With elevated INR,is it safe to undergo surgery?

Question

Hi doctor,

My wife is 34 years old. Her INR is 3.34 and blood factor VII activity test showed less than 2%. Her CT and BT are normal. She has been advised to undergo gallbladder removal.

With same condition, she had given birth to two babies through normal delivery (second one was one and a half years back). Recently, she had a tooth extraction without any extra bleeding. Kindly suggest the safe way to undergo surgery.

Answer 1

Hi,

Welcome to icliniq.com.

Based on your query, my opinion is as follows:

The values are highly abnormal to think of any major surgery. Bleeding should have occurred during tooth extraction, but I am not sure why it did not happen. If any bleeding occurs during surgery due to present values, it would be difficult to manage.

At present, bringing down INR (international normalised ratio) to less than 1.5 is necessary before starting surgery. Similarly, increasing factor VII level to at least more than 30% is absolutely necessary.
Before surgery, administration of FFP (fresh frozen plasma) to increase INR and also if necessary additionally recombinant factor VII administration to increase factor VII activity is necessary. Also, if she did not have any thrombotic events in the past year, anticoagulation therapy can be stopped for three to five days prior to surgery.
Once she is stable, to reduce the risk of thrombosis, if no further FFP is given, then anticoagulants can be continued as necessary to increase INR.

Answer 2

Hi,

Welcome back to icliniq.com.

Without FFP, the INR cannot be reduced and surgery would be a huge risk.

FFP, before it is given to patients is thawed at 37 degrees to get into human body temperature in which case there is no risk of thermal shock. However, if it is being given without thawing, which should not be done, the risk of thermal shock will be present. Also, FFP with thawing can be repeated after another six hours and given six more units (previously six hours earlier, six units) to improve INR. Once target INR is reached, the patient can be taken for surgery.

Recombinant NovoSeven (Recombinant factor VII) can be used, after checking for possible allergic reactions. Blood transfusion, if whole blood, carries a risk of volume overload. Also infection risk is definitely present, if not properly screened. Administration of vitamin K can reverse anticoagulation and improvement of INR can occur.

I would suggest you to go for FFP to reduce INR. If factor VII activity does not improve, then recombinant NovoSeven can be started (unless possible allergic reaction).