Upcoming non-cardiac surgery

[Susan]

Hi,
I'm new to the forum. I stumbled across it when looking up information on QAS and the Coaguchek XS machine. I'm so glad to have found this website! Now I can read about issues that relate to me and interact with people who have gone through what I have.

I'm having female surgery on December 2. Being that I'm on Coumadin, my cardiologist is having me go into the hospital 2 days prior to the surgery so I can get off my Coumadin and onto Heparin before the surgery, then back on Coumadin. Since I had my mitral valve repaired (which tore), then replaced over 9 years ago, I have had two other non-cardiac surgeries. With the first surgery, I was in the hospital for 6 days due to my Coumadin regulation. The last surgery, I was in 10 days. My blood (INR) is really all over the place. I'm very compliant, but no matter what I do, it's everywhere. One time when on a medicine that my pulmonologist prescribed, my INR got up to 14.9! My pulmonologist, nor pharmacy told me about the interaction with Coumadin. Also, during this time, I didn't have a protime scheduled. Needless to say I was hospitalized for that. I'm just curious about others of you that have had surgery and how long you were in the hospital for?

My cardiologist doesn't prescribe Lovenox. He says it's not indicated for mechanical valves and won't take a chance by having me use it. He is trying to get the Coaguchek XS approved by my insurance so maybe it will help me stay out of the hospital for one day prior to surgery. If I don't get it by my surgery, at least it will keep my out of the doctors office every week. It's been 9 years and I'm so tired of getting my blood checked. Any thoughts, anyone?

Thanks,
Susan

 

[kfay]

Susan, I just want to welcome you to this forum. It is a great place to get information and support. I don't know a lot about being on coumadin since I have a tissue valve and have only had to be on it for several short amounts of time. I can tell you though that the ones on here who know coumadin are going to know what your last couple of inr's were, what dosage you were taking and what change if any did you make. I also know that almost everyone on here who has had some type of surgery done with mechanical valves have bridged with Lovenox. Stick around and I bet they will get you straightened out.

Kim

 

[Danny]

Hi Susan, I dont know much about coumadin, but i just wanted to say welcome to the site.. lots of great and knowledgeable people here.

 

[Susan]

Thanks for the warm welcome Kfay and Danny. I look forward to being a part of this forum.

 

[KristyW]

Susan...look down a couple of threads and read the one by me called Bridging, Surgery and Recovery. I just went through a hysterectomy 2 weeks ago and definitely had issues with bridging procedures after the surgery.

Being admitted for a heparin drip sounds like the best plan. It seems that lovenox and fragmin just are a bit unpredictable.

Make sure that all bleeding is under control BEFORE they restart the heparin. Your coumadin can be started right away. It's a very slow acting drug.

Now to your issue of INR stability...my guess is that it isn't you that hard to manage...it's how your managers react when you are even a little out of range.

Read and learn from here. If you take all of our years combined...well there's got to be at least 500 years experience with coumadin.

Welcome!

 

[Ross]

My cardiologist doesn't prescribe Lovenox. He says it's not indicated for mechanical valves and won't take a chance by having me use it.
Thanks,
Susan

Hello Susan and welcome. You just fell into the best possible place for Coumadin/Warfarin stability. We are a new breed here. We've been self dosing and home testing for years and really have a much better understanding of how the drug works than even the doctors do. That is no joke!

Your Cardiologist is correct that Lovenox was never approved for use with Mechanical heart valves, but I can tell you that it does work and it's much shorter acting (12 to 16 hours per shot) then IV Heparin. Either one will cause far more bleeding then Coumadin could ever hope too, so for your sake, tell them to make darn sure the bleeding is stopped before starting Heparin up again or it will turn into a nightmare. Yes you'll be at risk for stroke, but the risk is very very small.

As for your instability, when this is over, come back and tell us everything your doing, taking and eating and we'll get you stabilized within 2 weeks(welll ok, maybe up to 4) unless you have some sort of blood disorder or they give you vit k while your in the hospital.

90% of the time, it's not the patients fault, but the Coumadin managers fault. Even though this drug has been around for 50 years, the medical community is numb to the facts of proper dosing and how the drug works. It shouldn't be like this, it's like we live in a third world country when it comes to anticoagulation, but it is.

