PDA

View Full Version : Nose Bleeds???



vero1
April 22nd, 2005, 08:07 PM
Hi all, it's Veronica, Genaro's wife, he had a mechanical valve replacement (aortic) a week ago and today all of sudden he got a nose bleed, not alot, just like a napkin, spots. His INR was 2.7 and they decreased his dose to 1mg instead of 2mg. I'm worried. Thank you, Veronica.

T-Money
April 22nd, 2005, 08:14 PM
Hi Vero.
I had the same surgery a week ago today except I had the root and valve replacement job on the aorta. I have a mechanical (St. Jude's) so I'm getting on the Coumadin train myself. I was told by the Coumadin clinic I go to that nosebleeds may happen to me and not to be alarmed. That being said, I haven't had any problems like that yet. I'm sure there are plenty of old pros around here that can give you better advice. My thinking on all of this bleeding stuff due to Coumadin is that if I bleed enough to get scared (and I'm sure I will some day) I'll just go to the emergency room and live with it. I hope everything works out OK.

geebee
April 22nd, 2005, 08:22 PM
Veronica,

One of the things you need to get used to and fast is the fact that doctors often respond too quickly when changing coumadin doses.

An INR of 2.7 is right where Genaro should be. A few spots of blood from the nose can happen to anyone, even those not on coumadin.

I would be much more worried about them cutting his dosages in half because of this. His INR could drop way too fast and put him at risk for a stroke.

Please question this decision. His dosage should not have been changed if his INR was at 2.7. The range for Aortic mechanical is 2.0-3.0.

vero1
April 22nd, 2005, 08:27 PM
Hey Gina, I'm sorry I forgot to mention that I took my husband to emergency room night before last (because of palpitations) and they took his INR then, it was 3.7, that is when the pharmacist cut the dose from 2mg to 1mg this was yesterday:

Wed INR 3.7 took 2mg
Thurs no test, called pharmacist took 1mg
Friday INR 2.7, again prescribed 1mg.

I hope I made sense. Thank you, Veronica.

geebee
April 22nd, 2005, 08:37 PM
OK - now I feel better :). Be sure and test in 3 days or so to see how the dosage change worked out.

3.7 IS too high and could have been responsible for the slight nose bleed. I rarely have nosebleeds and the ones I have had were when I had colds and my nose was "very active".

ALCapshaw2
April 22nd, 2005, 09:01 PM
WHOA Veronica !

It takes 3 to 4 days for the FULL effect of a dose change to 'settle out' so changing dose after only 2 days will almost GUARANTEE a wildly swinging range of INR.

Dosing is really based on a WEEKLY basis. Are you saying the pharmacist told him to go from 2 mg every day to 1 mg every day? That would be a 50% reduction, WAY TOO MUCH of a change. If this is the case, I would suggest he get tested 3 or 4 days after the change. My guess is that his INR will then be too LOW (and if you see that same pharmacist, he will recommend too much of an increase and on and on and on.... sorry, but the sad fact is some people simply don't know how to properly manage Coumadin. Find a GOOD Coumadin Clinic ASAP and let them be your guide.)

When a small change is needed, the WEEKLY dose is usually adjusted by 10% spread over the whole week.

Please read Al Lodwick's Website on managing Coumadin at www.warfarinfo.com

BTW, a few drops of blood from a nose bleed (or anything else) is TRIVIAL. That could be caused by dry air, even in someone NOT on Coumadin.

Here is another 'rule of thumb' guideline related to rectal bleeds. Pink on tissue, NOT SERIOUS. Pink in the commode water, call / see your Doctor. Heavy RED in the commode water, get to the ER ASAP. This probably can be generalized to any type of bleed. For cuts, use gause and PRESSURE.

Being a Heart Patient takes some 'getting used to' with a New set of Normals. One of my favorite sayings is "Heart Disease isn't for Sissies!" :D

Another saying (from Al Lodwick, our Coumadin GURU) is that "It's easier to replace Blood Cells than Brain Cells" which means that it is better to have a slightly higher INR (>4 or 5) and possible bleeding than to have too LOW an INR (<2)and a possible STROKE.

