Question 1 How would you manage patients on warfarin in the following four scenarios?

Question 1

How would you manage patients on warfarin in the following four scenarios?

1-     A 55 years old man with atrial fibrillation has an INR of 7 at his routine clinic appointment, having been stable over previous months, he has no bleeding problems.

2-     You are called by a dental surgeon about 30-year-old women on a permanent anticoagulation after recurrent venous thrombosis. Her INR a week ago was 2.5 and the dentist wishes to extract a molar tooth right now.

3-     A 65-year-old man on long term anticoagulation is admitted unconscious with intracranial hemorrhage. His INR is 12.

4-     A surgeon calls about a man on warfarin with a metallic mitral heart valve and a current INR of 4. He would like to perform elective cholecystectomy at some time in the next few weeks.

Question 2

·      A 3-year-old girl was referred to your hospital following presentation at her local hospital with headache and seizures. A CT scan had revealed a central mass. The neurosurgeon decided that mass was not respectable but that a tissue diagnosis was required.

·      It was his normal practice to perform pre-operative coagulation screening. The following results were obtained

·      APTT 89 seconds (normal 24-34 S)

·      PT 13.5 seconds (normal 12-14 S)

·      APTT 50% mixture with normal plasma is 76 seconds

·      Thrombin time 11 seconds (normal 11 S)

·      Fibrinogen 3.2 g/l

·      Full blood count Hb 113 g/l; WBC 10.4X10^9; Platelets 345 X10^9

·      The operation was postponed pending further investigations.

1-     What test would you perform to reach the diagnosis?

      2-   What advice would you give to the surgeon?