PathWays Case Study: April 7

A 60-year-old woman with a pancreatic mass is scheduled to undergo a non-emergency endoscopic procedure. She has a past medical history of stroke and has been on warfarin for the past 20 years. Pre-surgical lab values include an international normalized ratio (INR) of 10.0 (reference range: 0.8 to 1.2). She is not currently bleeding. The patient was given 5 mg of oral vitamin K; her INR was rechecked approximately five hours later and found to be 12.3.

Your Score:  

Your Ranking:  

Heidi Lehrke, D.O.

Heidi Lehrke, D.O.
Resident, Anatomic and Clinical Pathology Residency
Mayo Clinic




Dr. Justin Kreuter


Justin Kreuter, M.D.
Consultant, Division Transfusion Medicine
Mayo Clinic
Instructor in Laboratory Medicine and Pathology,
Mayo Clinic College of Medicine



April Josselyn

April Josselyn is a Marketing Associate at Mayo Medical Laboratories. She is the editor of Mayo Clinic PathWays and supports corporate communications strategies and internal communications. She has worked at Mayo Clinic since 2012. Outside of work, April enjoys the outdoors and being "hockey mom" for her two sports-crazed boys.


I disagree with that answer. With an INR > 10, the patient is super therapeutic (obviously) and while not showing any signs of bleeding; one small misstep or accidental bump could result in marked eccymoses and possible internal hemorrhage. With her clinical history and age, i would also be worried about spontaneous peritoneal bleeding.
Dr. Alter

I agree with Dr.Alter’s comments, you cannot “wait and see,” in a patient with a INR of 12. Particularly in a patient in the older age group, since this would be like sitting on a time bomb. Her physician should give her FFP as soon as possible to bring the INR into a safe zone of 1.5 to 2X the control. The bleeding risk is unacceptable otherwise. Alan Doyle,D.O.

This patient’s bleeding risk with an INR of 12 is too great. Her physician should treat her with FFP as soon as possible to bring the INR into an acceptable range. Alan Doyle, D.O.

Thank you for your comments, Dr. Alter and Dr. Doyle. Management of supratherapeutic INR in patients on warfarin is a challenging clinical issue. According to both the 2008 and 2012 American College of Chest Physicians Guidelines on management of vitamin K antagonists, when the INR is greater than 10 in the absence of bleeding, then oral vitamin K is the only recommended therapeutic intervention (in the 2008 guidelines, this is recommendation 2.4.3; in the 2012 guidelines, this is recommendation 9.1b). Patients should be closely monitored for signs of bleeding. If a patient does begin to bleed, then according to the 2012 guidelines, 4-factor prothrombin complex concentrate is recommended over fresh frozen plasma (in addition to IV vitamin K).




A very interesting scenario.

If we look at the possible answers: IV Vit K: 5 hours after the oral vit K dose, it is not going to work any faster that the dose already given. It would make a total dose of 10mg VitK that is usually seen before high risk surgeries, like heart transplant or valve surgeries ( I work in medical cardiology).
FFP: will bring the INR down, but the effect is short lived, about 4 to 6 hours, so won’t help for the up coming procedure.
PCC: and the likes: One needs to know that they do carry a thrombotic risk when given; their effect is short lived, 4 hours and the INR may rebound, unless vit K was given too (which was the case here) .
One thing the clinician should look into is why the INR is so high. The answer may be trivial like a recent antibiotic course (very common cause). But in a patient with some abdominal mass that needs to be investigated, the reason can be more sinister. It would be important to have an idea before the procedure, just to lessen the odd of a bad surprise during the procedure.
Just my 2 cents..

Comments are closed.