'AL Capshaw'

Gemma
April 23rd, 2005, 01:58 AM
Hi Veronica,

Jim used to get really heavy nose bleeds bedore his AVR. Had a vessel in his nostril cauterised a couple of times. Then for a week or two after he was home, he had some light ones like you describe - his INR was always in range (2-3) bar one reading of 3.2, so his dosage wasn't changed at all (it has since increased due to increasing activity levels). It seemed weird that they weren't heavier with the warfarin, but we believe the high blood pressure he had with the regurgitating valve may have caused the nose bleeds pre-op, so after the replacement that was no longer a problem.

Although it seems like Genaro's pharmacist was right to reduce the warfarin with an INR of 3.7, it does seem like a big change to make - 50%... A change of 1mg doesn't make a huge difference to someone on, for example, 6mg a day, but when it's half your dose that's a big deal! I'm with Al on this one - if the pharmacist suggests a big change again at Genaro's next INR test (assuming it has dropped too low of course), question it.

Good luck!
Gemma.

LisaD0365
April 23rd, 2005, 04:42 AM
Someone said an INR of 3.7 is too high...what about someone like me who has to have a rate of 3.5-4.0?...I had a nosebleed but then my INR level was 7.9.... :eek: ...

Ross
April 23rd, 2005, 04:47 AM
3.7 is not that bad. In fact, I wouldn't even change the dose for it, maybe pig out on some greens and such. Nosebleeds can occur for many different reasons. I'm having them almost daily and it's because of this messed up weather we are having. It's been unusually dry, combined with allergies and away it goes. Who recommended 3.5 to 4.0 for you?

Nancy
April 23rd, 2005, 05:04 AM
Joe gets nosebleeds every once in a while. They are unrelated to his INR, some happen when it is low, some when it is high and some when it is in range. He has a vulnerable blood vessel in his nose, and when it gets irritated--too dry, for example, it can bleed a little.

Just a thought, but Genaro probably had oxygen in the hospital for a while, right? That can dry out your nasal passages. Possibly this is a left over problem that will straighten itself out.

Emma
April 23rd, 2005, 06:10 AM
Chloe suffered badly with nosebleeds for about a year after her replacement, although would that be cos kids are more prone to them anyway?! And when I say badly - i mean she had one which didnt stop for 3 days!!!! (although not that heavy throughout the whole time!)
But her INR has always been between 3 and 4 (in the UK where the INR's seem to be set higher) so i wouldnt have considered 3.7 to even be that high - well not to justify a drop in dosage like that. Make sure you test again in about 3 days cos I would guess he may go too low now.
Hope it gets sorted out soon!
Emma
xxx

geebee
April 23rd, 2005, 07:48 AM
Sorry for any confusion. When I said 3.7 was too high, I just meant it was too high for an aortic valve (since the range is 2.0-3.0). I did not mean it was dangerously high. However, a 3.7 (in a new coumadin user) could concievably cause the slight nosebleed Veronica was describing.

My range is 3.0-4.0 because I have a mechanical mitral and a-fib. So 3.7 is in range for me and where I like to see my INR (3.5 or above). I have gradually built up to that level.

Didn't mean to worry anyone, especially someone new at this.

perrybucsdad
April 23rd, 2005, 08:03 AM
First off, why is the pharmacist telling you to reduce your dose? Shouldn't a Dr be the one giving that advice?

allodwick
April 23rd, 2005, 08:43 AM
Most anticoagulation clinics are managed by pharmacists. I have been doing it full time for the past 8 years. I suspect that you got a "fill in" pharmacist. Anybody who would make a 50% dose reduction for an INR of 3.7 and check the INR again two days later does not have the slightest idea of how warfarin works. I don't care how much the nose was bleeding. You must NEVER put someone at risk of a stroke for a bloody nose. You have every reason to be worried.

BTW, I appologize to whoever really first said that it was easier to replace blood cells than brain cells. I wish I had thought of it first but I know that I didn't. I admit to having repeated it, but I have not tried to lay claim to it.

Harpoon
April 23rd, 2005, 08:50 PM
Just a quick note on INR scores...


I saw my cardiologist this past Wednesday and one of the things we talked aobut (briefly) was where my target INR's should be.

He said anywhere between 3.0-4.0 is just fine, with a plus/minus variation of maybe 3 tenths or so of a point.

So I can be as high as 4.3 or as low as 2.7 without any real cause for alarm.

