INR levels

KittyeeTrix

Just was wondering what is the highest INR levels any of the docs or nurses here on this forum have encountered...

My mum's INR level a few weeks ago registered 17:eek:.
She ended up with a GI bleed which thankfully was taken care of.

As I've said, I'm just curious to know what is the highest any of ye guys have come across and what were the general outcomes for the patients??

liberal

wow in biomed we learn that an inr of 8+ is to be treated with both fresh frozen plasma and vitamin K, ffp is only used as a last resort, ive never even seen a fictional case where an inr is that high

KittyeeTrix

liberal wrote: »

wow in biomed we learn that an inr of 8+ is to be treated with both fresh frozen plasma and vitamin K, ffp is only used as a last resort, ive never even seen a fictional case where an inr is that high

I know, it's all a bit mad. The doc in casualty that night said that the results were sooo out there that they didn't want to believe them!!
Don't know what happened but I was a bit concerned that she had some drug interaction with the tramadol/acetaminophen that she had been prescribed only a few days earlier. Not many cases of this type of interaction on the net but they have been severe where they have occured.
She was also on duloxetine which has a risk of interaction with regards bleeding when on warfarin.
She is very compliant with her warfarin dosage and never misses or overtakes any of her tablets
I was researching it on the net and learnt that many labs stop recording the level after 6 and 10.
I read on a nurses forum somewhere that one nurse had seen a case of 15+ but the patient had died.
What is ffp if you don't mind me asking?

DrIndy

Depending on the assay - whenever it times out, that means the INR is above the absolute cutoff measurable by the machine.

Therefore INR's or a 100 are possible, but not measurable. 8 is a good cutoff though as all big problems arise after that.

liberal

fluffyorganic1 wrote: »

I
What is ffp if you don't mind me asking?

Fresh Frozen Plasma its a component of blood taken from blood donations, it will contain all the coagulation factors and fibrinogen, its only used in extreme cases since the haemphilia scandal in the 1980s that saw many patients infected with HIV after receiving ffp that was bought in from America (in America people are paid for blood donations, this attracts drug addicts that may be infected with HIV, the cornerstone of good blood donation in Ireland is that all donors are volunteers and dont get paid), but ffp in ireland toady is safe, and in the case of Warfin overdose (i had presumed Heprin) vitamin K is all thats needed

drzhivago

fluffyorganic1 wrote: »

I know, it's all a bit mad. The doc in casualty that night said that the results were sooo out there that they didn't want to believe them!!
Don't know what happened but I was a bit concerned that she had some drug interaction with the tramadol/acetaminophen that she had been prescribed only a few days earlier. Not many cases of this type of interaction on the net but they have been severe where they have occured.
She was also on duloxetine which has a risk of interaction with regards bleeding when on warfarin.
She is very compliant with her warfarin dosage and never misses or overtakes any of her tablets
I was researching it on the net and learnt that many labs stop recording the level after 6 and 10.
I read on a nurses forum somewhere that one nurse had seen a case of 15+ but the patient had died.
What is ffp if you don't mind me asking?

One of the more common things to look at is food such as grapefruti which can potentiate actions of warfarin as can some antibiotics by displacing it from plasma proteins

drzhivago

liberal wrote: »

wow in biomed we learn that an inr of 8+ is to be treated with both fresh frozen plasma and vitamin K, ffp is only used as a last resort, ive never even seen a fictional case where an inr is that high

That is not quite correct you treat patients not numbers hence someone with INR of 8 who is not bleeding needs to have does monitored until it comes down not aggressive treatment with Vit K and FFP

You need to consider why they are on it in the first place and what the risk benefit analysis is ie

Have heart valve Target INR 3.5- 4.5 in some hospitals find an 8 as above treat with vit K and FFP (reduce INR but not in controlled fashion as can drop very quickly) now at risk of getting clot on valve and subsequent stroke versus risk of possible bleed while waiting for INR to come down to target level

charlieroot

Would have though someone with an INR > 8 would have been given vitamin K (maybe not FFP unless they had a bleed)? On a related note - doesn't it take a few days for an injection of Vit K to reverse the effect of warfarin - i.e. you need time for the clotting factors to be produced?

DrIndy

Vitamin K takes 6-24 hours to take effect and guidelines are to give 0.5mg-2mg to gently downturn the INR - particularily if at risk (previous big bleed etc..).

This is done extremely cautiously if there is a good reason for a high INR like a metal valve. Most people simply watch and wait or give a tiny dose of vitamin k orally to speed it up - but the caveat is it is very easy to swing too low which defeats the purpose of being on warfarin!

The 10mg tablets and the full 10mg injections are ONLY for patients with liver failure where there is no reason at all for a high INR.

FFP has been surplanted by PCC (prothrombin complex concentrate) which are synthetic recombinant vitamin K dependent clotting factors - as they are synthetic, the risk of a new viral infection or the established HIV or Hep B or C is zero. FFP is reserved if this is not available or in liver disease where all the clotting factors are needed.

The only indication for emergency reversal is an active bleed which cannot be controlled like a stomach or bowel bleed or a brain bleed.

FFP and PCC are not used in bleeds post fibrinolysis (clot busting drugs for heart attacks) - the counter agent here is Cryoprecipitate which contains much higher levels of fibrinogen. This was also the old agents used in haemophilia as it contains higher levels of VIII which is the main haemophilia agent and the cause of most viral outbreaks.

Vitamin K is not used if too much heparin is given - the counter agent (also only if there is a massive bleed) is protamine sulphate. This can also be used to partially reverse low molecular weight heparins such as clexane (enoxaparin) or tinzaparin.