"Emergency" Management of Elevated INRs
Patients taking Coumadin (warfarin) are occasionally referred to the ER by well-meaning primary care physicians when, as often happens, the INR is noted to be abnormally elevated on routine laboratory surveillance. Other times, elevated INR values are incidentally discovered during emergency department evaluations for unrelated concerns.
This article, impressively discovered by Nurse K (despite the fact that she has never taken the MCAT nor received a medical degree) confirms that adverse outcomes are rare in asymptomatic patients with INR elevations in the 5-9 range, and that the majority of such patients can be managed conservatively.
Bravo, Nurse K. Thanks for educating us.
This article, impressively discovered by Nurse K (despite the fact that she has never taken the MCAT nor received a medical degree) confirms that adverse outcomes are rare in asymptomatic patients with INR elevations in the 5-9 range, and that the majority of such patients can be managed conservatively.
Bravo, Nurse K. Thanks for educating us.
posted by scalpel at 12:55 AM
25 Comments:
You're the best.
And the grossest. ;-)
I got the mad, crayzee Google-Fu skeelz. Bow to the queen.
If you want to be REALLY educated on warfarin, there are tons 'o articles in the EM News on warfarin.
Happy 4th!
Interesting...
...by nurse k's own admission: anyone who can plug in terms [even if mis-spelled] can search Google. Agree 1000% - no need for MCAT nor residency for that!
...wonder how this information will help any liable prescriber, when he/she sits in deposition for a mishap that the article itself, written by an ER physician cites:
"Warfarin has been implicated as the one medication associated with the highest incidence of outpatient morbidity, and up to 10 percent of patients will experience a bleeding episode on this drug. Most emergency physicians have a limited knowledge of warfarin, and primarily understand bleeding complications.
"Summary: Patients treated with warfarin can become excessively anticoagulated in a rather surreptitious and clandestine fashion. Even if the INR has been stable for many months, there are just too many variables in maintaining a proper INR to allow patients and clinicians to eschew INR testing on a regular basis. This is especially true in ED patients. My advice has always been to do an INR on almost any patient taking warfarin who presents to the ED with almost any complaint or issue. If nothing else, you give them a free coagulation update. Particularly at risk for erratic INR evaluations are elderly, noncompliant patients and those with excessive comorbidity (and that probably defines almost anyone on warfarin). Even minor changes in diet can wreak havoc with a previously stable INR. Those otherwise healthy leafy green vegetables contain vitamin K that can negate warfarin effect. Of course, almost any drug you prescribe, even antibiotics, will bump the INR one way or another, usually to the upside."
...2 quotes above make the points of the article, written by an ER physician, ironically for his ER colleagues who maybe lost at how to manage elevated INRs
...after ruling out bleeds not discernible by history alone [or even physical exam unless, bleeding is already overt], the ER docs problem goes back to the admitting colleague if he/she, despite additional information gathered from the protected STAT capabilities of the ER, insists on admitting just to feed the arrogance and irritation started before he/she put on his "RETROSPECTOSCOPE"
...funny but not, perhaps the Internist who has escaped into the protected box of the ER, will never have to deal with the liabilities and risk numbers cited in the article, and can continue to be arrogant and pompous
'nuff said
POed at pompous providers carrying 20/20 retrospectoscopes
Why would we insist on admitting, oh frightened and po'ed one? Did you not read the article?
It's not an emergency. Just hold the Coumadin for a day or two.
Even a nurse knows that.
your highness, i am frightened!
as i should be...i do not carry a retrospectoscope, nor a stat crystal ball to know who will surreptitiously and clandestinely be in the 1.3% high risk [info from the article which by the way, actually addresses ED docs' education, and addresses in a phrase the continuing friction between ED and admitting docs]
i would defer to your sage insight [IM & EM residencies?] regarding selling out to nurses to make life easier...after all, that's how doctors must have gotten to their present predicament
have a great 4th!
