Still Bleeding!

[Gail in Ca]

It's been 16 days since my surgery to cut out a melanoma. The first 2 return visits I was still bleeding and the Doc left my stitches in and had the nurse re-boot my leg. Today, I was hoping to get the stitches out and leave without a boot. No such luck as my incision is still oozing. I have dropped my warfarin dosage from 52.5 per week to 50mg this past week, but my INR went up. So, this week I am dropping another 5mg and hope it comes down more. I'm trying to get it into the low end of my range, but not having much luck.
The Tylenol and inactivity has lead to this I'm sure. The Doc says it's not uncommon to bleed, and she was expecting it could happen.
But, today my wound looked worse and red, so I'm taking Keflex for 7 days and go in again. I'm going to try to keep it elevated more.
This is really the first time I have dealt with bleeding affecting a wound like this. I guess the shin is also a place where I would bleed more, as well.
I just want the darn thing to heal!

 

[pellicle]

hope it settles. I agree that the elevation is a good thing too and was going to suggest it.

I was going to add that slipping down to the lower INR would be my idea too. Inactivits seems to effect metabolism and thus INR too. sine coming to Finland I have had to reduce my warfarin intake from 51 to 49 (done by changing my 7.5 | 7mg daily alternation)
and still my INR is a few points higher in the range (but still in the range) than it was. So dont be surprised if you need to drop it more.

I know that you know these things anyway, so I don't know why I'm saying this.

Best wishes for the healing.

 

[Protimenow]

When you take an antibiotic, your INR usually goes up. Making such a modest adjustment in your dosage will probably not counteract the elevation that the antibiotic causes.

If it was me, I would probably make a drop of somewhat more than 10% of my daily/weekly dose. I would increase my intake of greens. I might even start taking a supplement with Vitamin K or K2. I would also test my INR every day or two to see if it's dropped to the low end of my range.

You may present your doctor with this information -- he or she SHOULD know that antibiotics raise the INR (and this can make it harder to form and retain a clot); and that dietary changes or the use of Vitamin K can also reduce your INR, making it more likely that the site will finally close.

Unfortunately, many doctors who are extremely focused on one specialty forget that they're working on healing an entire body.

 

[Bina]

I don't know what your INR readings are, so I won't make any suggestions, but wish you well

 

[Gail in Ca]

My inr was 3.0 last tues and 3.1 this tues. My range is 2-3. When I knew I was having the surgery I lowered my dose by only 5mg/wk, that 1st week. Inr was 2.5.
But, with all my inactivity, Tylenol use, and not really eating much leafy green veggies, it has risen to 3.
So, I dropped the dose again and now will drop it this week too. Thank goodness I just got my delivery of strips, I was down to only 1.
My doc gave me Keflex because she said it wouldn't affect my inr. I haven't looked into that to see if that's true.
Thanks for the responses. I took a picture of my incision with my phone when the unna boot was removed and my husband didn't want to see it!
He is grossed out by things like that. So, I showed it to my 95 yr old Mom, and I'm sure she'll talk about it to her friends, Ha! I truly never expected to have such a huge incision for a melanoma removal. I was very naïve.

 

[pellicle]

Hi

If I was you I would be making more serious adjustments to your warfarin dose to get your INR down a bit faster. Of course I don't know what your thrombosis risk is like (such as which valves you may have had reolaced) but you need to weigh thromboembolism against infection.

My experience in INR suggests that minor dose adjustments won't have the effect you need. Perhaps two days of 4mg would see it dive. There is a myth among even the more experienced INR self testers that you won't see INR changes in a day. That's wrong. The myth exists to assist self testers to not over react when making dose adjustments.

In this case the American habit of thinking in weekly dose is leading you astray.

I also thought there were some blood tests to check for signs of thrombosis, which may be worth considering if you are at risk from TIA

 

[Gail in Ca]

Holy you know what! I just got a message from my dermatologist and the culture she took of my wound is infected with staph aureus. I am scared now. She said the Keflex is the right antibiotic for this bacteria. With my endocarditis history, I don't know whether to let my cardiologist know about this.
She's a good doctor, so I'm sure she has dealt with this before, but....
Yikes!

 

[pellicle]

5hit Gail thaw no bl00dy good!

Well don't panic (won't help anyhoo) and definitely let your cardiologist know about this!

Are you seeing any redness in veins spreading outwards from the wound?

