A 68-year-old male with chronic atrial fibrillation is noted to have the following coagulation profile
Parameter | Patient Value | Normal Range |
PT | 101 | 12-14 |
APTT | 45 | 34-38 |
INR | 8.7 | 0.8-1.2 |
a) What is the likely diagnosis?
b) Outline your management of this patient?
a) What is the likely diagnosis?
Supratherapeutic warfarinisation
b) Outline your management of this patient?
If not bleeding:
Stop warfarin
Vitamin K
Consider FFP or prothrombinex if high risk of bleeding
If bleeding:
Resuscitation
Stop warfarin
Vitamin K in as low a dose as possible
FFP 10-15ml/kg or prothrombinex 20-25IU/kg
This question stems from guidelines for the reversal of anticoagulation.
It does not take a great deal of cognitive effort to deduce that this AF patient must be on warfarin, and the high INR suggests he has had a little too much.
The model answer for management is derived from anticoagulation reversal guidelines, which vary from place to place but ultimately derive from the 2004 MJA article I have referenced below. Certainly, my local reversal guidelines seem to be based on this. A brief entry on the reversal of anticoagulant therapy deals with this mundane irritation in slightly more detail. In brief, the general trend is to follow various published consensus statements.
Thus:
Thus, one would merely withhold warfarin for a patient with low risk of bleeding. If the risk of bleeding is high, one would give vitamin K or FFP/prothrombinex. If bleeding has already occurred, one would resuscitate the patient and also give FFP/prothrombinex.
Ross I Baker, Paul B Coughlin, Hatem H Salem, Alex S Gallus, Paul L Harper and Erica M Wood Warfarin reversal: consensus guidelines, on behalf of the Australasian Society of Thrombosis and Haemostasis Med J Aust 2004; 181 (9): 492-497.
There is also this local policy document.