INR, nonresponse to coumadin therapy

[cddbme1]

Patient: hx chronic at fib, CABG x2, cardiomyopathy, pacemaker, AICD.

7 weeks post op VAD with hx bleeding in stomach and lungs since VAD surgery.

Coumadin therapy prior bleeds and post bleed have not produced increase in his INR. Coumadin 2.5, 5mg, 5mg, 7mg=inr 1.27; 1.06; 1.12, 1.04.

Also hx 3 PICC lines; 2 clotted off.

No other signs symptoms of bleeding irregularity other than platelets slowly dropping 400,000 to current 247,000. Stools + blood (probably old from stomach bleed)

Everything else normal except pt has c/o of stomach and lower abdominal pain since surgery.

Ileus resolving. Took 1 month for bowels to work.

Bowels currently working but unable to get off NG tube d/t n/v.

J-tube feeding successful at low rates but when rate up 50-70cc/hr GI symptoms get worse.

GI symptoms vary to pinpoint pain LLQ near J-tube insertion, LLQ, RLQ abdominal fullness fairly consistent. Intermittent belching, flatus, Hyperactive bowel sounds now with lots of fliud present upon percussion, abd soft most of time even with fliud. NG drainage varies 450-1000cc/24hr. OU OK

Please comment on coumadin/INR, Persistent symptoms of GI tract not emptying properly. MD's feel problem will resolve. Coumadin being given IV now. Several KUB's. No Cat scans or other tests. Pt on vent with trache (bleeding in lungs prior to trache) Coumadin and AC therapy stopped to get lung bleeding under control. Presently only streaks of blod in NG and ETT small amount bleeding.

[misswoosie]

Patient: hx chronic at fib, CABG x2, cardiomyopathy, pacemaker, AICD.

7 weeks post op VAD with hx bleeding in stomach and lungs since VAD surgery.

Coumadin therapy prior bleeds and post bleed have not produced increase in his INR. Coumadin 2.5, 5mg, 5mg, 7mg=inr 1.27; 1.06; 1.12, 1.04.

Also hx 3 PICC lines; 2 clotted off.

No other signs symptoms of bleeding irregularity other than platelets slowly dropping 400,000 to current 247,000. Stools + blood (probably old from stomach bleed)

Everything else normal except pt has c/o of stomach and lower abdominal pain since surgery.

Ileus resolving. Took 1 month for bowels to work.

Bowels currently working but unable to get off NG tube d/t n/v.

J-tube feeding successful at low rates but when rate up 50-70cc/hr GI symptoms get worse.

GI symptoms vary to pinpoint pain LLQ near J-tube insertion, LLQ, RLQ abdominal fullness fairly consistent. Intermittent belching, flatus, Hyperactive bowel sounds now with lots of fliud present upon percussion, abd soft most of time even with fliud. NG drainage varies 450-1000cc/24hr. OU OK

Please comment on coumadin/INR, Persistent symptoms of GI tract not emptying properly. MD's feel problem will resolve. Coumadin being given IV now. Several KUB's. No Cat scans or other tests. Pt on vent with trache (bleeding in lungs prior to trache) Coumadin and AC therapy stopped to get lung bleeding under control. Presently only streaks of blod in NG and ETT small amount bleeding.

I cannot believe that they considered coumadin one because he was clearly do sick, and 2 because he has a hx of bleeding.

The reaason for his INR not going up into therapeutic range, was because he wasn't absorbing it from his gut, plus the NG feed may have had fairly high levels of VIT K in it.

I assume he was on coumadin for stroke prevention with the Hx of AF, but frankly he has far more pressing problems by the sounds of it ! LMWH would have been a better choice if they were determined to anticoagulate him.I would hate to ask what happened when his INR became therapeutic on the IV coumadin.

He needs a scan to see what is going on in his gut.