ER nurses are special. It is they to whom you should bow down, my friend. Join me in anointing them.
Have a great Independence Day!
PO'ed sounds like one of those docs who is intimidated by strong, confident, knowledgable nurses.
Sad. Instead of recognizing and utilizing and appreciating one of his/her best resources in the clinical setting, he/she needs to prove that he/she is the BIG SHOT.
The best docs are not threatened by the best nurses. They LIKE working with these nurses.
I can always spot an insecure doc, both in practice and in my personal experience as a patient. When I go to a physician who is insulting to the nurses, I never go back, because I immediately question this physician's competence.
What are you so afraid of, PO'ed?
Oh, Anon 11:15 -
I anoint, defer and pay homage to nurses, be they ER, floor or community. Unfortunately, the real good nurses are rare and far between...most others prefer to strive to make decisions they cannot be held accountable for? They want to have the benefits of being the doctor without putting in the effort? Bitching and critique, so easy...just like making your off-the-cuff judgments, with little knowledge to go by...very dangerous!
Are you even real, RN?
btw, i won't like u as a patient either if you are that OVERconfident; actually wonder why you [and your likes] even go to the doctor if you can treat yourself with WHAT YOU KNOW? beats me!
the more i know, the more cautious and frightened i have become...
PO ed
I agree with the article and it all seems like sound advice. However can someone explain to me what "The INR was between 5.0 and 6.0 in 96 percent and less than 7.0 in 80 percent," means?
How is that mathematically possible?
I didn't get that part either. Must be a typo somewhere.
PO'ed:
Thanks for your reply to my comment.
It confirms everything I said. :o)
For most of us, somewhere between 6.0 and 9.0 lies a magical line, a chicken out point where we'll decide a little Vitimin K wouldn't hurt. Maybe it's a little lower in patients who've bled before, or are falling every day, maybe a little higher in alert, interested, and motivated patients who will agree to serial INR monitering while their medication is held...
In Canada most Family Docs are probably capable of taking care of all of this in their office, but unfortunately on our side of the border there is no available oral form of Vitimin K available. Ye, the parenteral form can be used orally, but it doesn't happen to appear in the stock cupboard of most Family Docs offices, and so these patients sometimes end up in emerg....
So give 'em a nice spinach salad.
You know Scalpel being on coumadin was the worst drug experience I ever had, and it wasn't the drug that made it so, it was my medical team.
I was placed on it following my total knee replacement. In the hospital I was also getting those heperin (sp) injections in my stomach all the time. Now, all I know about this drug is what it does, prevents clots from forming.
When I was released it was a hassle for the next 6 weeks. My scripts were always for 1 week of pills only and every time it seemed the strength would be increased. Finally I was taking 7.5 mg but the problem I had was getting my Dr. to call in this medication following my lab work, so i didn't run out.
One day I actually talked to his assistant 3 times, because it was getting late and I was out and had been all day. I didn't know how important it really was to be out of this med. or if being without it would hurt me. They had the lab results but had just not called in my med to the pharmacy. Finally their office was closed and surprise the pharmacy did have a script called in. This is a big orthopedic institute so I called and talked to the Doc on call. It was about the most silly phone conversation I ever had.
Would he call my coumadin in for me/ No he would not
Would he call in just one until I could talk to my Doc's office again in the morning? no, he wasn't comfortable doing that.
Was it Ok for me to just not take one that day?
No, he says, "I'm not going to tell you to do that either."
just wtf kind of responses was this anyway?
Bottom line, my home health RN had other patients on coumadin and she went borrowing and brought me some.
It was something like this every week I was on this med. I was never so glad to be off a medication in my life.
I meant the pharmacy did NOT have the script called in.
