Correcting coags - What's the INR of FFP?

[bulgethetwine]

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Common occurrence: A patient who needs central access, but coags are a little high -- say 1.7 INR. So prior to putting in a subclav line, give FFP to bring the INR down per request of admitting team (forget for a minute that I don't think you need to correct from this level for a line anyway, but that's not the point).

Today, I learn from a new source that the INR of FFP itself is actually in the range of 1.6 to 1.7. So, in theory, you can give FFP all day long, but you'll never correct to better than 1.6 with just FFP.

Agree? Any comments?

 

[WakeDoc]

interesting, we just had a very good lecture on this subject last week. You are correct that FFP is about 1.6, so it won't correct below this. So, you give Vit K. There was an algorithm for the dose, but I don't remember. Basically, w/ this low an INR the thought was that you can give a low dose of Vit K (I think 3 for some reason) which will correct for the procedure, but is then easily overcome w/ increased anticoagulant dosing. If your INR was higher, you would have to use a larger dose of Vit K which may not be able to be overcome...i.e. they will need Heparin for a week or so. We had a really interesting case where a guy had a pretty brisk GI bleed (dropping his H/H) and a St Jude valve that prompted this discussion.

 

[EctopicFetus]

Common occurrence: A patient who needs central access, but coags are a little high -- say 1.7 INR. So prior to putting in a subclav line, give FFP to bring the INR down per request of admitting team (forget for a minute that I don't think you need to correct from this level for a line anyway, but that's not the point).

Today, I learn from a new source that the INR of FFP itself is actually in the range of 1.6 to 1.7. So, in theory, you can give FFP all day long, but you'll never correct to better than 1.6 with just FFP.

Agree? Any comments?

Per NSG here you cant get them below 1.5 without some Vit K. FFP wont get your below 1.5

 

[deleted109597]

Don't give them a subclavian line. Give them a femoral, and then correct the coags.

40% of subclavian lines (all types, including PICC lines that just go through there) cause stenosis. You may negatively affect this patients ability to receive dialysis access on that entire side for this line. IJs have only a 10% rate of stenosis. You won't find many vascular guys using the subclavian for anything, including portacaths, for this reason.
Vit K will work, just make sure they don't have a CT surgeon of any kind, because that person will yell at you, a lot. They hate Vitamin K because it is so hard to reestablish therapeutic levels for their valves, etc.

 

[bartleby]

If you have a sickie who is over-anticoaguated and is bleeding acutely, vitamin K is not going to make any change in the patient's INR for the next 24 hours at least, so you can save the trouble. If someone is at acute risk of embolism from a mechanical heart valve, you should strongly consider avoiding it entirely.

We had a really interesting case where a guy had a pretty brisk GI bleed (dropping his H/H) and a St Jude valve that prompted this discussion.

 

[southerndoc]

Ah, the beauty of ultrasound guided IJ's. I've placed them with INR's as high as 7. I will place a femoral introducer sheath (Cordis) with INR's that high too, but only with ultrasound guidance. If it's lower, then I do it without ultrasound. Ignorance is blissful sometimes. I placed an introducer sheath on a hypotensive trauma patient only to find out the INR was 11. Thankfully I never hit the artery.

Our MICU hospitalist had a patient who suffered severe internal hemorrhage after a failed subclavian attempt in a patient with an INR of 2.5. It definitely has made me more aware of the dangers of subclavians in the setting of coagulopathy.

 

[bulgethetwine]

Don't give them a subclavian line. Give them a femoral, and then correct the coags.

40% of subclavian lines (all types, including PICC lines that just go through there) cause stenosis. You may negatively affect this patients ability to receive dialysis access on that entire side for this line. IJs have only a 10% rate of stenosis. You won't find many vascular guys using the subclavian for anything, including portacaths, for this reason.
Vit K will work, just make sure they don't have a CT surgeon of any kind, because that person will yell at you, a lot. They hate Vitamin K because it is so hard to reestablish therapeutic levels for their valves, etc.

In most patient populations, infection propensity of the femoral line is more of a risk than your subclavian stenosis citations. The data for infections is pretty compelling. The vascular guys I work with have no problem with dialysis in the subclavian, so it might be a regional thing for you (and, by extension, for me if I move on to another center. Something for me to keep in mind).

This thread really wasn't about the merits of access where or how, though, it was really about the FFP correction below 1.5 - 1.7.

