/VA type environment where the ER is almost next door?

Also, how closely do your physicians/pharmacists follow the CHEST guidelines on administration of Vitamin K? Do you see people using IM/IV Vitamin K very often in situations where PO is obviously a better choice?

If the patient is hemodynamically stable and shows no signs of bleeding (gums, bruises, blood in urine), but INR>5, I would just withold warfarin.

In addition, I would find out why the patient's INR>5.

Vit K might not be needed and deciding when to use it is complicated. Risk factors that might require the use of Vit K (w/o bleeding) includes elderly, unstable heart failure; cancer.

http://www.dml.co.nz/inr.asp
http://www.annals.org/cgi/content/full/135/6/S37
http://vitualis.wordpress.com/2006/06/23/how-to-reverse-warfarin/
http://www.sign.ac.uk/guidelines/fulltext/36/section13.html

 

[Priapism321]

> 10 and potentially bleeding gets them a seat in the ER waiting room.

 

[rxblitzrx]

> 10 and potentially bleeding gets them a seat in the ER waiting room.

Why 10 and not 9? I thought the guideline category was [ INR > 9 with bleeding ]

 

[Priapism321]

Why 10 and not 9? I thought the guideline category was [ INR > 9 with bleeding ]

Ok sure, greater than or equal to 10. I was just saying it had to be high, and I think 9 is the number because assays cannot determine the INR once it reaches that point. But thanks sport.

 

[rxblitzrx]

Ok sure, greater than or equal to 10. I was just saying it had to be high, and I think 9 is the number because assays cannot determine the INR once it reaches that point. But thanks sport.

I wasn't trying to be nit-picky or challenge your knowledge on the subject. Sorry if my question came across a little aggressive.