Warfarin and lovenox ...trach bleeding

[usRNs]

Hello everyone I hope you guys can help.... At work I had a patient who was both on lovenox and warfarin... I held warfarin because the patient was bleeding "not profusely" it was dark red from her trach having a quarter of the canister filled and there was some on the foley as well... My thought was the patient is bleeding and though is not profusely if I give the warfarin which will remain 3-5 days in the system he will probably reach therapeutic INR level (it was 1.4) and I didn't want her to bleed much more, i administered the lovenox because my thought was well at least she will be anticougulated until the morning without lowering the INR so much, it only remains in the body 24-36hours and in the morning the primary can decide...I work at night so I was a little hesitant on calling the doctor for it... "My question is was my though process wrong?" I was told that I should have not held it because this two meds have two different pathways, I'm not sure on the pathways but I know they both increase INR. As I'm writing this post I realize more and more the things I could of done and the reason why, but I would like to hear from you. Tnx :)

[imintrouble, BSN, RN]

I would have called the doc. I would not have given any anticoagulant to a pt who was actively bleeding without notifying the MD.

Just to clarify, I don't work critical care.

[blackvans1234]

I was under the impression that lovenox does not alter pt/inr levels, nor does it alter appt.

Just my thought.

[blackvans1234]

Im a student, so this is all based on my theory, and I do not have much clinical expertise.

What were the VS of this patient?

If pulse was significantly trending upward and bp downward, I would have definately made a call.

If the patient appeared to be stable, I would consult with the charge nurse.

QUESTION:

If the patient is actively bleeding, would it be better to hold the lovenox instead of the coumadin?

Lovenox has a shorter half life, so any bleeding may be stopped faster, when compared to coumadin (as OP stated) would take a day or so.

So which would be better to hold?

[KBICU]

Both of them. Lovenox is used to bridge patients' to Coumadin and it is frequently used to prevent DVTs. Regardless of the pathway it works on, I would call the doctor before giving ANY anticoagulant or blood thinning medication if I saw any signs of bleeding in my patient. It sounds like your patient was experiencing hematuria too which in itself should raise a red flag to avoid these meds.When looking up the med in any nursing drug guide, I am pretty certain contraindications/adverse effects explicitly state bleeding. Any word on the outcome of this patient?

[usRNs]

The bleeding was not severe... Her vitals where pretty stable SBP 120's HR 80's pt a&o x4... Mouthing words... The MD was informed by days shift and ordered to hold warfarin and aspirin (aspirin sch in am QD), and cont to administer lovenox... And I agree I think I should just called the md at night to get an official order... Although the order correlated w what I did I wish I had an explanation on my approach or my thought process...

[jadelpn, LPN, EMT-B]

LOVENOX®-- Do's and Don'ts

I would always call the MD no matter what for what they want to do. Especially if patient is actively bleeding, no matter how slight.

I would also be sure to read up on what it is I am giving, as lovenox is an anti-couagulate as well. And if you are making decsions to alter the meds (by holding the Coumadin) I would want orders to back that up, especially in light of the fact the patients condition had changed--even if the patient was seemingly stable. The MD could have asked for labs, all sorts of things......

Some things I do think are within a nurse's judgement. And most often there is a correct way of thinking, however, without an order is what I would be hesitant about. And even with the vitals still being in a "normal" range, I would want assurances that the H&H were not dropping, where the platelets were at, if the INR was high...and all things that could have been ordered by the MD.

[usRNs]

INR was 1.4, sorry forgot to mention h&h 9.9 & 30.9

[usRNs]

I agree with everything. U just said jaldepn...:) thank u for the feed back...:) thank you all for the feed back... Not sure who stated earlier reg lovenox not affecting INR ur right the only way to monitor lovenox is to check Xa factor for what I read from med facts

[jadelpn, LPN, EMT-B]

From what I understand, in the most simpliest terms, Lovenox helps the coumadin do it's job better and quicker. Also depends on what theraputic range the MD is looking to (2-3 is a norm, but not always--depends on what the coumadin is for).

It would kind of make me take pause with an H&H of 9.9 and 30.9. That is a tad low. Bears watching, anyways.

My point is that any time there's something acute, a change of condition of any kind that is different than the norm for a patient, I would call the MD for guidance. No one says you have to go solo on this either. To run down the facts with your charge nurse is also a viable option.

It is difficult to document that patient was actively bleeding, the MD was not called, and that you altered the medication orders without an order to do so.

[thelema13]

Why was she receiving these anticoagulants?

What was the platelet level?

Type and screen on chart?

I would have held both meds, contacted MD for clarification. In regards to the hematuria and active bleeding, is this new onset or been going on for a few days?