Category: Neurology
Keywords: lumbar puncture, meningitis, INR, warfarin, spinal, bleeding (PubMed Search)
Posted: 9/28/2016 by Danya Khoujah, MBBS
Click here to contact Danya Khoujah, MBBS
You have a patient in whom you suspect meningitis, but he is on warfarin for a history of pulmonary embolism. You started empirical antibiotics. His INR is 2.6, and you want to do a lumbar puncture (LP) to confirm your diagnosis. Can you use Prothrombin Complex Concentrate to lower his INR and safely perform the LP?
Take Home Point:
Using PCC to lower INR to enable LP is relatively safe and effective in patients on vitamin K antagonists. The dose used was individually determined by the physician according to initial INR.
Limitation:
This is a retrospective study, with no control group. One patient (2.7%) had a myocardial infarction that was “possibly related” to the PCC administration.
In Depth:
This is a retrospective study, with no control group. However, it is the largest study to date that was specifically designed to answer this clinical question, including 37 patients over a 10-year period, with the following results:
- PCC was effective 90% of patients
- The median INR was 2.2 before, and 1.3 after (checked immediately after the infusion)
- The median time from starting the infusion and LP was 135 minutes.
- None of the patients had a spinal hemorrhage or allergic reaction.
- Some patients were started on vitamin K according to the physician’s discretion, with variable starting times of anticoagulation after the procedure (if at all).
Laible M, Beynon C, Sander P, et al. Treatment with Prothrombin Complex Concentrate to Enable Emergency Lumbar Puncture in Patients Receiving Vitamin K Antagonists. Ann Emerg Med. 2016 Sep;68(3):340-4
