Lovenox order for patient with active GI bleed

[callbelldiva]

Hello,

Just wanted some advice here. I had a 76 yr old patient that came in with active GI bleed, taking Coumadin 7mg at home since 1990 for mechanical aortic valve replacement. He said he had been having dark stools since December, but it comes and goes that is why he didn't seek treatment earlier. He was to recieve an EGD in AM. His HGB was 6.9, and I transfused 2 units of PRBC on him. He was ordered a platlet count which was normal, but no order for PT/INR from Dr. on admission. My question is, was it a good thing to hold the lovenox last night ( I did) although the orders didn't state to hold until after procedure. Also shouldn't a baseline PT/INR and PTT be ordered before Lovenox is given. I know PTT assoc. with Lovenox, and PT/INR for Coumadin. But none were ordered. Would any of you have given the lovenox the night before the procedure given the information.????.

[Laurie52]

Lovenox does not alter the PT/INR or the PTT. It is very short acting so depending on other factors such as the PT/INR on admission and the extent of the bleeding, I might have held the morning dose but not the evening dose.

[BelgianRN]

Hey I wanted to add my five cents.

In general I check in with the physician on call when they prescribe LMWHs when patients are admitted with a bleeding disorder. Not sure how things are organized in your ICU, but mine uses the PDMS to prescribe medications and it has some automated sets that include LMWHs when our physicians don't think about deselecting it before they launch it. And the computer tends to make them lazy and unthinking.

In our hospital we'll usually DC all anticoags until we find out the extend of the bleed and localization. I do think this patient needs a PT/INR, PTT to be drawn. Thankfully we are blessed by a few wonderfully liberal intensivists here that allow us nurses to draw extra labs as we see fit (within a few boundaries) that they'll OK it afterwards. If you're not at liberty to draw those I would probably have advocated heavily on that before anything else.

In some occasions we'll continue anticoags usually when the cardiovascular status is very critical (e.g. main stem stent with HX of in-stent thrombosis elsewhere etc). But generally that's communicated very well so we're all aware that we continue giving anticoags even in light of a bleeding disorder.

In this case I wouldn't have been comfortable at giving any kind of anticoags before additional tests were run. So I would have held the dose until I got a hold of a physician that can explain to me his rationale (or admit he was just ignorant/sleepy/...*insert comment here*).

As I don't practice in the US I might be ignorant about certain rules/guidelines that are in place over there.

[ckh23, BSN, RN]

For someone with an active GI bleed that is requiring a blood transfusion, I would have held the Lovenox and let doc know. As someone stated, it could just be an oversite for computer orders. I also would have politely reminded them that coags need to be drawn so you can get a baseline. I don't understand this workup for a GI Bleed and no coags are done. For all you know this persons INR is 5.

[FLGAZRN]

I would definitely have held the lovenox and would have drawn a PT/PTT/INR because that patient has been taking coumadin. This baseline lab can help that patient later get his coumadin dosing figured out because it seems like the 7mg that he is taking is too much. At the facility I work in, we see GIBs VERY often and commonly, anti coagulant medication is always held until the bleeding has resolved and the patient has been appropriately rescucitated. I am surprised you only transfused 2 units of packed cells. Definitely use your nursing judgement and then chat with the doctor.