 

[deleted109597]

Yeah, the original topic about INR was sort of glossed over, but you can still place a line in the femoral/IJ until you have the coags corrected. FFP will, as stated, not correct past about 1.7 depending on your lab and how they compute the INR. But on the other hand, we usually don't correct past that here anyway. Even IR will poke holes on people with an INR of 1.8. Like you said, it probably has more to do with hospital/regional politics than actual medicine.
Even with the slightly lower infection rate from subclavians over IJs (yes, femorals are the most likely to get infected), the much higher pneumothorax rate makes me prefer IJs.
Why do so many people insist(attendings,etc) on subclavians anyway? Other than the slightly "easier" floating of a PA cath, which is highly subjective, I don't see the benefit over a comparable IJ. With U/S guidance, there is minimal risk.
As far as the dialysis thing, we just had a grand rounds on access, and the vascular guy brought up that stenosis or any other downstream problems can affect dialysis fistula flow rates. They're moving away from shunts by mandate from CMS, etc, etc.

 

[WakeDoc]

Before I continue the thread hijack....The case above w/ the St Jude valve having GI bleeder was a real issue I think while it was in the ED. And yes, the CT surgeons just about exploded when they found Vit K was given. However, a clean and squeaky hrt valve is of little use in the completely exsanguinated patient. The prevailing thought in these situations (per CT surgery attending) is that you can in fact reverse w/ Vit K for 1 - 2 hours w/o causing a significant clot burden. So, we did exactly that, and then the pt was loaded on Heparin after the GI crew did their thing.

Back to the hijack...I think the reason SC is traditionally favored over IJ is that probably before the advent of the U/S every attending knew somebody or had themselves caused some serious problems w/ a carotid stick. Now, w/ U/S this risk is obviously much less. Given quick detection and intervention, people aren't going to die from an iatrogenic dropped lung...but a hole in big red in a coagulopath w/o vascular surgery handy can kill fast. Also, for a lot of us (myself included) we really got good at lines in the trauma ICU, which of course is almost exclusively SC approach due to those nasty C collars rotting into most of the patient's necks.

 

[Arch Guillotti]

The number I remember for the INR of FFP is 1.5. It is definitely not less and there is no utility to giving FFP to correct an INR of 1.5 (1.6,1.7 etc.).

We get pts. in the heart rooms who are routinely fully anticoagulated (MI, valve, etc) and routinely place an IJ cordis. We don't use ultrasound on all of them, it really is attending dependent. If their anatomy looks possibly difficult then we will wheel the ultrasound in there.

The only time I have ever hit big red was on a fully anticoagulated pt. Bleeding stopped after a few minutes of direct pressure. The ******ed part about it was that I was doing it under u/s!

 

[bulgethetwine]

Yeah, the original topic about INR was sort of glossed over, but you can still place a line in the femoral/IJ until you have the coags corrected. FFP will, as stated, not correct past about 1.7 depending on your lab and how they compute the INR. But on the other hand, we usually don't correct past that here anyway. Even IR will poke holes on people with an INR of 1.8. Like you said, it probably has more to do with hospital/regional politics than actual medicine.
Even with the slightly lower infection rate from subclavians over IJs (yes, femorals are the most likely to get infected), the much higher pneumothorax rate makes me prefer IJs.
Why do so many people insist(attendings,etc) on subclavians anyway? Other than the slightly "easier" floating of a PA cath, which is highly subjective, I don't see the benefit over a comparable IJ. With U/S guidance, there is minimal risk.
As far as the dialysis thing, we just had a grand rounds on access, and the vascular guy brought up that stenosis or any other downstream problems can affect dialysis fistula flow rates. They're moving away from shunts by mandate from CMS, etc, etc.

I think it is just how comfortable you are with subclavians and the availability of u/s.

Yes, it is quickly steaming toward 'standard of care' to use u/s for all central lines -- IJ anyway -- but it's not like that everywhere because not all places have u/s in the community. Obviously you know HOW to do an IJ without u/s guidance, but as I'm sure you know, a lot of it is confidence game.

And, incidentally, some studies show higher risk of pneumothorax with IJ than subclavian. Turns out, anatomically, the apex of the lung is closer to (potentially) your entry point on the IJ then on the subclavian since you've got a fair bit of space in and around the 1st rib. Honest 🙂 (I'm an old anatomy prof).

