CHF with low BP

[E tank]

What is that margin of error? Can it be such a large margin that a therapeutic INR of 2-3 would show up at >5?

A Coumadin does is difficult to dial in because of variables that differ from patient to patient. Liver function and diet play a big role in getting the dose right. A patient can be on more than 2 times the dose of another for the same INR. That's why frequent INR's need to be checked, sometimes as frequently as every 2 weeks. It's also why Xa inhibitors and direct thrombin inhibitors (DTI's) are becoming so popular. They don't need any testing at all, but they're not approved for some things patients need blood thinners for, like mechanical heart valves.

 

[FLdoc2011]

Sounds like decompensated HF. They are wet and white. They need inotropic support (Digitalis), very careful loop diuresis, and pressors like epi. By very careful I mean slowly and with heavy monitoring so that you don't further tank their BP. What is their LVEF%?

Why in the world in the PT's INR 5.9? Who the heck overdosed them on their Warfarin. For that matter WHY are they on an anticoagulant? Give VitK to reverse that and do it right away.

An elevated INR doesn't mean someone "overdosed" them on warfarin. There are some many drug and diet interactions that it's one of the tougher drugs to manage. And in the absence of acute bleeding I'm not at all excited about an INR of 5.9 and would just let it trend down. Certainly if the guy has a mechanical heart valve the last thing you want to do is give him a dose of Vit K if you can avoid it. Treat the patient, not a number.

 

[FLdoc2011]

Not much to add here, other than honestly the most important that can be done is clarifying his code status and bringing in the DNR paperwork. I routinely see these patients in the ED after they show up, there's no family or paperwork and they get intubated.

Otherwise not much to do beyond supportive care, give O2, can use some sort of CPAP or BiPAP if needed depending on his mental status and go from there. If they want to be aggressive in medical treatment and he's truly in a low cardiac outpt state would put him on an inotrope, possibly dobutamine.

 

[Alan L Serve]

An elevated INR doesn't mean someone "overdosed" them on warfarin. There are some many drug and diet interactions that it's one of the tougher drugs to manage. And in the absence of acute bleeding I'm not at all excited about an INR of 5.9 and would just let it trend down. Certainly if the guy has a mechanical heart valve the last thing you want to do is give him a dose of Vit K if you can avoid it. Treat the patient, not a number.

So true! But that doesn't answer my original question of the expected margin of error of INR and Warfarin.

 

[jcroteau]

This is exactly why I love this forum! New information all the time. Now I know I can throw that "well they have a palpable pulse at this location, so their BP must be this" thought process out the window.


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[GMCmedic]

Sadly, and this isnt a stab at anyone here, we have PI's teaching that whole systolic by palpation estimate stuff to Medic students to this day.

Theyre also still warning that albuterol will cause flash edema and Ipratropium is a no no for patients with peanut allergies.

And I wonder why new medics in our area cant asses their way out of an open paper bag.

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[Handsome Robb]

Ipratropium is a no no for patients with peanut allergies.

I had a nurse at a pediatric hospital come unglued at me for giving an asthmatic 10 year old duonebs.

"He has an allergy to peanuts, no wonder his wheezing didn't resolve!"

"No...his wheezing didn't resolve because he's status asthmaticus and I probably should'be pulled the trigger on the epi but he had improved with duonebs, fluids, solumedrol and mag. [emoji849]"


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[E tank]

So true! But that doesn't answer my original question of the expected margin of error of INR and Warfarin.

The sampling/instrument margin of error for INR? Not sure I'm following, but if that is the question, the answer is insignificant enough to not be any kind of consideration when sending these tests. Different brands of equipment will give different margins, but non of them will be large enough to affect a clinical decision. Looking at results in the context of what is going on with the patient, you can pretty much tell if it is instrument/sampling artifact or not. Further, an INR like this in a patient like this is not out of the ordinary and wouldn't be redrawn because it didn't make sense and might be an error.

A healthy 40 yo going for aortic valve replacement, yeah, you'd question it and resend. Margin of error of the lab equipment would have nothing to do with that decision.

 

[Alan L Serve]

The sampling/instrument margin of error for INR? Not sure I'm following, but if that is the question, the answer is insignificant enough to not be any kind of consideration when sending these tests. Different brands of equipment will give different margins, but non of them will be large enough to affect a clinical decision. Looking at results in the context of what is going on with the patient, you can pretty much tell if it is instrument/sampling artifact or not. Further, an INR like this in a patient like this is not out of the ordinary and wouldn't be redrawn because it didn't make sense and might be an error.

A healthy 40 yo going for aortic valve replacement, yeah, you'd question it and resend. Margin of error of the lab equipment would have nothing to do with that decision.

Right, but someone before indicated there is a wide margin of error with INR testing which was both confusing and incorrect.

 

[Carlos Danger]

Right, but someone before indicated there is a wide margin of error with INR testing which was both confusing and incorrect.

