This is a young female patient post SLEEVE gastrectomy, presented with massive PE, her baseline INR was 1.9 "mostly nutritional", she was started on therapeutic LMWH and warfarin, second day her INR jumped to 4, what is the right action.
Can you please provide more detail on the case, such as age, other therapy she might be taking (prescription and OTC), food and drink habits, renal function, blood pressure values, etc...?
Actually this patient is otherwise healthy, she is 34 years old not on any medication , she underwent SLEEVE gastrectomy few weeks ago, she was admitted because of massive PE with INR 1.9 , she was started on enoxaparin 1mg per kg twice daily and warfarin 5mg once daily, next day her inr jumped to 4 , enoxaparin stopped and warfarin dose reduced to 2.5 mg
my question is it was a right call to stop her enoxaparin after only one day? And is starting warfarin with this high baseline inr was suitable?
This is a most particular case. I believe that it is not possible to give a "evidence-based" answer about which treatment is more correct at time of emergency. The solution would necessarily require the study of etiology of the baseline alteration of the INR, despite which there was anyway a serious thromboembolic event.
Would not have started warfarin immediately with a high baseline INR until there was a good idea as to what the high baseline INR represented-?liver congestion from right heart failure.
However I agree that it was best to cease the enoxaparin when the INR reached 4 as the risk of spontaneous haemorrhage was increased (and the patient was still only two weeks out from her initial surgery).
How is the patient doing now? Has the warfarin dosing become more straightforward?
Answering directly your question, I don't think it was the best decision to stop enoxaparin only after one day, but now that it's done the best solution is to manage the dose of warfarin to achive optimum INR.
We must answer 2 questions: What was the cause of elevated baseline INR,Was it elevated preoperative denoting poor synthetic liver function or this elevation occured postoperative ,which if combined with pulmonery embolism may point to the possibility of DIC.The second question is:is there any DVT?its presence my change our decisions.
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