Whoa! Crazy ProTime/INR

clou · Apr 7, 2007

I had an admit a while ago, male in his 50's. He was W/C bound, fell out of his W/C on a steak knife that stabbed him in the chest. He received a stab wound below his right nipple. He didn't come to the floor until approx 48hrs later because the stab wound wouldn't quit "oozing" he said. He admitted to the floor with the dx of hypercoagulation. INR 17.6 --- Dr only gave him 10mg SQ vitamin K!!!!!!!!!!

pcicurn7 · Apr 7, 2007

Dont know much about INRs and adults, but all you need for an INR to go through the roof in peds is a nice little cold. I have had a patient go from therapeutic range to 3 times that, in a matter of a day or two.

When you told the doc and he said "ok, thanks", did you ask how you should proceed? FFP is also used in peds, but not unless it is extremely high (the highest i've had was a 9 month old with a 12.something, and all we did was hold the dose).

I've heard stories about teenagers who drink or do the occasional recreational drug on the weekends, then get their INRs taken a day or two after can show some pretty insane numbers. Perhaps this wasnt the case with your lady, but the moral of the story is that ANYTHING can make it go up (colds, diet, new drugs, etc etc), at least in peds, that's the way it is.

Sorry about the craziness of your day!!! That's scary.

meownsmile, BSN, RN · Apr 7, 2007

A pt/inr that high meets ICU criteria in my book.

And i can understand about your day.. I got 3 surgicals and admit within an hour during a 4 hour period of my day. Spent the rest of my shift trying to get all the paperwork and stuff done and didnt get to do any more than peek in on the other patients i picked up at 3.

GrnHonu99, RN · Apr 7, 2007

Had a total ":eek:" moment at work last night.
I walk onto the floor and we're getting slammed - 5 admits in half hour,
Ofcourse, all during shift change time
Had 7 patients all to myself: One very agitated, combative post bowel resection patient in restraints. A 60 year old with CP, mental retardation, MS, seizures (who should be on the neuro specialty floor but wasn't because neuro was full) who was on tele with a Cardizem and Dilantin drip and weird heart rhythms. An ICU transfer. A post perf'd duodenal ulcer with 5 lines going in and 7 lines/tubes coming out. A post hyst who couldn't stop puking all night. My only "normal" patient was a bilat. prophylactic mastectomy...
... and last but not least, a "direct admit" - LOL all of 80 years old who tends to be "forgetful" at times. Dx: Fatigue and loss of appetite. Hx: Chronic a-fib, osteoarthritis, carotid artery clot repair.
All this on a "surgical" floor :selfbonk:
34 beds. 34 patients. 5 nurses. 1 CNA!
I literally zombie'd through my shift. Naturally missed lunch and pee breaks. :trout:
Come morning time - still doing chart checks at 0530. Haven't started charting for the entire night!
Waiting for AM shift to get out of report. Get called a critical value on my LOL 80 year old:
PT > 120
INR > 13.4
[Yes. It meant "greater than". Values were so far beyond the high range end, lab machines were not caliberated for it!!]
I thought someone was playing an April Fool's joke a week late.
Not so!
Had a total ":eek:" moment right there!
Burned my fingers hitting he MDs pager number on the telephone....
Sweated bullets till he called back.
I read him the values and I can almost see him *shrug his shoulders* and he just says "Ok. Thanks!"
His reaction kinda felt like a let down.
Found out later patient takes 2.5mg Coumadin for prophalaxis following a-fib diagnosis. Wondering if she'd been popping one pill too many ...
Oh well. I finally made it home an hour ago.
Just wondering how common it is to see PT/INR values that high...

Wow. I had one once of 5ish and I thought that was high!

Mommy TeleRN, RN · Apr 7, 2007

Ironic thread...as my pt in clinical this week... elderly pt who had CABG in March. Then had a PE. Finally dc'd home, started having hematemesis. Went to the ER, INR was 15! She was having a bleeding ulcer. MD sclerosed the ulcer. But now developed pleural effusion and a UTI and that is when I was assigned to care for her. I felt so bad for her because up til this year she's never even had surgery and said she felt like giving up We did have a great clinical day with her and her daughter though and the MD finally ordered her off bedrest and she looked much happier getting to sit on the couch :)

traumalover, RN · Apr 7, 2007

Highest INR I've seen was 17-on an acute abdomen in septic shock needing or .....five jumbo ffp's and two vit K sq later she rolled into or-she was on coumadin and turns out hadn't had her level checked in over a month.....ooops.