I totally agree that the safest line, when high coags might be in play, is an IJ under ultrasound. But having my 'go to' line as subclavian is a complimentary skill in my toolbox. And in a community without u/s, I'm fine placing an IJ blind. And don't forget the 'pocket shot' either (supraclavicular).

The point is, practice all of 'em as a resident. You never know where and when in your practice you're gonna come across the weird guy with a stent someplace, or a previously accessed, now scarred down vessel precluding you from placing that IJ (or that subclavian if that's your preference).

 

[deleted109597]

The point is, practice all of 'em as a resident. You never know where and when in your practice you're gonna come across the weird guy with a stent someplace, or a previously accessed, now scarred down vessel precluding you from placing that IJ (or that subclavian if that's your preference).

Absolutely. I think having the full armament is important. Blind, not blind, location of choice, rescue locations, you name it. Just like airways, if you don't have access, you go can go down real fast. Hell, I don't have anywhere near enough to say that I'm an expert (although I can do them in my sleep pretty well).
The other factor is that we have a resident here who is notorious for bagging the lung, and without an adequate teaching base (small community hospital), continues to do so because nobody can teach them not to.
I usually reserve femorals for trauma/level 1 type things, because they can be removed once things get less hairy, and there is usually other stuff going on up at the head of the bed.
I've still yet to try a supraclavicular approach, that is one that I really don't have the confidence to try. I can just imagine the fun that will exist there.

I'm not sold on the idea of stopping the FFP just because you get to the magic threshold, simply because whatever caused you to lose the factors might still be happening, and you can still replace them. I just wouldn't push it as fast. Also, platelets might be warranted in this situation as well.

 

[Apollyon]

depending on your lab and how they compute the INR.

Dude, remember what "INR" stands for? "International Normalized Ratio" - it doesn't matter HOW the lab computes it - the INR is the same wherever you go.

 

[DeLaughterDO]

Dude, remember what "INR" stands for? "International Normalized Ratio" - it doesn't matter HOW the lab computes it - the INR is the same wherever you go.

Sure, the computation is the same everywhere you go, but the actual values may be slightly different from lab to lab since the sample specimen is compared against a pooled sample from individuals in YOUR community. The sources of the "standard" population differ.

 

[deleted109597]

Sure, the computation is the same everywhere you go, but the actual values may be slightly different from lab to lab since the sample specimen is compared against a pooled sample from individuals in YOUR community. The sources of the "standard" population differ.

Yeah. What he said.
I was once quoted a 10% swing in values for INR by a lab person, so 1.7 and 1.5 could be almost the same at two different places.

 

[Rony]

Visiting from the surgery forum..

I am sorry Dr. Mcninja, but what you said of the rate of pneumothorax with subclavian lines and IJs is inaccurate.

The rate is the same, the data are clear.

Femoral lines do not have a higher infectious rate, the data are clear on that too, more recently. The risk here is thrombosis.

Remember, there are no absolute contraindications to central line placement. That means, if a line is necessary, you can use adjunctive imaging guidance if you need it but don't waste time correcting coagulopathies.

 

[DrQuinn]

Visiting from the surgery forum..

Femoral lines do not have a higher infectious rate, the data are clear on that too, more recently. The risk here is thrombosis.

I would love to see the data on that. I have never heard of an article debunking this...

and a quick pubmed search:

Central venous access sites for the prevention of venous thrombosis, stenosis and infection in patients requiring long-term intravenous therapy.
Hamilton HC, Foxcroft DR.

Oxford Radcliffe Hospitals NHS Trust, TPN and Line Insertion Team, Level 6 C/D, John Radcliffe Hospital, Oxford, UK, OX3 9DU. [email protected]