He also said that if I stay consistantly at say, 2.8, then an adjustment might need to be made (I test monthly right now) and that because I have an artificial tricuspid valve, he'd like to see higher scores than would be typical for MVR/AVR's...


Now then, the fun part is when I tell my clinic people this. They get all fidgity when I say stuff like, "4.2 is just fine..." because that's not what they've been told.

But then, I'm the ONLY patient in the group practice that has an artificial tricuspid valve...



I asked once.

allodwick
April 24th, 2005, 12:48 PM
Your doctor needs to send a note to the clinic to give them justification for keeping the INR in this range.

I have one patient that we keep up as high as 4.5. She went to get a mechanical valve and wound up with heparin-induced thrombocytopenia and lost her right leg below the knee and the tip of her tongue. I double checked this with her doctor who is a hematology professor and got a letter to that effect from beth the hematologist and her primary care doc.

vero1
April 24th, 2005, 01:21 PM
Your doctor needs to send a note to the clinic to give them justification for keeping the INR in this range.

I have one patient that we keep up as high as 4.5. She went to get a mechanical valve and wound up with heparin-induced thrombocytopenia and lost her right leg below the knee and the tip of her tongue. I double checked this with her doctor who is a hematology professor and got a letter to that effect from beth the hematologist and her primary care doc.



That's scary, what could cause that????? Veronica.

Sagebrush
April 24th, 2005, 02:18 PM
Veronica,
I get nose bleeds allllllll the time.....before and after I had a mechanical mitral valve and was put on comidin. I finally had my nose cauterized because the bleeds were such a pain. I live in the high mountian desert where the air is dry all the time 15% humidity. I have blood vessels close to the surface and I believe it is heriditary because my 6 year old nephew gets nose bleeds all the time too. Nose bleeds are not a big deal unless they don't stop after 30 to 45 minutes. After I had my valve replaced I was scared to death that I was going to bleed to death if my inr was 3.7 but because of this web site and all the awsome people like Ross and Allodwick and Allcapshaw2 I have decided that I won't bleed to death if my inr is at 3.7.....in fact mine inr was 4.3 last Tuesday. I have my own home testing unit and have been adjusting my own dose for the last 1year and 4 months. I cut my dose by 1 mg a week and ate some greens.....yum...yum...I just love it when it is high cause I can have some broccoli too...just a few bits!!!

whomever said the phrase about brain cells and blood cells it is funny whomever said it!!!! Made me LOL!!!! :D

Karlynn
April 24th, 2005, 03:33 PM
That's scary, what could cause that????? Veronica.

Veronica, just a caution. Don't let the fact that Genaro is on Coumadin scare you into thinking that his life is now fragile because he is on it. Al's experience of the woman losing her leg is a rare occurance. If you were to read the warning for any prescriptions, you wouldn't want to take anything. :) There are many of us here that have lived quite a while on Coumadin without any catastrophic occurances. I've sliced my finger cutting vegetables many times, banged my leg on bed frames, been jumped on by my 120 lb. dog etc. etc. Life goes on pretty nicely.

His nose bleed is most likely from irritated sinus passages due to weather and the horribly dry environment they keep the hospitals in. Or at least that's my guess. The Coumadin probably helped it along a bit, but my guess would be that he'd have had a nost bleed of some sort even without the Coumadin.

terryj
April 25th, 2005, 05:07 AM
My husband tested at 4.5 on Thursday he was taking 7.5 4 days a week and 6.0 three days a week. He changed to 6.0 5 days a week and 7.5 2 days a week. I made cole slaw this weekend and bought him some fresh broccoli to eat. He took his chainsaw Saturday and went to cut a neighbors tree up that fell in the storm Friday. He will retest this week. After 3 years of coumadin I don't panic near as much. I still hate him using the chainsaw but I just asked our son to go with him to call 911 if he cut anything.

perrybucsdad
April 25th, 2005, 05:43 AM
Well, if you are on Coumadin or not, you cut yourself with a chainsaw, you are going to be bleeding quite a bit either way.

Gemma
April 25th, 2005, 05:45 AM
Hi Veronica,

Hope Genaro's doing OK - let us know when he has another INR test and what the results/dosage changes are, OK?

