quick question...

[sylviayasgur]

hi all,
my dad is having a cath and pre-op this wed. at nyu med. and his minimally invasive mitral and tricuspid repairs done on thursday, 9/14.
he already has a st. jude's aortic valve and takes coumadin.
some of you may remember that he almost bled to death a few years back because of mismanagement of coumadin/lovenox bridging before and after a hernia operation.

my dad's inr was 4.0 on saturday and he was told not to take any coumadin for the next few days pre-surgery.

as much as i may read here, i'm still unsure of how dosing works (i imagine that's because i don't need to know right now), but does that sound extreme, considering the cath/surgery won't be until this wed?
i am concerned that they should be giving him lovenox or heparin so that his inr doesn't drop too low for too long, but i'm not sure how this works.
can anyone who has more experience with coumadin/act reassure me that this is ok, or tell me that i have every reason to be nervous about it, please?

thanks so much for all your help. sorry to ask such (what may seem to you like) a silly question.
be well all,
sylvia

 

[RandyL]

hi all,
my dad is having a cath and pre-op this wed. at nyu med. and his minimally invasive mitral and tricuspid repairs done on thursday, 9/14.
he already has a st. jude's aortic valve and takes coumadin.
some of you may remember that he almost bled to death a few years back because of mismanagement of coumadin/lovenox bridging before and after a hernia operation.

my dad's inr was 4.0 on saturday and he was told not to take any coumadin for the next few days pre-surgery.

as much as i may read here, i'm still unsure of how dosing works (i imagine that's because i don't need to know right now), but does that sound extreme, considering the cath/surgery won't be until this wed?
i am concerned that they should be giving him lovenox or heparin so that his inr doesn't drop too low for too long, but i'm not sure how this works.
can anyone who has more experience with coumadin/act reassure me that this is ok, or tell me that i have every reason to be nervous about it, please?

thanks so much for all your help. sorry to ask such (what may seem to you like) a silly question.
be well all,
sylvia

The general rule is to stop coumadin 3-5 days prior to a procedure depending on the procedure. In this case I believe the 5 day rule would apply. It takes at least 48 hours or longer for your body to get rid the coumadin. Heperin is only available thru an IV so he would have to be in the hospital prior to surgery to bridge with Heperin. He could take Lovenox shots at home to bridge with(under Doctors Care of course) but would still have to stop the Lovenox shots 12-24 hours before the surgery.If he stops the coumadin today(Sunday), the coumadin will linger on thru Monday. No sense in having Lovenox on Tuesday since he could only get 1 shot and then would have to stop if surgery is on Wednesday.If it were me I would do nothing if stopping my coumadin on Sunday.

 

[PJmomrunner]

This is from Al Lodwick's website:


MY CURRENT RECOMMENDATION FOR BRIDGING

Keep in mind that this is an expensive injection. Not every insurance will cover it. Not every pharmacy will have it in stock. The preparation for doing this should start about two weeks before the surgery so that insurance arrangements and the pharmacy getting it in stock can be arranged.

Day -5 Stop warfarin (Coumadin, Jantoven).

Day -4 Start enoxaparin 1 mg/kg every 12 hours

Day -3 Continue as in day -4

Day -2 Continue as in day -4

Day-1 Give only the morning enoxaparin dose.

Day 0 Do the procedure

Day +1 Start enoxaparin at somewhere between 0.5 mg/kg and 1 mg/kg between 12 and 24 hours after the procedure. The dose should be based on the assessment of the patient's likelihood of bleeding. (Remember there is little evidence and no approval for this.) Start warfarin (Coumadin, Jantoven) at or slightly below the level the patient was taking prior to the surgery. DO NOT USE A LOADING DOSE AS THIS WILL LIKELY INCREASE THE RISK OF BLEEDING. Monitoring the creatinine clearance may reduce the risk of serious bleeding. PLEASE NOTE: Bleeding at this point is the major complication of this procedure. Some are choosing to use enoxaparin 40 mg once daily to provide some protection from clotting and reducing the risk of bleeding.

Day +2 and more Continue the enoxaparin and warfarin (Coumadin, Jantoven) until the INR is in range for two days. Do not rush this by using high warfarin (Coumadin, Jantoven) doses. Allow the INR to increase gradually over 5 to 7 days. Continue monitoring the renal function.

 

[Karlynn]

Do they have him starting on anything when he stops the Coumadin? I would imagine that given his last experience with Lovenox, they probably don't want to do that. My OB/Gyn mentioned to me that he doesn't like Lovenox but uses Heparin. My limited understanding at the time was that Heparin had to be by drip in the hospital. But that's not the only form. T
Did his doctors not want him admitted for heparin drop prior to surgery? I would think they'd be cautious after his last experience. There are forms that can be injected at home. But I'm not familiar with the specifics on them.

 

[sylviayasgur]

thanks for the speedy replies

thanks for the speedy replies

hi randy, pj., and karlynn,
thanks so much for the speedy replies. my dad was taken off all coumadin with no plans to bridge at all. i think the cardio who is on his case for dr. colvin in nyc (not his regular cardio) felt that since his inr was as high as 4.0 he would just take him off starting saturday night and just have his inr go down in preparation for the first procedure on wed.(4 days later). then he'll stay off for surgery the next day and then they will resume as i think they see fit while he is in the hospital.

i know they usually admit you for heparin (which i think i would have preferred in his case, given his history), but they seemed to feel this was good enough.

my only concern is that his inr will drop for the cath and stay low for the surgery. is he at risk, with his existing valve, of having clots develop?

i guess i have to learn to trust these doctors a little more and not be so nervous, right? just because one was just plain stupid a few years ago, doesn't mean they all are, right?
guess i'm a born worrier..
thanks again for all your help.
i am so grateful for you all.
-sylvia

 

[Phyllis]

Can't answer your question, Sylvia, but I put your Dad on the calendar and we will be sending our prayers and anxiously awaiting word from you. Godspeed!

 

[Karlynn]

Sylvia, the concern I have is that the amount of Coumadin he takes will affect how fast his INR drops. For me, I would not want to go from now until Wednesday unprotected because I know my INR would be just about 1.0 by Monday. The more Coumadin you take, the faster the INR drops.

I'm sure they are being very cautious because of his last experience, but check out what his dose is.

 

[RandyL]

hi randy, pj., and karlynn,
thanks so much for the speedy replies. my dad was taken off all coumadin with no plans to bridge at all. i think the cardio who is on his case for dr. colvin in nyc (not his regular cardio) felt that since his inr was as high as 4.0 he would just take him off starting saturday night and just have his inr go down in preparation for the first procedure on wed.(4 days later). then he'll stay off for surgery the next day and then they will resume as i think they see fit while he is in the hospital.

i know they usually admit you for heparin (which i think i would have preferred in his case, given his history), but they seemed to feel this was good enough.

my only concern is that his inr will drop for the cath and stay low for the surgery. is he at risk, with his existing valve, of having clots develop?

i guess i have to learn to trust these doctors a little more and not be so nervous, right? just because one was just plain stupid a few years ago, doesn't mean they all are, right?
guess i'm a born worrier..
thanks again for all your help.
i am so grateful for you all.
-sylvia

That is exactly where he needs to be for surgery. He can not be ACT during surgery. As you can see by my signature I had a bleed after surgery and I think I was on ACT during it.I am still waiting for my records to find out.