BACKGROUND: Central venous access (CVA), in which a large bore catheter is routed through a vein in the neck, upper chest or femoral area, is needed to give drugs that cannot be given by mouth or via a conventional cannula in the arm. OBJECTIVES: To establish whether either the jugular, subclavian or femoral CVA routes result in a lower incidence of venous thrombosis, venous stenosis or infection related to CVA devices.To determine whether the circumference of a long-term central venous access device influences the incidence of venous thrombosis, venous stenosis or infection related to CVA devices. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2006, Issue 4), MEDLINE, CINAHL, EMBASE (from inception to December 2006), reference lists of identified trials, and bibliographies of published reviews. We also contacted researchers in the field. There were no language restrictions. SELECTION CRITERIA: We included randomized controlled trials comparing central venous catheter insertion routes. DATA COLLECTION AND ANALYSIS: Two authors assessed potentially relevant studies. We resolved disagreements by discussion. Relevant outcomes were: venous thrombosis, venous stenosis, infection related to CVA devices, mechanical complications (e.g misplaced catheter, minor bleeding, haematoma). MAIN RESULTS: We considered 83 studies for inclusion in the review. Six studies appeared eligible but five were subsequently excluded because they did not randomize participants for either site of access or catheter circumference size. One study was a high quality block randomized controlled trial. Allocation concealment was good and randomization was by a central computer. In all, 293 patients were randomized to a femoral or a subclavian CVA group. Results from this one trial were as follows. 1. CATHETER-RELATED INFECTIOUS COMPLICATIONS: Infectious complication (colonization with or without sepsis: the relative risk (RR) was 4.57 (95% confidence interval (CI) 1.95 to 10.71) favouring subclavian over femoral access.Major infectious complications (sepsis with or without bacteremia): the RR was 3.04 (95% CI 0.63 to 14.82) favouring subclavian access. Colonized catheter (greater than 103 colony-forming units/mL of gram positive microorganisms): the RR was 3.65 (95%CI 1.40 to 9.56) favouring subclavian access. Colonized catheter (greater than 103 colony-forming units/mL of gram negative microorganisms): the RR was 5.41 (95% CI 1.61 to 18.15) favouring subclavian access. 2. CATHETER-RELATED MECHANICAL COMPLICATIONS: Overall complications (arterial puncture, minor bleeding, haematoma, misplaced catheter): the RR was 0.92 (95% 0.56 to 1.51) favouring subclavian access. 3. CATHETER-RELATED THROMBOTIC COMPLICATIONS: Catheter-related thromboses (fibrin sleeves, major and complete thrombosis): the RR was 11.53 (95% CI 2.80, to 47.52) favouring subclavian access. AUTHORS' CONCLUSIONS: Subclavian CVA is preferable to femoral CVA. Further trials of subclavian versus femoral or jugular CVA are needed. Research on the impact of catheter circumference on catheter-related complications is required.

 

[Aloha Kid]

The other issue is if the ER doc puts in a femoral line, and it is taken out the next day by the ICU doc or at least within 3 days, is there still a higher incidence of infection vs up top lines.

 

[kungfufishing]

The only time I have ever hit big red was on a fully anticoagulated pt. Bleeding stopped after a few minutes of direct pressure. The ******ed part about it was that I was doing it under u/s!

I've done this under ultrasound, in this kind of patient, too. Double walled the needle, boy did I ever feel like a genius. I will say that using U/S for the IJ has only made me surprised I had not hit the carotid more often - think of how many people are found to have slightly variant anatomy when you put the probe on.

 

[dchristismi]

There is one thing worse than having a CT surgeon yelling about you for giving the Vitamin K, and that's the neurosurgeon yelling at you for not giving it. I ended up letting them duke it out in one of the craziest cases of my career, in which an anticoagulated, mechanical valved patient develped both a basal ganglia hemorrage AND a descending aortic dissection. The same day. In my ER. She did surprisingly well, considering.

And for the off-topicness, I love my IJs. Threw an US guided one in a massive-GI-bleed last week with INR of 4.4. I didn't have the INR back at the time, but didn't have good enough access without it.

 

[deleted109597]

Visiting from the surgery forum..

I am sorry Dr. Mcninja, but what you said of the rate of pneumothorax with subclavian lines and IJs is inaccurate.

The rate is the same, the data are clear.

Femoral lines do not have a higher infectious rate, the data are clear on that too, more recently. The risk here is thrombosis.

Remember, there are no absolute contraindications to central line placement. That means, if a line is necessary, you can use adjunctive imaging guidance if you need it but don't waste time correcting coagulopathies.

Which data?
We have a Duke CV training course that begs to differ. Maybe they need to update their course, but since the references were pretty new, I doubt it (they included the checklist study).

 

[pseudoknot]

Femoral lines do not have a higher infectious rate, the data are clear on that too, more recently. The risk here is thrombosis.

I would love to see the data on that. I have never heard of an article debunking this...

