PT with INR Disaster

[Jo Dirt]

I was sent out to get a PT with INR on a patient whose previous level was way off (blood was like syrup coming out). So the doctor put her on 9 mg coumadin for 3 days then 5 mg daily after that.

So the woman is hard to stick, anyway. I start with a 23 gauge butterfly needle and she has some veins on her hand and I attempt to use those, but her veins are tough and you can literally see them roll as you try to push in them, but I get a return but it is very slow to come out and the vein blows. After that, I finally find a vein on the arm and using a 21 gauge I get return from that but the blood comes so slow and halfway down the tube it just stops. To the private duty nurse and me it looks like her blood is so thick it won't do anything. The nurse tells me she isn't suprised because the patient will hardly bleed enough to get a blood sample for the glucose monitor.

So I call the nurse at the doctor's office and explain what happened. She was very rude and said "I don't believe that!"

Then I told her the patient had an issue with this before and the doctor put her on 9 mg's coumadin for 3 days and then 5 mg daily. She said she didn't believe that, either. I told her I had the order in front of me and she put it on hold. Then she comes back and says to bring her in the office and they will do it there.

The nurse takes her to the doc's office. I call the residence about 15 minutes ago to see what happened, and the nurse tells me, well, they weren't very happy with us. They didn't draw her blood but they did a finger stick with this big lancet and got her PT that way but I don't think they got an INR, but her PT was 2.2 and they left her on 5 mg's of coumadin.

I did not know they could check her PT with a finger stick. Anytime I have brought that blue topped tube to a lab they said it is very important I fill it to the top.

Someone please explain what happened. What's this fingerstick deal? I feel like a real idiot. Why do blood draws for PT in the first place if all it takes is a fingerstick?

[ICRN2008, BSN, RN]

As an aside about samples, many laboratories do not accept microtainer samples because the volume required for coagulation testing is higher than that which is required for chemistry testing, for example. In addition, if a microtainer is needed to collect a sample on an adult, that usually means that the person is a difficult stick. Coagulation tests are especially sensitive to the inaccuracies that result from poor samples obtained from difficult sticks.

Unfortunately with coagulation testing, the option does not exist to collect only a portion of a blue top tube. This is because there is a precise ratio of anticoagulant to blood that must be achieved in order to obtain accurate test results. This means that the tube must not be overfilled or under-filled. Most tubes have some sort of marking on the outside showing how much blood is needed.

I hope that this information helped. If anyone has any questions, please let me know and I will do my best to answer them.

[Nascar nurse, ASN, RN]

I work in long term care. We were recently shown the "new" PT/INR machines. As another poster described it looks like a very large glucomter and a lancet is used for a finger stick. We have not implemented this into practice in our facility yet and I feel that is a good thing. The whole procedure sounded quite time consuming (not 30 seconds or so like a glucometer), had multiple, multiple steps, the machine had to be set down just so, etc, etc, etc. In our enviornment at least, this sounds like a situation just begging for errors. We could easily have 10 residents needing PT/INR any given am and I just know some nurse will try to hurry it along (because they don't have much time/choice) and some big screw up will occur. Maybe could be a great thing for a home health situation - but LTC = YUCK!

[fetch33]

I work on a large Ortho unit. Most of our total joint patients get PT/INRs daily. I have never heard that you have to waste 3 ml of blood when using a butterfly, which we use exclusively. We use both the regular 4.5ml blue tops and the peds version if the patient is a hard stick.

[TrudyRN]

That office person shouldn't have gotten her knickers in a twist. Shame on her.

I would have to question some lab experts to know the right answer. The accucheck idea sounds like a godsend if it gives accurate results.