International Normalized Ratio (INR) is Comparable to MELD in Predicting Mortality after Cholecystectomy

Abstract

Guidelines suggest targeting a preoperative international normalized ratio (INR) < 1.5. We examined and compared the predictive value of INR relative to the Model for End-Stage Liver Disease (MELD). We reviewed the American College of Surgeons NSQIP from 2005 to 2016 for adult patients undergoing open or laparoscopic cholecystectomy. Patients with a preoperative INR were stratified into groups: ≤1, >1 to ≤1.5, >1.5 to ≤2, and >2. Thirty day postoperative mortality was the primary outcome. Multivariable logistic regressions controlled for baseline differences. Of 58,177 cholecystectomy patients, 15.2 per cent had INR ≤ 1,80.4 per cent had INR > 1 to ≤1.5,3.7 per cent had INR > 1.5 to ≤2, and 0.7 per cent had INR > 2. Patients with INR > 2 were older and more likely to have diabetes and hypertension ( P < 0.001). Multivariable regression demonstrated a stepwise increase in mortality for INR > 1 to ≤1.5 (odds ratio (OR) = 1.50 [1.10–2.05]), INR > 1.5 to ≤2 (OR = 2.96 [1.97–4.45]), and INR > 2 (OR = 3.21 [1.64–6.31]) relative to INR ≤ 1. C-statistic for INR (0.910) and MELD (0.906) models indicated a similar value in predicting mortality. INR groups also faced an incremental, increased risk of bleeding. Although unable to track preoperative correction of INR, this analysis identifies that INR remains an excellent predictor of postoperative mortality and bleeding after both open and laparoscopic cholecystectomies and is comparable to MELD.

Effect of an Elevated Preoperative International Normalized Ratio on Transfusion and Complications in Primary Total Hip Arthroplasty with the Enhanced Recovery after Surgery Protocol

“…P reoperative elevated INR has been confirmed to increase bleeding, complications, and mortality in some other diseases [34][35][36][37][38][39][40] . Measuring INR before joint surgery was a standard pattern in our institution.…”

“…The INR is widely used in predicting mortality and bleeding in some diseases. Rudasill et al found that the INR showed important value in predicting mortality and bleeding in end-stage liver disease 34 . Patients who underwent endarterectomy with high preoperative INR (≥1.5) exhibited higher 90-day mortality than low INR patients (<1.5) 35 .…”

Preoperative Elevated International Normalized Ratio Cannot Increase Transfusion or Complication in Primary Total Hip Arthroplasty: A Retrospective Study of 552 Cases

“…Preoperative elevated INR had been con rmed to increase bleeding, complication and mortality in some diseases [11][12][13][14][15][16][17]. Measuring INR before joint surgery was a standard pattern in our institution.…”

“…Among the warfarin used patients, INR was kept between 2.0 and 3.0 as the therapeutic range [10]. A preoperative international normalized ratio (INR) target < 1.5 is suggested by the guidelines [11]. INR was widely used in predicting mortality and bleeding in some diseases.…”

“…INR was widely used in predicting mortality and bleeding in some diseases. Rudasill et al found that INR showed an important value in predicting mortality and bleeding in End-Stage Liver Disease [11]. Tan et al observed that patients who underwent endarterectomy with high preoperative INR (≥1.5) exhibited higher 90-day mortality than ones with low INR [12].…”