Even if the doc does nothing despite being aware of it-make sure she's on bleeding precautions!!!!

fultzymom · Apr 7, 2007

Have seen them. I work LTC. Usually our MD orders Vit K injection stat. Sometimes he will order one now et one later in the PM et then recheck in the AM. It does give you a moment when you get a call from the lab with a critical level that high. Makes you want to put them in a protective bubble. :lol2:

Roy Fokker, BSN, RN · Apr 7, 2007

LOL! Please tell me you charted calling these numbers to the doc, the response, and filled an incident report.

Standard proceedure is to document Critical Lab value on EMR and date/time/MD paged and response.

I followed that with a more detailed nurses note just to be on the safe side.

In anycase, when I paged MD, he was already at the hospital and was just on a different floor. I saw him in person 5 minutes later...

This is too much to be ignored. Does your lab not call to follow up with the nurse on critical values like this?

They did :) They were the ones who called the floor - it is standard proceedure. I've just never seen a value this high!

HOLEY SMOKES! God bless you floor nurses because you are so resilient. You need to pat yourself on the back for surviving that shift. These are the kinds of days I try to block out of my memory from when I worked on the floor, but heck they are the ones I remember most.

Thanks! Repeated today (minus the crazy patients) - 7 patients/nurse, one tech :rolleyes:

I swear it wouldn't be half as bad if we had at least one more tech.

The assignment you describe sounds insanely scary and dangerous - just had to mention that.

Somedays are just nuts and some days you have 7 patients and you get out early! Acuity makes all the difference. Not saying I like doing 7/nurse...

But then again, I work nights. And we know that all patients do is sleep at nights and all we nurses do is sit around and drink coffee ... right?

Zip - straight from a "risen on the thigh" to "ICU here we go"!

I couldn't send her anywhere - ICU was full. Step down was full. CCU was full. ER was running 18 hour waits...

There was not a single bed in the entire hospital - peds was treating 60 year olds :bugeyes: . It was a perfect madhouse!

did you see earlier labs?,.maybe INR was 22 and is actually on the way down so Doc didn't get real excited? (giving him the benifit of the doubt:o ) just a thought,...hope your next shift is better!!!!

Actually, I did some digging around today. Earlier labs had been checked in ER (PT: 119, INR 13.2). ER doc had given 5 mg Vit. K :rolleyes:

My fault - I should have checked earlier labs. In any case, my default "protocol" for all LOLs upon admit is to insist and constantly remind them to "call me for anything". I remind them that under no circumstances are they to get up by themselves. Besides, I noted that she was mildly hypotensive, so I made double sure she was on fall precautions.

I got 3 surgicals and admit within an hour during a 4 hour period of my day. Spent the rest of my shift trying to get all the paperwork and stuff done and didnt get to do any more than peek in on the other patients i picked up at 3.

Heck, atleast give us a charge nurse or unit sec during nights. Float us one even - I mean, just someone to organise the admit paperwork and fax stuff down to Pharmacy would save us a truck load of time. They don't have to do the paperwork - just organise the charts.

Makes you want to put them in a protective bubble.

Tell me about it. I was thinking "Gee! Sneeze too hard and she could bleed to death from a nose bleed!" :uhoh3:

ZuZuTrauma · Apr 7, 2007

That's quite high. I've only seen that when a pt was on a heparin drip in which you would just go down on the drip. If only on coumadin, makes you wonder if the specimen was hemolyzed. Either way, I'd check the patient for any signs of bleeding and draw another lab before freaking out.

ZuZuTrauma · Apr 7, 2007

Oh, PT/INR... was the patient on any other anticoag therapy?

Anyone see my Vitamin K shot? :idea:

gitterbug · Apr 7, 2007

Roy,

I can only hope one or two less stressful shifts are ahead of you. Happy Easter/Passover.

ritarunningfeet · Apr 8, 2007

Sorry to hear about your crazy night! Hopefully the next shift will go better. I have had folks with crazy high PT/INR's. Guy from nursing home sent in for INR of 16.4 and received 10mg vitamin k,came in and INR came down to 14. something, no s/s of bleeding. He got sent back. Then 2 high ones in one week, little old lady 92, takes 4mg coumadin daily, bleeding slightly when iv started, small hematoma at sight. can't remember PT, INR was 19.5, she got 10mg vitamin k po. Then just this tuesday, had eldery fellow with INR 24.5, again no s/s of external bleeding, taking 10mg coumadin daily. FFP ordered for him. Then one day I had a gal come in with an ICB, whose INR was only 7.9, crazy the difference in INR's have in some people.