Bridging for OHS#3

[ALCapshaw2]

I discussed Bridging Protocol for my upcoming MVR (OHS#3) with my surgeon yesterday.

He approved using Lovenox Bridging BEFORE surgery, to be prescribed by my local Coumadin Clinic.

I was surprised to learn that he does NOT generally use bridging AFTER surgery, citing the risk of bleeding. He said he was willing to approve Heparin Bridging afterwards if I so desired, noting the 'balancing act' between risk of bleeding vs. the risk of stroke.

Note that I have a St. Jude Mechanical Valve in the AORTIC Position and have requested an On-X Mechanical Valve for the MITRAL Position. My current Warfarin dose is 30 mg / week (4mg X5 + 5mg X2).

SO, my question to my fellow learned Anti-Coagulated Patients (and Provider is:

What are your thoughts / experiences with Bridging or NOT Bridging AFTER Major Surgery?

'AL Capshaw'

 

[LUVMyBirman]

I have had issues with bleeding after both of my surgeries and other proceedues when bridging with Lovenox was used. Though, I still have mixed feelings about not using a bridge. As we know......bleeding can almost always be reversed. Clotting cannot.

With double valves...I would be more inclinded to opt for the bridge.

 

[ALCapshaw2]

Thanks for your input Gina.

If you don't mind, could you be more specific about your post-op "bleeding issues"?

Where was the bleeding?
What did they have to do to control it?
Did you have a full sternotomy incision?
Anything else?

'AL Capshaw'

 

[RandyL]

I really thought that they put me on Heparin after my AVR and continued it until the coumadin was therapeutic. I have had quite a lot of procedures in the past year that required a bridge. In all cases this was done with Lovenox since I was not an inpatient. In all cases I was told to wait 24 hours before resuming my Lovenox bridge. I thought I was on Heperin right after my AVR, not sure how long but I know it was within a couple of days, heck your only in the hospital for 5 days. So I think you will be back to bridging quite quickly after your surgery unless I am totally wrong which could quite possibly be the case.

 

[Guest]

Most bleeding complications occur after surgery. For thie reason, some are now saying to wait (maybe) two days after high risk of bleeding surgeries and then (maybe) use half the Lovenox dose from before surgery. This hasn't been tried enough to be sure that it is the best but it seems to be better than the old way of the same dose on both sides of the surgery.

 

[Birky]

bridging

bridging

Sorry to hear that you are having your 3rd surgery. I was bridged with heparin for my shoulder surgery and did have a bleed 5 days postop. My regular cardiologist and the one that I had in the hospital both agreed this was the best way. They stopped the bleeding by opening up the whole shoulder and cleaned it up. Had to give me platlets prior to the surgery to counteract the heparin and coumadin since it was emergency surgery. I had to get 2 units of blood 3 days later since I was so low on fuel. Good luck to you,

 

[LUVMyBirman]

Al -

It was tamponade. 2 liters around percardium. They went in through the original incision, up and under the sternum. Fully transfused. Packed cells so they could get me in surgery to drain the blood and fluid from the percardium. Bridging is a necessary evil. I do like Al's thoughts on using a reduced post op dose!

 

[Karlynn]

Not that this is your area of medical issues, but my gyno said that he prefers using heparin instead of Lovenox. He said he has much less bleeding incidents than with Lovenox. I cannot speak from experience as yet, because I have not had to bridge for anything yet. We were discussing an elective procedure.

 

[RandyL]

Not that this is your area of medical issues, but my gyno said that he prefers using heparin instead of Lovenox. He said he has much less bleeding incidents than with Lovenox. I cannot speak from experience as yet, because I have not had to bridge for anything yet. We were discussing an elective procedure.

I thought it was standard procedure to bridge with Heperin while in the hospital and Lovenox while out of the hospital.

I would like Karlynn to respond to my comment because she hasn't talked to me in months and I think she must be mad at me Just kiddin

 

[bvdr]

Al, I'm at the end of day six of Lovenox. I'm to stay on it until my INR is up to 2.5. Last night my INR was 2.0. The night before I got up during the night and noticed the front of my nightgown was stained with bright red blood. If all the spots were combined it would have been larger than a dinner plate. I found that blood was oozing from about 5 of the injection sites on my belly. I cleaned it all up and put band-aids on them. In the morning my new nightgown was all stained by my knee where it was bleeding around an old scab as well. The band-aids on my belly were saturated again and so was my nightgown, through my sheet and through the mattress pad. I delayed my AM Lovenox until 3 this afternoon. I only mention this because I've never had bleeding issues while on my warfarin but I bruise like crazy when on the Lovenox. In fact, I'm going to test my INR in a few minutes and if it has risen over 2.0, even a little, then I'm going to stop it now. I would not be at all comfortable on Lovenox on the same dose post-op as pre-op. I can just imagine the bleeding that could occur inside! I find what Al L. posted very interesting about changing doses post-op.

I haven't spent much time on the boards lately. Do you have a date scheduled yet? I hope all goes well for you and you will be in my prayers for a successful surgery and recovery as well.


( I had been on Lovenox for several days before a root sleeve epidural, was off of it for 1 1/2 days and then started the 6 days referred to above)

 

[RandyL]

Betty,
Hows your pain? Any relief?
I am sorry you have had a tough time with the Lovenox injections. How many mg a day was your precription for?
I was on 60mg twice a day and I am a large guy. 6' 3" and 260 lbs.WQas just wondering since you had so much trouble.

 

[bvdr]

Betty,
Hows your pain? Any relief?
I am sorry you have had a tough time with the Lovenox injections. How many mg a day was your precription for?
I was on 60mg twice a day and I am a large guy. 6' 3" and 260 lbs.WQas just wondering since you had so much trouble.

Randy, I don't want to hijack Al's thread so I'll just answer quickly...I was on 80mg every twelve hours......and I weigh about 100 lbs less than you do. I would have to look it up but I think it usually is 1 mg per kg.body weight. My INR is now 2.7 so hopefully everything is heading in the right direction. I did not get eggplant belly this time though. The syringes were from the manufacturer and I think the new syringe design helps? Pain....

 

[Guest]

Yikes, a bleeding pincushion!!

Betty, you are probably OK to stop your Lovenox - call your Doc to make sure. One problem with Lovenox is that it cannot be easily reversed. It has to be cleared by the body on its own.

 

[tommy]

I'm sure on board with post op bleeding on Lovenox, and pursuing a reduced dose. I'm not real big on waiting to re-start anti-coagulation. Betty, my "stains" were all internal - not a pin cushion, but a kaleidescope!

 

[doyo]

What about warfarin dose?

What about warfarin dose?

I have a related question.

At what dose and when do you resume the warfarin after the operation?
It probably depends on how big the operation.


I think Al's dosing chart said to start at the expected normal dose for the patient. I think this statement on the original operation.
With a big operation, your food intake and activity level will be much lower.
So if you took 8 mg/day, would you start at 1/2 (4 mg) or even less?
From our experience with just 1 operation, the required dose was really low in the beginning (2 mg) compared to the current dose (8gm) 6 months post-op.

EJ

 

[Guest]

After a big operation you are probably hospitalized for several days and the INR will be checked daily. I tend to start people like this at the dose they took before or at 4 or 5 mg daily. It is not an exact science. My philosophy of warfarin management is to make little changes in the right direction.