Fingers crossed this end mate!

Just did a quick Google around and Keflex seems to be used against msr staphylococcus.

You probably found this anyway...
http://www.vdh.virginia.gov/Epidemiology/Surveillance/MRSA/

Colonization vs Infection
The distinction between staph (including MRSA) colonization and infection is important.

Colonization = the presence of the bacteria, but no signs of illness or infection. Staph thrives in warm, moist places; common sites of colonization include the nostrils, belly button, underarms, groin, etc.

Infection = clinical signs of illness or inflammation (e.g., localized pain/tenderness, redness, warmth, swelling; pus; fever). These are due to tissue damage caused by invasion by the bacteria. Infection requires treatment - various treatment options exist. Treatment does not always require the use of an antibiotic.

 

[Gail in Ca]

I called my cardio and he answered his phone! He asked if I felt sick (NO) and asked about the redness of my wound. He felt it was just the skin, but to call him if I have any of the usual symptoms like I had with my last go around with staph. He would do cultures but I have been on Keflex since tues, and my wound was already cultured. I mentioned trying to get my inr down and he did say the antibiotics would affect it.
The darn thing has been wrapped since I got the surgery. Only taken off once a week, and then re-wrapped. This bacteria is rampant in health care situations.
Crap! I didn't realize it could be MRSA! Okay, I won't let it get to me. Time to elevate my leg, read a book and try to play fetch with my terrier while sitting.

 

[Bina]

Sorry to hear about the staph, but at least your INR has been co-operating and is in a safe range. Pushing some good vibes !

 

[Gail in Ca]

Update! Went to get my unna boot changed by the nurse on Friday because it was cutting into me. My doc was not in, and the nurse had another dermatologist look at my incision. He said we had to get the stitches out, and then steri strips and just an ace bandage, and keep off of it all weekend, see my doc on Monday. On Monday, my doc wasn't too pleased. When the nurse just started to take off the gauze pad, my incision erupted with blood, dripping down my leg. My doc said the other doc didn't see my case as serious as it is! So, she peeled 2 steri strips off, and then it was wrapped again very tight in the unna boot for another week at least!
Jeez, I cannot believe this is becoming a big ordeal. On a good note, my inr was 2.2 today. But, really, it didn't seem to make a difference yesterday. I guess 2 or 3, I'm gonna bleed like a stuck pig! This will go on until I stop bleeding and it finally begins to scab and heal. She did say it doesn't look infected anymore, so the Keflex is doing its job. My eyes are opened, now, about major other-than-heart procedures while on Coumadin.

 

[Protimenow]

We've had some threads in the past about people who have had teeth pulled - and the seeping stopped until they removed the gauze packing, and it started up again. It sounds like your situation may be somewhat similar -- the less you use that incised area, the more likely it will be that the bleeding stops -- until you move around and reopen it. I know that it's not easy to do NOTHING, but in this case, it may be the best thing that you can do in order to let the seeping stop, and to keep the closed area closed. (At least, this is probably what I would do, if I was in the same spot).

 

[pellicle]

I cannot believe this is becoming a big ordeal.

Well I suspect that now you are a candidate for a VAC dressing. Ask them about it.

On a good note, my inr was 2.2 today. But, really, it didn't seem to make a difference yesterday. I guess 2 or 3, I'm gonna bleed like a stuck pig!

I believe that this is no longer an INR problem, but caused by the wound colonisation by bacteria.

I would raise this as a serious matter. My neighbour has an infection from a ankle wound that became colonised by staph. It took months to control and he was not on warfarin.

http://www.ncbi.nlm.nih.gov/m/pubmed/18075142/

From the company site

The V.A.C.® Therapy System, also known as NPWT (Negative Pressure Wound Therapy), is an integrated wound management system for use in acute, extended and home care settings. It is intended to create an environment that promotes wound healing by secondary or tertiary (delayed primary) intention by preparing the wound bed for closure, reducing edema, promoting granulation tissue formation and perfusion, and by removing exudate and infectious material. It is indicated for patients with chronic, acute, traumatic, subacute and dehisced wounds, partial-thickness burns, ulcers (such as diabetic or pressure), flaps and grafts.

http://www.kci1.com/KCI1/indicationsandcontraindications

My experience with it is great

http://cjeastwd.blogspot.com/2012/11/vac-pack.html