Case: 52 year old male after thoracotomy for recurrent pleural effusion with previous history of mechanical MVR (Mechanical Valve Replacement) is in ICU POD # 3. Epidural was inserted at the time of surgery. Warfarin was initiated on POD # 1 on surgeon's recommendation. Today patient's international normalized ratio (INR) is 2.9. As you mention administration of Vitamin K to decrease INR for safe removal of epidural catheter, surgeon strongly advised you to avoid vitamin K as patient has very high risk of thrombosis. Your next action plan would be?


Answer: Remove Epidural

Ideally, INR should be less than 1.5 for epidural removal but if risk of reversing warfarin is higher than removal of epidural, it can be remove without any intervention such as reversal with Vitamin K up to INR of 3.0. Caution should be exercise to watch any other concomitant drug which may affect hemostasis and continuous neurologic monitoring after removal.



References: 

1. Horlocker TT, Wedel DJ, Rowlingon JC, et al. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition). Reg Anesth Pain Med 2010; 35:64. 

2. Wysokinski WE, McBane RD. Periprocedural bridging management of anticoagulation. Circulation 2012; 126:486.