Future surgeries on coumadin

[bbb]

Hello,
I am two weeks away from OHS in Cleveland and considering a St. Jude's and coumadin. What happens when you have to have another major surgery in the future? I know there is bridge therapy, like heparin and lovenex as Al explained in response to my last question.

Is the major risk again when to start the bridge therapy? Risk of Stroke vs. Risk of Bleeding? And how well versed in anti-couagulation is the average hospital/surgeon in departments other than heart surgery?

Thanks, Betsy

 

[geebee]

Betsy,

I have had 4 major surgeries after going on coumadin in 1980. 2 were OHS, a hysterectomy and chest/abdominal surgery to clear out an infection. Each time I was bridged as an in-patient and had no problems. My cardios handled the bridging and the staff at each hospital seemed to know their stuff.

There is little risk when done properly although I hear that bridging is still a questionable procedure to some and has never been approved by the FDA. However, I would not have surgery done without bridging if I was unable to stay on coumadin. I feel the necessity of giving myself all possible chances of avoiding clots.

 

[ALCapshaw2]

The Secret to Successful Bridging seems to be to have a Competent Anti-Coagulation Manager in charge of the Bridging, with the knowledge and concent of the Surgeon.

The CRNP's at my Coumadin Clinic seem very knowledgable and have handled (or at least advised) when I was hospitalized and required Bridging for invasive procedures.

Once, I did have to threaten to 'raise the roof' when a nurse would NOT give me a Lovenox injection the day after an invasive procedure. I had been admitted through the ER and there was NO "Continuity of Care" and NO Orders for Bridging *after* the procedure.

He (male nurse) finally called my Cardio (which is what I would have done) who said "YES, give him a Lovenox Injection". They released me that afternoon (i.e. got rid of the 'problem patient').

This, after a SEVERELY Bruised (PURPLE from Bicep to wrist) arm due to an automatic Blood Pressure Machine which MAXED out (300 psi) after getting an erroneous reading. Lesson Learned: If a BP Cuff Maxes Out, RIP IT OFF, do NOT 'grin and bear it' until the pressure drops down to a reasonable level.

'AL Capshaw'

 

[Sierra Bob]

On 11/28 I will have major surgery at Stanford Medical Center to replace the titanium plate in my right jaw which replaced my mandible last January due to osteoradionecrosis (dead jaw bone) resulting from radiation for cancer in '99. The surgery will involve a fibula free flap from my right leg and include the fibula, arteries, veins, tissue and skin. The surgery is projected to require eleven hours and will involve four specialized surgeons.

Five days prior to the surgery I will discontinue the warfarin and my wife will start injecting me twice each day, as she has done three times before, with enoxaparin (Lovenox) when my INR is <2.0. We will discontinue the enoxaparin twelve hours prior to the surgery. They will start a heparin drip after the surgery and start me back on warfarin at a very slow rate (I presently take 66mg/7days for an INR target of 3.5) and discontinue the enoxaparin when my INR is >2.0. My hospital stay is anticipated to be fourteen days. This will be the fourth MAJOR surgery I've had since 4/99 when I had OHS with four bypasses and my aortic valve replaced with a St Jude Silzone impregnated mechanical valve, including two surgeries for Head & Neck cancer and the mandible resection and reconstruction plate placement in January.

I did have substantial bleeding at the local hospital here in the Sierras after the mandible surgery in January, but I believe this was due to the internist (my cardiologist was on medical leave) starting me back on too high a dose of warfarin too soon after surgery, and I was back on enoxaparin, not a heparin drip. Anyway, no lasting problem.

Wishing you the best with your upcoming surgery and saying: "Don't worry about being on warfarin, it's manageable." Regards, Sierra Bob

 

[bvdr]

I've dealt with anti-coagulation, bridging, and surgical procedures several times. I personally think future medical needs should be considered when making a valve choice. I have problems with my spine and joints and although I have never had a complication during procedures or surgery I am still uncomfortable with the additional risk involved. My anti-coagulation requirements have made what would have rather routine procedures more complex but doable. I have found that many health care professionals are not up to date whatsoever on anti-coagulation so make it a priority to be well versed yourself so you can be your own advocate.

 

[Sierra Bob]

I "misspoke" in my previous message when I said the "enoxaparin" would be discontinued when my INR was >2.0. I should have said the "heparin drip" would be discontinued. But, this is the first time I will be on a heparin drip rather than enoxaparin after surgery, so I misspoke. I will also point out I'm on a high INR target for a mechanical aortic valve because I had a Central Retinal Artery Occulsion in my right eye on December 30,2004, and I'm essentially blind in that eye. It is not known if it was a blood clot or?????. So, my cardiologist arbitrarily raised my INR because I'm not normally a bleeder and he wanted to lessen the chance I could have a CRAO in my left eye..

I should also mention other reasons for the bleeding last January is due to the internist not recognizing I was on a fairly high dose of warfarin for a high INR and I had been very active at home and was bedfast in the hospital; I had a can of V-8 every morning at home and none in the hospital and a large salad every night with romaine lettuce, not ice berg, and broccoli and other greens (I dosed the diet, not dieted the dose). In the hospital I was on a soft diet with no greens, hence minimal vitamin K, so my INR quickly shot up before the incision could handle it. Also. I was intubated through the nose. The anesthetist couldn't get the tube through the left nostile, so he went through the right. Consequently, he compromised both nostiles and I also bled through them as well as the incision.

As others have said, you do need a knowledgable person managing your anti-coagulation and he/she must ask the right questions or you must advise the person regarding your specific situation including activity and menu intake, which I have done with Stanford.

Hope this clarifies my situation. Sierra Bob

 

[Nancy]

Joe had many surgeries during his lifetime while anti-coagulated. Everything went fine for the most part, except one time, he had a major bleed. It was a gallbladder surgery and the surgeon nicked his liver. He had a total bleedout while on bridging therapy, and almost died. I believe at the time, the surgeon was handling his anti-coagulation. BAD IDEA!!!!!

Make sure you have someone managing your Coumadin and bridging that knows YOU and knows your anticoagulation from A to Z.

If done correctly by a doctor who has a clue, it is OK.

If done by a clueless person, it is not OK.

It's a finesse kind of thing requiring frequent testing and adjustments. Not all doctors want to fool around with it.

There is a political situation while in the hospital that can be a sticky wicket--the person under whose care you are, may not be the right one to manage your anticoagulation. Sometimes they are filled with hubris and will not ask for help when they clearly need it.

I would be as proactive as can be about making sure the right person is there for the right job. And I can tell you that you might have to come down on some people like a ton of bricks.

You may NOT be popular, read ALCapshaw2's post again.