Interesting, I just saw a pt with a SDH. Her only abnormality, an INR of 4.5 (on coumadin) and a mild HA. No fall, no trauma, nothing. I work in Heme so I can safely say I probably have more experience with coumadin than most docs (and RN's). I don't typically send pt's off to the ER with moderately elevated INR's over goal but I have been around long enough to have a VERY healthy respect for this drug. If I am at all worried after talking to the pt, then I do refer to the ER if they cannot be seen. I am saying this as someone who manages pt's on warfarin for the LONG TERM not a snapshot in the ER. Reading nurse k's link finds one shocking comment "The INR has supplanted the PT". Actually it has not, and I really wonder if Dr James understands the PT and it's relation to the INR. Dr James has a little reading to do.
All patients on Coumadin with any headache should get a CT scan of the brain in my opinion. But such patients are not who we were discussing, are they?
The discussion was regarding management of asymptomatic patients with mildly elevated INRs. We don't (and shouldn't) scan any of those patients.
Scalpel:
The point is to have a healthy respect for the drug. The pt's HA (and it was mild) only came out with questioning. It was not a presenting complaint. I manage coumadin in the long term so I happen to know a little about the subject and I don't dump asymptomatic mildy elevated INR's on you guys. However, I get very tired of hearing bitching from the ER staff and docs about how they get dumped on. For christsakes IT'S YOUR JOB. If you don't like it go do something else. You work 12-14, 8-12 hour shifts a month. You take no call. I take 24 hour call 4-6 times per month and work the next day. The difference between you (nurse k) and me, is I don't incessently whine about it like a child. Please grow up or go do something else.
PS: Again the article makes me wonder if the auther/doc even knows what the INR is, and how it is derived.
"The pt's HA (and it was mild) only came out with questioning."
Exactly. You are notified of an elevated INR on one of your patients. You call the patient and ask "do you have a headache? Are you bleeding anywhere? Is your stool black?"
Or you can send them to the ER and I'll ask for you. It really isn't that complicated.
And the author is right. The PT value alone is not useful, that's why someone came up with the concept of the INR.
Decision tree:
"Yes, I have a headache" = Go to the ER
"No, everything is great. I feel perfectly normal...no headache, no bleeding, no melena, no problems" = Hold your Coumadin today and take a half dose tomorrow, then I'll see you in the office on Monday. If you develop any of those symptoms, then go to the ER.
Sheesh.
"And the author is right. The PT value alone is not useful, that's why someone came up with the concept of the INR."
Try reading the article scalpel. An INR IS BASED ON A GIVEN PT. The author is telling you to look at an INR without a PT. That is simply impossible. But don't believe me I'm just a hematologist. As far as your comments about warfarin. I am not going to waste any more time with someone who doesn't manage warfarin pt's in the long term. Your statements show me one thing. you don't manage pt's on warfarin and nurse k certainly doesn't.
PS: If you noticed I agreed with you about totally asymptomatic MILDY/MODERATELY elevated INR's over goal. But anything, and I mean anything that gives me any type of concern whatsoever with this population. They get an eval. I have seen bad outcomes from this population FROM EXPERIENCE too many times to listen to the blathering from the unexperienced.
PS: Your statement about holding a dose of coumadin one day/taking half a dose the next day makes me wonder if you really understand the dosing of coumadin. May I suggest a review.
A value less than 5 is a mildly to moderately elevated INR. I have managed patients on coumadin long-term, and I do understand the pharmacokinetics, thank you.
The purpose of the INR is to standardize the various PT measurements between labs, so the specific PT reported by an individual lab is unnecessary and meaningless.
I do agree that if any concern is present, the patient should be personally evaluated. But that concern should not be based solely on a mildly elevated laboratory value alone, it should be based upon specific patient characteristics and specific symptoms.
"I do understand the pharmacokinetics, thank you."
A: If your idea is holding coumadin one day and giving half a dose the next, then I don't think you do.
B: Again, read the article. The author does not appear to understand the relation of the PT to the INR. Very simply you can't derive an INR without a PT (as you pointed out).
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