Just had a couple of points to add -

1) Like Al said, it takes 3 or 4 days for a dosage change to show a change in test results, so the Friday test wouldn't have shown the effect of the new dosage. Testing more than every 3 days can lead to all sorts of ups and downs in the INR. I hope he's been tested today or will be tomorrow - that should give a much clearer picture of what's going on.

2) You also need to look at the trend his INR's been following - if it had been going up steadily on a dose of 2mg daily, probably it did need to be decreased although 50% is still a big change to make. That kind of "adjustment" can lead to massive swings in the INR as well.

3) Don't panic! :) It can take a while for the INR to settle down. It's still early days and until Genaro's routine becomes more normal, his INR may fluctuate a bit. It took Jim and I a few months to figure out the whole INR testing/dosage thing. It got a lot easier when he got his home-testing machine - now if his INR is out of range we can pretty much decide what his dosage will change to before even being told by the hospital! (bit different over here - his clinic won't allow him to decide his own dosages or even accept his readings which are usually within 0.2 of theirs but he does a test at home just before going for the blood test at his doctor's surgery. Very long-winded story I'm sorry - that's the abbreviated version!!)

4)Keep an eye on what this pharmacist is up to. Your gut instincts are normally right and if you're concerned about his advice, question it.

Best wishes,
Gemma.

Ross
April 25th, 2005, 06:08 AM
Well, if you are on Coumadin or not, you cut yourself with a chainsaw, you are going to be bleeding quite a bit either way.
You think? We people on Coumadin are bullet proof. We can jump out of airplanes without parachutes we are so tough. ;) http://img.photobucket.com/albums/v442/Ross/images.jpg

terryj
April 25th, 2005, 06:27 AM
My husband does everything he did before coumadin. He fishes,hunts,cuts up wood,builds everything and works as a maintenance mechanic in a large Fiberglas factory.

allodwick
April 25th, 2005, 07:48 AM
Heparin-Induced-Thrombocytopenia is an allergic reaction to heparin or Lovenox, Fragmin etc. Instead of preventing clots, the heparin suddenly causes clots. You can read more about it at http://warfarinfo.com/hit.htm

Barry
April 26th, 2005, 08:32 AM
With the exception of no longer riding motorcycles for fear of road rash being a terminal condition, and no longer engaging in power drinking, I haven't changed my lifestyle one bit since I've been on Coumadin/Warfarin. I bleed more from minor cuts, and do get nosebleeds more often (which is more than never), but I don't worry about it: I just apply pressure until the bleeding stops - which, on Coumadin, is a rather long time.

I figure that so long as I'm not bleeding so profusely as to be endangered, it's just an annoyance.

INRtest
April 26th, 2005, 01:44 PM
With the exception of no longer riding motorcycles for fear of road rash being a terminal condition, and no longer engaging in power drinking, I haven't changed my lifestyle one bit since I've been on Coumadin/Warfarin. I bleed more from minor cuts, and do get nosebleeds more often (which is more than never), but I don't worry about it: I just apply pressure until the bleeding stops - which, on Coumadin, is a rather long time.

I figure that so long as I'm not bleeding so profusely as to be endangered, it's just an annoyance.

I just got a stupid paper cut. Wrapped a tissue around it, put pressure on it and guess it is not unlike my pre-coumadin self, just a little longer to clot. Definitely a PITA, but not too terrible.

I used to use my chain-saw pretty often and now that I'm on C., I don't use it any more because I would certainly miss a finger, hand, arm or leg. :D

Barry
May 2nd, 2005, 01:55 PM
Now that I think of it, I've had far fewer problems with nose bleeds now that I've stopped making passes at other men's wives in bars.

sharon
May 2nd, 2005, 07:17 PM
Hi Veronica,

Don't panic about the inr numbers - although I'm sure that most of us did in the beginning. The bloody nose is not unusual as you've read. I get them all winter when the heat is on. I find that if I just spray my nose several times a day with a saline solution it helps stop my nose from bleeding. Also you should take into consideration the fact that Genaro had surgery just over a week ago and during the procedure he had tubes in his nose (along with other places) and that had to disturb the membranes in his nose and irritated it so much that perhaps a small blood vessel in his nose may have broken. If it continues to bleed he should consider having it cauterized.

Sharon
St Judes avr 4/97