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What Does High INR Indicate?
Question: 1) If a pt has a high INR (2.1, next day 2.2) but is not on Coumadin (warfarin) or any other anticoagulant then should some sort of work up be done to establish the cause? Why? 2) If the pt has suspected sepsis & pneumonia then can the underlying cause of the high INR be reasonably assumed? 3) Is it appropriate in these circumstance (without a work up) to administer 1 mg of Vitamin K? 4) if an elderly pt is administered 0.5 mg of haloperidol IM for delirium with nil effect then is it possible that the lack of effect could indicate some underlying medical problem that needs to be investigated and not simply that a higher does is needed?
Brief Answer:
Disseminated intravascular coagulation/ liver fail
Detailed Answer:
Hi,
Thanks for asking.
I am Dr. Prakash HM and I will be answering your queries:
The answer for the queries are as below:
1. INR if increased means, the coagulation system is functioning less. Decreased availability of clotting factors or decreased functioning of the clotting factors is the usual cause. In a patient who is not on any anticoagulants, it requires investigation as it indicates the possibility of coagulation system being abnormal. Usual causes include liver failure and disseminated intravascular coagulation (DIC).
2. In a patient with septicemia, DIC is the usual cause strongly suspected. However, liver failure due to liver infection secondary to septicemia also needs to be ruled out.
3. Vitamin K function is to increase production of clotting factors from liver. The clotting factors which are increased are 2,7,9 and 10. Only in deficiencies, Vitamin K will increase the production of clotting factors. As INR is high, reduced clotting factors is always assumed, and therefore Vitamin K injection is given. At this dose, Vitamin K injection would not complicate anything and can be given without workup.
4. Delirium is always due to a underlying medical problem. To reduce the delirious state, haloperidol is used. Looking at the clinical history there are multiple causes which could complicate things. Investigation would take much longer, and patient if delirious, would be difficult to manage. Usual line of management is to increase the dose to help the patient function adequately.
Any further queries, happy to help again.
Dr. Prakash HM
Disseminated intravascular coagulation/ liver fail
Detailed Answer:
Hi,
Thanks for asking.
I am Dr. Prakash HM and I will be answering your queries:
The answer for the queries are as below:
1. INR if increased means, the coagulation system is functioning less. Decreased availability of clotting factors or decreased functioning of the clotting factors is the usual cause. In a patient who is not on any anticoagulants, it requires investigation as it indicates the possibility of coagulation system being abnormal. Usual causes include liver failure and disseminated intravascular coagulation (DIC).
2. In a patient with septicemia, DIC is the usual cause strongly suspected. However, liver failure due to liver infection secondary to septicemia also needs to be ruled out.
3. Vitamin K function is to increase production of clotting factors from liver. The clotting factors which are increased are 2,7,9 and 10. Only in deficiencies, Vitamin K will increase the production of clotting factors. As INR is high, reduced clotting factors is always assumed, and therefore Vitamin K injection is given. At this dose, Vitamin K injection would not complicate anything and can be given without workup.
4. Delirium is always due to a underlying medical problem. To reduce the delirious state, haloperidol is used. Looking at the clinical history there are multiple causes which could complicate things. Investigation would take much longer, and patient if delirious, would be difficult to manage. Usual line of management is to increase the dose to help the patient function adequately.
Any further queries, happy to help again.
Dr. Prakash HM
Above answer was peer-reviewed by :
Dr. Ashwin Bhandari
Thank you very much Dr Muddegowda. May I have some further information/clarification? (1) You mentioned that Vitamin K could be given for the high INR. The person also has a high PT Test result of 22.4 seconds. Could this have any relevance to the matter? Does it also justify the administration of Vitamin K? (2) Is there a treatment for DIC? (3) With regard to the nil effect of 0.5 mg of haloperidol, you stated that it would be difficult to manage to investigate (which I can well understand). All the same, it is possible that the inefficacy of the haloperidol (I've been told that 0.5 mg IM of haloperidol is not a low dose) could be a SIGN of a WORSENING underlying cause even if it is difficult to determine what it may be? If so, what possible underlying causes or causes could be worsening?
Brief Answer:
No specific treatment for DIC
Detailed Answer:
Hi,
Thanks for asking again.
My opinion is as follows:
1. Elevated prothrombin time means clotting function of clotting factors is reduced either due to quantity of quality. INR elevation occurs in warfarin therapy due to inhibition of coagulation and hence PT will be more. At present, as he is not on any therapy, it is assumed that his clotting factors is deficient and Vit K at this dose can be given. It is very much justified.
2.No specific treatment of DIC is there as there are numerous causes. Treatment of specific cause is the choice.
3. Associated with DIC, causes of delirium could be hypotension, stroke, liver or renal failure commonly. As I mentioned earlier, Haloperidol is the used to control delirium but underlying treatment could be any of the cause of DIC or complication of DIC like organ failures of liver and kidney or hypotension due to hemorrhage or stroke in brain or metabolic disorders due to organ failures. Infection can also lead to DIC thereby contributing to organ failures.
Any further queries, happy to help again.
Dr. Prakash HM
No specific treatment for DIC
Detailed Answer:
Hi,
Thanks for asking again.
My opinion is as follows:
1. Elevated prothrombin time means clotting function of clotting factors is reduced either due to quantity of quality. INR elevation occurs in warfarin therapy due to inhibition of coagulation and hence PT will be more. At present, as he is not on any therapy, it is assumed that his clotting factors is deficient and Vit K at this dose can be given. It is very much justified.
2.No specific treatment of DIC is there as there are numerous causes. Treatment of specific cause is the choice.
3. Associated with DIC, causes of delirium could be hypotension, stroke, liver or renal failure commonly. As I mentioned earlier, Haloperidol is the used to control delirium but underlying treatment could be any of the cause of DIC or complication of DIC like organ failures of liver and kidney or hypotension due to hemorrhage or stroke in brain or metabolic disorders due to organ failures. Infection can also lead to DIC thereby contributing to organ failures.
Any further queries, happy to help again.
Dr. Prakash HM
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Above answer was peer-reviewed by :
Dr. Ashwin Bhandari
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