coags for endoscopy

[Gas you down]

anesthesiologist here. what is your cutoff INR that is needed before proceeding with a non-emergent, more semi-urgent case?

the reason i ask is bc/ i had a GI doc say he didn't really care what the INR was before proceeding with an endoscopy. pt had overdosed on aspirin. so in liver failure, INR >6. platelet count <40k. he ordered 2U FFP but didn't order a follow up set of labs to check for adequate correction.

again, at what level of INR would you be ok with? and not just for this patient, any pt that is getting a scope.
thanks, i am curious if i am being overly conservative in the eyes of the gi docs

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[Gastrapathy]

anesthesiologist here. what is your cutoff INR that is needed before proceeding with a non-emergent, more semi-urgent case?

the reason i ask is bc/ i had a GI doc say he didn't really care what the INR was before proceeding with an endoscopy. pt had overdosed on aspirin. so in liver failure, INR >6. platelet count <40k. he ordered 2U FFP but didn't order a follow up set of labs to check for adequate correction.

again, at what level of INR would you be ok with? and not just for this patient, any pt that is getting a scope.
thanks, i am curious if i am being overly conservative in the eyes of the gi docs

Put me in the same camp. There's no evidence that it matters. I'm not going to do some big EMR with an elevated INR but thats about it.

 

[VCMM414]

As a newer GI I am perhaps a bit more cautious. I use ASGE guidelines, depending on whether a procedure is considered high or low bleeding risk and how urgent it is I modify my INR threshold accordingly. INR >6 is pretty darn high, though. I am comfortable with ~2.5 for low risk procedures.

 

[Gas you down]

As a newer GI I am perhaps a bit more cautious. I use ASGE guidelines, depending on whether a procedure is considered high or low bleeding risk and how urgent it is I modify my INR threshold accordingly. INR >6 is pretty darn high, though. I am comfortable with ~2.5 for low risk procedures.

Thanks to you both for answering!

 

[LossForWords]

The rule of thumb the fellow I'm working with told me was INR<1.7 and platelets above 50K for our non-emergent scheduled inpatient scopes.

Maybe he's overly cautious?

 

[jabreal00]

Was the patient bleeding?

Anyways, for diagnostic cases (taking a look) the INR level doesn't matter. However, if I am going to cauterize a potential bleeding vessel do a sphincterotomy I'd like the INR around 1.5.

 

[virilep]

We had an M&M on this. In ESLD, patient INR doesn't really correlate well to actual level of thrombotic risk.

http://www.nejm.org/doi/full/10.1056/nejmra1011170

 

[Gas you down]

Was the patient bleeding?

Anyways, for diagnostic cases (taking a look) the INR level doesn't matter. However, if I am going to cauterize a potential bleeding vessel do a sphincterotomy I'd like the INR around 1.5.

well he'd been bleeding enough to drop his Hct <9. and his INR mattered to the GI guy enough to where he'd transfused FFP, even though he didn't recheck it.

so some people say 1.5-1.7 (which sounds reasonable to me) and some people say they don't really care and it doesn't matter to them.

i was hoping for more of a "Board" answer...something i can use to educate my colleagues so that we have more consistency between us. but i'll take what i can get...i'll say 1.7 unless there is a profound and documented reason to go forward.

 

[gutonc]

well he'd been bleeding enough to drop his Hct <9. and his INR mattered to the GI guy enough to where he'd transfused FFP, even though he didn't recheck it.

so some people say 1.5-1.7 (which sounds reasonable to me) and some people say they don't really care and it doesn't matter to them.

i was hoping for more of a "Board" answer...something i can use to educate my colleagues so that we have more consistency between us. but i'll take what i can get...i'll say 1.7 unless there is a profound and documented reason to go forward.

Next time you want to mess around with the lab, grab a bag of FFP, pull a couple mLs off of it and send it for an INR check. Know what you'll get? Between 1.5 and 2 (depending on the bag and the lab). So trying to get an INR that's already <2 any lower using FFP is a fools errand and a waste of time and resources.

In the case you described, the patient is bleeding like a stuck pig and has several good reasons for that, none of which you can fix, either acutely or chronically. So you do what you can (pour in a couple of bags of FFP, maybe some cryo and a platelet pack or two), put on your big girl panties and go do what needs to be done. This isn't a screening colo, this is "patient will likely die in the next 24h without some sort of intervention". Good on the GI in the case for sacking up and doing the right thing. I hope nobody tried to get in his/her way.

 

[Gas you down]

In the case you described, the patient is bleeding like a stuck pig and has several good reasons for that, none of which you can fix, either acutely or chronically. So you do what you can (pour in a couple of bags of FFP, maybe some cryo and a platelet pack or two), put on your big girl panties and go do what needs to be done. This isn't a screening colo, this is "patient will likely die in the next 24h without some sort of intervention". Good on the GI in the case for sacking up and doing the right thing. I hope nobody tried to get in his/her way.

I didn't say he was unstable. This wasn't an emergency. I canceled the case for an INR of >6. He got FFP, labs were actually checked. Case went just fine the next day, and the doc "who got the in gi guy's way" actually made a reasonable decision.

 

[gutonc]

I didn't say he was unstable. This wasn't an emergency. I canceled the case for an INR of >6. He got FFP, labs were actually checked. Case went just fine the next day, and the doc "who got the in gi guy's way" actually made a reasonable decision.

Good news bro. Your rotator cuff seems to be in fine shape after all.

If all you wanted from this thread was a pat on the back or a handy, you could have just asked for it at the get go.

 

[Gas you down]

Good news bro. Your rotator cuff seems to be in fine shape after all.

If all you wanted from this thread was a pat on the back or a handy, you could have just asked for it at the get go.

I got my answer earlier from those above.

 

[Gastrapathy]

But it's our fault for involving anesthesia in a case that only needed a little sedation. This is why endoscopy is 2x as expensive in the northeast.