From the Research
The safe International Normalized Ratio (INR) for tube thoracostomy is generally considered to be less than 1.5. Before performing a chest tube insertion, the INR should ideally be corrected to this level or lower to minimize bleeding complications. If a patient has an elevated INR due to anticoagulation therapy and requires urgent tube thoracostomy, reversal agents should be considered. For warfarin-induced coagulopathy, vitamin K (5-10 mg IV) and/or prothrombin complex concentrate (PCC) can be administered 1. Fresh frozen plasma (FFP) at a dose of 10-15 mL/kg may also be used, though it requires larger volumes and takes longer to administer than PCC. For patients on direct oral anticoagulants (DOACs), specific reversal agents like idarucizumab for dabigatran or andexanet alfa for factor Xa inhibitors should be considered if available.
In life-threatening situations such as tension pneumothorax, tube thoracostomy should not be delayed for INR correction, as seen in a case of nontraumatic massive spontaneous hemothorax with concomitant warfarin use 2. The risk of bleeding must be balanced against the urgency of the procedure, as delaying chest tube placement in critical situations can lead to worse outcomes than the risk of bleeding from mild to moderate coagulopathy. The use of vitamin K in patients with warfarin over-anticoagulation lowers excessively elevated INR faster than withholding warfarin alone 1.
Key considerations for tube thoracostomy include:
- Correction of INR to less than 1.5 before the procedure, if possible
- Use of reversal agents for warfarin-induced coagulopathy
- Consideration of specific reversal agents for DOACs
- Balancing the risk of bleeding against the urgency of the procedure
- Safe insertion of the chest tube within the pleural space, without focusing on achieving a specific tube location 3. The timing of fresh frozen plasma administration is also crucial, with shorter times to administration associated with improved INR correction 4.