 

[Susan]

Ross,
Thanks for replying. My cardiologist's nurse is the one who adjusts my Coumadin dose. She only uses two doses when she adjusts my Coumadin. Either 5mg or 7mg. She pretty much sticks with those doses, whether is MWF at one dose, then 7mg the rest of the week, for example. Some times if I'm really thin, she'll have me hold a dose. I don't know if there is a formula for calculating the correct dose or not? I can't imagine dosing yourselves, as you say alot of forum members do. Don't you have to stay in touch with your cardiologist or PCP? They are wanting me to get a monitor, so I can test at home some, instead of coming in the office all of the time. I will be the first one my cardiologist will be using the monitor with. QAS requests that I call in my INR to them, then they contact the clinic. At least that what the nurse told me today. I'm still waiting to get it approved by my insurance. Is that the way it works with you?
Thanks,

 

[catwoman]

Susan:

Here's a link to purchasing the algorithm dosing chart that Al Lodwick sells (only about $5-$6).

http://www.warfarinfo.com/publications.htm

Al is a retired pharmacist who ran an anticoagulation therapy clinic at a hospital in Pueblo CO for a number of years. He now presents seminars throughout the U.S. (maybe the world, too) to medical professionals on how to manage folks like us.

I use this algorithm chart. Dosing charts use several different approaches to adjusting doses: Some use whole tablets (add 1 pill, drop one pill, for example), some do it in percentages. Al's is the latter. My PCP's office uses a chart based on the former method. I find it easy to do the percentage method.

I take 6mg on M, W & F, 5.5mg on T-TH-Sat-Sun. That's a total of 18mg+22mg=40mg a week. If I have one "high" INR -- say 4.2, I really don't worry about it. If I get 2 INR's in a row of 4.0+, Al's chart says to "Hold one dose (optional). Decrease weekly dose by 10-15%. Recheck 2-4 weeks."

So I reduce the 40mg by 10%, which gives me 36mg. Divide 36mg by 7 days and it's a little over 5mg per day. Take 5mg 6 days and 6 mg the other day.

I've been using this method for nearly 6 years, and it's worked for me. And I'm not the math expert in my family (my husband's the math teacher).

I gave my PCP a photocopy of Al's chart so he'd know what I was basing my dosage adjustments on, and he was satisified.

Hope this helps.

 

[netmiff]

I've only been home testing for almost 2 year now, have not set foot in a clinic in that time, nor in fact had my INR monitored for well over a year now. I have also been in range all that time, except for when I had surgery recently in my new small town..

I moved from a large town about 6 months ago to a small town. Here in Ontario (maybe even all of Canada) we need a presctiption to get our monitors, and we have to be "trained" by a certified trainer on how to use it. There is no certified trainer in this town, so I am probably the only one self-testing. None of the medical people I have been in contact with have had a problem with it.

About a month after we got here, I borke my arm. Went to emerg on the Sunday, was refered to an ortho doc on the Tuesday, stopped the coumadin and got Ino-hep needles (again, in Canada, different brand names etc). Ortho doc kept me in overnight for IV anti-biotic for mechanical valve), and my discharge instructions simply said something like "needles until INR reaches target range". By that time, my DH was doing the needles, and helping me with self-testing as it was not easy to poke myself with my wrist in a cast!

If you have any specific questions, feel free to e-mail me or PM me, although you may get better - and shorter! - advice from others here.

 

[Susan]

Thanks for the great info. I'm going to get one of those charts and hopefully without stepping on my cardiologist's nurse's toes, show it to her and see what she thinks.
So do you do all your dosing yourself without contacting your PCP?
Thanks,

 

[Cris N]

I've been home testing and self-dosing for about 3.5 years now. I usually see my PCP about every 6 months (once for physical, the other just for blood pressure adjustments if needed) - I tell him what prescriptions I need. He asks if I have any questions about the testing/dosage and when I say no he just says, Fine.

You can do it... lots of help here!

 

[Susan]

Cris,
Wow. I guess it's just that I'm a newbie with all of this home testing. I just don't see my cardiologist cutting me loose with a monitor. Especially since I will be his first patient with one. I don't live in a large area. Maybe in time he will. But I'm thinking they'll still want me to come in to have it checked once a month. I don't have the monitor yet, so I'll have to see what happens.

 

[Ross]

Cris,
Wow. I guess it's just that I'm a newbie with all of this home testing. I just don't see my cardiologist cutting me loose with a monitor. Especially since I will be his first patient with one. I don't live in a large area. Maybe in time he will. But I'm thinking they'll still want me to come in to have it checked once a month. I don't have the monitor yet, so I'll have to see what happens.

Who's in charge of Susan? Susan or your cardiologist? You've got to assert yourself and take control. Do not be intimidated.

 

[catwoman]

Susan:

There are a lot of studies on the internet about home-testing and self-dosing, that patients are in range more than those who go to clinics.

 

[Susan]

Catwoman,

That's very interesting. I'll have to wait to see what happens when I get a monitor with how my cardiologist will handle everything. But, that's a good point to know.

Thanks,