The only question that matters first: “Is he bleeding?” And then: bleeding where, and how much?
Tell the nurse: hold the next dose pending assessment — which is not automatic for a trivial bleed in someone with a mechanical valve · full vitals · look for bruising, gums, urine, stool · IV access if there is any bleeding at all.
Bleeding versus not bleeding, on one axis. Major/critical-site versus minor, on the other. Your action comes from the box, not the number.
- Critical site bleeding — intracranial, intraspinal, intraocular, pericardial, retroperitoneal, intramuscular with compartment syndrome, or any bleed causing haemodynamic compromise. Immediate reversal, whatever the number
- Major bleeding — reversal plus resuscitation
- No bleeding, high INR — manage by the actual number, the bleeding risk and the indication, per local protocol: roughly, 4.5 to 10 means withhold and monitor closely; above 10 means oral vitamin K — BSH guidance is 1 to 5 mg by mouth in the non-bleeding patient, and the IV route is for bleeding, not for a number. Reversal products are not free, they carry thrombotic risk, and nobody gives prothrombin complex to tidy up an INR in a patient who is not bleeding
- DOACs are a different problem entirely. The INR does not measure them — a “normal” INR on apixaban tells you precisely nothing. What matters is the agent, the exact last dose, and renal function. Renal clearance dominates for dabigatran and matters rather less for the factor-Xa inhibitors, so “renal function is the half-life” is a slogan that is only true of one of them; age, weight, liver function and interacting drugs fill in the rest. Agent-specific assays exist — calibrated anti-Xa, thrombin or dilute thrombin time — and in a life-threatening bleed you do not wait for them. Specific reversal agents exist for some agents, are not interchangeable, and live behind a local pathway: idarucizumab for dabigatran, andexanet for the Xa inhibitors where it is approved and stocked, prothrombin complex per protocol where it is not
FIRST MOVES Establish drug, dose and exact time of the last dose. Send full blood count, coagulation screen, creatinine, group and save. Look for the cause of the high INR: a new antibiotic (very common), amiodarone, an antifungal, a change in diet, alcohol, liver disease, or heart failure. Make the reversal decision explicitly and document the reasoning both ways, including when you chose not to reverse. Then, crucially, address the restart question — the indication for anticoagulation has not gone away, and a patient with a mechanical valve who is off anticoagulation is now in a different kind of danger.
Ward call: [AGE]-year-old [SEX], day [X] for [REASON]. Anticoagulant: [WARFARIN with INR X / APIXABAN / RIVAROXABAN / DABIGATRAN / EDOXABAN / LMWH — dose and exact time of last dose]. Bleeding: [NONE / SITE, ESTIMATED VOLUME, DURATION]. HR [X], BP [X], Hb [X] (previous [X]), platelets [X], INR [X], creatinine [X], eGFR [X]. Indication for anticoagulation: [AF / VTE / MECHANICAL VALVE / OTHER]. New drugs in the last two weeks: [ANTIBIOTIC / AMIODARONE / AZOLE / OTHER]. Planned procedure: [Y/N, when]. Place this in the bleeding/no-bleeding and major/minor grid and tell me which box. Give the specific reversal option for THIS agent with dose, or argue against reversal if that is right. Name the likely cause of the derangement from my drug list. Then tell me when and how anticoagulation should be restarted and who owns that decision.