pt/inr platlets and coumadin and fragmin

April, RN, BSN, RN · May 11, 2010

4.2 is a pretty high INR. It sounds like the Fragmin was being used as a bridge to a Coumadin. What would the purpose of the Fragmin be if the blood was already that thin? That nurse was out of line calling you an idiot for asking that. You were right in your thinking. Did you hold the Fragmin?

NurseLoveJoy88, ASN, RN · May 11, 2010

Those labs are really high and does increase the risk of bleeding. I would of called the doc just to make sure it would be ok to give the framin. Especially since fragmin is given to many post op patients that may be at risk for clotting. I would also find what the patients theuraputic range is... I have a patient who always have an inr of 2.0 and pt of 24 and this is her therapuetic level thus the doc doesn't make any change in her coumadin dose.

megcd · May 11, 2010

Yeah the fragmin was already being held. The doctor was aware and a hematologist was on the case for that and other reasons. And I gave my explaination for what I thought the doctor was holding it. And she acted like I was stupid because pt/inr "is not related to fragmin." And I understand that, yet the pt was at risk for bleeding.I just told her she can ask the doctor that day if she wanted to know what. But I was sure he would keep it held.

I just left angry and really wanted to give her a piece of my mind because this is not the first time she has acted like that.

I just figured "common sense! Very high pt/inr, then hold all anti-coags and anti-plts and give VI."

Thanks for the replies

I just fu

megcd · May 11, 2010

Yeah the fragmin was already being held. The doctor was aware and a hematologist was on the case for that and other reasons. And I gave my explaination for what I thought the doctor was holding it. And she acted like I was stupid because pt/inr "is not related to fragmin." And I understand that, yet the pt was at risk for bleeding.I just told her she can ask the doctor that day if she wanted to know what. But I was sure he would keep it held.

I just left angry and really wanted to give her a piece of my mind because this is not the first time she has acted like that.

I just figured "common sense! Very high pt/inr, then hold all anti-coags and anti-plts and give VI."

Thanks for the replies

I just fu

aCRNAhopeful · May 11, 2010

It was good that you made sure the doctor was aware before giving any other anticoags but the reasoning of always hold all anticoags and antiplatelets if you have a high PT/INR is not really correct. Reason being that each of the drugs mentioned (coumadin, heparin or LMWH, and aniplatelets) each work with a different part of the clotting cascade as you may be aware. So for example, to hold Plavix just because you have a high PT/INR would not be a good idea and could cause some serious issues like a stent thrombosis-->Acute MI. Sounds like you did the right thing so don't worry about that other nurse.

Penelope_Pitstop, BSN, RN · May 12, 2010

I still don't understand the difference between all of these drugs, and I've been a nurse a good deal longer than you have...so don't feel bad!

I also haven't given Fragmin in quite some time. The only time I've seen it ordered is on a joint replacement patient. I remember platelets being the important lab value in those patients, and I'm not sure if all of them even had PT/INRs drawn. (Probably, but it's been more than two years ago, I don't recall).

Anyway, I'd question giving any "bleeding precaution" drug with an INR of 4.2. You did right, don't let that other nurse make you feel badly.

But if someone could explain the difference between these drugs...I'd really appreciate it. (Really missing Daytonite right about now..)

cokristinug · May 12, 2010

i remember that one time a nurse was going to hold the fragmin bc a patient's platelets were low and the doc wrote on the chart "dont hold fragmin, has nothing to do with platelets" so idk....

Penelope_Pitstop, BSN, RN · May 12, 2010

From my healthcare system's formulary in regards to Fragmin:

Monitoring Parameters: Periodic CBC including platelet count; stool occult blood tests; monitoring of PT and PTT is not necessary. Once patient has received 3-4 doses, anti-Xa levels, drawn 4-6 hours after dalteparin administration, may be used to monitor effect in patients with severe renal dysfunction or if abnormal coagulation parameters or bleeding should occur.

aCRNAhopeful · May 12, 2010

Regarding the differences between those drugs: Since clotting occurs as a series of chemical reactions anticoagulant meds can intervene to stop some part of that chemical reaction to prevent clotting. There are three main parts to this chemical pathway: the intrinsic, the extrinsic, and the common pathway. The intrinsic and extrinsic pathways are two separate pathways that can occur independent of eachother. If you picture a "Y" the intrinsic and extrinsic make up the two top pieces of the Y. Then they meet in the common pathway to finish out up clot formation. So coumadin effects only the chemical reactions in the extrinsic pathway, heparin and LMWH's effect the intrinsic pathway, and antiplatelets don't necessarily effect the pathway itself, only the platelets. So antiplatelets keep them from sticking together to start the process of clot formation, since a platelet plug is one of the first mechanisms of hemostasis. So that is why someone could be on all of these meds and it be OK or even essential that they are. And that's why the doctor made the remark of "fragmin has nothing to do with platelets". This is from the top of my head so there could be mistakes, feel free to correct!:)