No, nobody said that.

 

[Alan L Serve]

No, nobody said that.

Yes, somebody said that.

Aside from the inherent margin of error with Warfarin dosing it is very likely the patient would have either congestive hepatopathy from their CHF or Ischemic Hepatitis from the current shock.

 

[Handsome Robb]

No they didn't.

Chase said: aside from the inherent margin of error with Warfarin dosing it is very likely the patient would have either congestive hepatopathy from their CHF or Ischemic Hepatitis from the current shock.

No one said there was a wide margin of error in INR testing, they said there's a wide margin of error in warfarin dosing.


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[Carlos Danger]

Yes, somebody said that.

Read Chase's comment again. He never mentions INR testing at all.

 

[VFlutter]

I meant that there is a some inherent error in the dosing of Warfarin. It is not exact science but rather guess work usually trial and error. It is not uncommon to have supratheraptuic levels even with routine testing and consistent dosing. And as stated an INR of 5 isn't that impressive and usually the only treatment necessary is stopping dosing until levels drop, which will take longer in a shocky patient like this. But unless the patient is actively bleeding to death Vit K reversal can be more deleterious. Especially if they are on it for a valve/filter.

 

[Alan L Serve]

No they didn't.

Chase said: aside from the inherent margin of error with Warfarin dosing it is very likely the patient would have either congestive hepatopathy from their CHF or Ischemic Hepatitis from the current shock.

No one said there was a wide margin of error in INR testing, they said there's a wide margin of error in warfarin dosing.


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Oh that's quite interesting. There is a reasonable chance you might be more right than otherwise.

 

[MackTheKnife]

Proceed with transport. Do you have a question somewhere? There isn't much to be done with this patient other than bring the DNR in. Also, what did, sorry, "does" this hypothetical patient's DNR say? How specific are the wishes? The patient is 90, I am going to guess their INR being elevated is for any number of reasons, again, none of which will change my treatment course.

Hypotensive and an INR of 5.9? Maybe bleeding somewhere??????

 

[VFlutter]

Hypotensive and an INR of 5.9? Maybe bleeding somewhere??????

Bleeding could be on the differential however in this context cardiogenic shock sounds more likely. As stated most people with an INR of 5.9 do not have catastrophic spontaneous bleeds.

 

[MackTheKnife]

Bleeding could be on the differential however in this context cardiogenic shock sounds more likely. As stated most people with an INR of 5.9 do not have catastrophic spontaneous bleeds.

I'd like to know the BNP as well to help confirm it's truly CHF. As pressors aren't available, I'd transport and monitor BP. From the info, the MAP is approximately 50. Curious where the INR value came from.

 

[VentMonkey]

Hypotensive and an INR of 5.9? Maybe bleeding somewhere??????

Lol, I'm too lazy to go back and re-read my other stuff. I do remember: 90, DNR, and hypotensive.

I guess i figured if I was this patient, what would I want?

For my DNR to be honored, i.e., transport, monitor accordingly, and enter whatever algorithm completely, and respectfully coincides with my wishes.

 

[MikeC]

I'm throwing another scenario out here:

You respond for an Altered MS-- on arrival RN states that patient has been lethargic and O2 Sats were low around 80 so they placed them on the customary 2L NC with 500 feet of tubing and gave them a Neb Treatment (straight albuterol). Denies having checked a BgL "they're not a diabetic" or administering any recent Narcotics. They also stated that the patient has been lethargic since this morning (its around dinner time now).

Patient is lying semi-fowlers in bed, with a very audiable "wet" sound when they exhale with labored respirations. Lower extremities show pitting edema. And they are responsive to verbal. Questioning is futile due to patient being advanced dementia.

Get them into the truck, place them on a NRB at 15L which improves Sat to 95%. 12-lead shows no elevation or block. HR is around 100bpm. Blood Pressure is 65/42. Lung assessed as crackles in all fields. BgL 290. Closest facility is 20 minutes out. And no pressors on board the truck although it is otherwise fully stocked.

What would be your coarse of action?

**Edited to fix grammar**

Crackles/rales suggests pulmonary edema, which is often caused to left-sided CHF (which is unsure if she has this dx from what's posted here). The ekg could read normal with CHF.

With that low of a BP, I'd place in the semi-fowler position and elevate the legs using pillows/blankets. I'd try to get compression socks from the nurse prior to departure.

The bgl is 290 which is high. If the individual is "not diabetic" and at her age, it most likely is d/t insulin resistance and consuming food recently. The high blood sugar level will be treated with insulin at the hospital, and is not as high of a priority as her low blood pressure and respiratory distress.

I'd continue with the NRB at 15 lpm getting her to the closest facility asap. Positive pressure ventilations such as CPAP or BVM could potential help with the rales, but increasing the intrathoracic pressure with an already decreased blood pressure is contraindicated.