I did see this recently, although I don't know what the impact of it has been.

http://jama.ama-assn.org/cgi/content/short/299/20/2413

Femoral vs Jugular Venous Catheterization and Risk of Nosocomial Events in Adults Requiring Acute Renal Replacement Therapy
A Randomized Controlled Trial

Jean-Jacques Parienti, MD, DTM&H; Marina Thirion, MD; Bruno Mégarbane, MD, PhD; Bertrand Souweine, MD, PhD; Abdelali Ouchikhe, MD; Andrea Polito, MD; Jean-Marie Forel, MD; Sophie Marqué, MD; Benoît Misset, MD; Norair Airapetian, MD; Claire Daurel, MD; Jean-Paul Mira, MD, PhD; Michel Ramakers, MD; Damien du Cheyron, MD, PhD; Xavier Le Coutour, MD; Cédric Daubin, MD; Pierre Charbonneau, MD; for Members of the Cathedia Study Group
JAMA. 2008;299(20):2413-2422.

Context Based on concerns about the risk of infection, the jugular site is often preferred over the femoral site for short-term dialysis vascular access.

Objective To determine whether jugular catheterization decreases the risk of nosocomial complications compared with femoral catheterization.

Design, Setting, and Patients A concealed, randomized, multicenter, evaluator-blinded, parallel-group trial (the Cathedia Study) of 750 patients from a network of 9 tertiary care university medical centers and 3 general hospitals in France conducted between May 2004 and May 2007. The severely ill, bed-bound adults had a body mass index (BMI) of less than 45 and required a first catheter insertion for renal replacement therapy.

Intervention Patients were randomized to receive jugular or femoral vein catheterization by operators experienced in placement at both sites.

Main Outcome Measures Rates of infectious complications, defined as catheter colonization on removal (primary end point), and catheter-related bloodstream infection.

Results Patient and catheter characteristics, including duration of catheterization, were similar in both groups. More hematomas occurred in the jugular group than in the femoral group (13/366 patients [3.6%] vs 4/370 patients [1.1%], respectively; P = .03). The risk of catheter colonization at removal did not differ significantly between the femoral and jugular groups (incidence of 40.8 vs 35.7 per 1000 catheter-days; hazard ratio

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, 0.85; 95% confidence interval [CI], 0.62-1.16; P = .31). A prespecified subgroup analysis demonstrated significant qualitative heterogeneity by BMI (P for the interaction term < .001). Jugular catheterization significantly increased incidence of catheter colonization vs femoral catheterization (45.4 vs 23.7 per 1000 catheter-days; HR, 2.10; 95% CI, 1.13-3.91; P = .017) in the lowest tercile (BMI <24.2), whereas jugular catheterization significantly decreased this incidence (24.5 vs 50.9 per 1000 catheter-days; HR, 0.40; 95% CI, 0.23-0.69; P < .001) in the highest tercile (BMI >28.4). The rate of catheter-related bloodstream infection was similar in both groups (2.3 vs 1.5 per 1000 catheter-days, respectively; P = .42).

Conclusion Jugular venous catheterization access does not appear to reduce the risk of infection compared with femoral access, except among adults with a high BMI, and may have a higher risk of hematoma.

 

[bartleby]

There should be no impact on clinical practice from one study whose findings disagree what is fairly well proven regarding the infection rates of femoral (i.e. crotch) lines. In the age of ED ultrasound, the femoral vein should be considered the line of last resort.

I did see this recently, although I don't know what the impact of it has been.

http://jama.ama-assn.org/cgi/content/short/299/20/2413

Femoral vs Jugular Venous Catheterization and Risk of Nosocomial Events in Adults Requiring Acute Renal Replacement Therapy
A Randomized Controlled Trial

 

[sese]

actually, in the icu literature, fem and ij lines seem to have similar rates of infection.
the 2008 jama parienti et al trial was actually a decent trial, better than most of the observational stuff out there. it's not ED patient population though.

Other articles (if anyone's interested)
1) Charalambous et al. Arch Surg 1998; 133: 1241-1246
(IJ's but not SC's assoc with higher infection rates)

2) Merrer et al. JAMA 2001; 286(6): 700-707
(RCT concluding that fems > SC in infection risk)

3) Deshpande et al. Crit Care Med 2005
(concludes that infection rates are low at all 3 sites so who cares which site!)

4) Lorente et al. Critical Care 2005; 9: 631-5
(largest study in SICU pts with infection greater in fem > IJ > SC)

5) Gowardman et al. Intensive Care Med 2008.
(Fem and IJ > SC for infection)