Invasive procedure perioperative management of INR (extended)

Good morning.

Well finally I've written up the experiences of @Chuck C who was kind enough to share his results with me. Chuck recently had to undergo a procedure which would in the past mean going off warfarin and bridging. He (like me) found that onerous and undesirable and (probably) agrees with my views that the risk benefit analysis does not hold up.

He had read my previous work on this:

https://cjeastwd.blogspot.com/2017/12/perioperative-management-of-inr.html
and felt that it could be improved upon and set about constructing his own version of it, extending and honing it. This is the goal of any science driven endeavour, to have it examined, critically appraised and developed. Personally I think he did a great job and I'm very happy that he's such a networker and sought to include me in this..

Of course this is not for everyone, heck even within this community mech valvers are perhaps a minority of members. Mech valvers who self test even less and those who self test and self dose are smaller again. Yet there are potentially readers who are not members and who do not live in the USA and do not have simple easy access to heparin or simply don't enjoy that process and are looking for an alternative.

So with that disclaimer here is the latest work in exploring self directed perioperative INR management.

https://cjeastwd.blogspot.com/2022/05/rapid-dust-off-inr-management.html
I believe it also has applications in other areas such as contact sports, for I have over the years met a few valvers who were into martial arts (as I once was) or other contact sports (like soccer).

So, I'm ready for questions if there are any.



Best Wishes

*PS I wavered on publishing this but a few people whom I keep in touch with here have suggested I publish this here for the reasons that I mentioned above. I know I'll no doubt get flak from various arm chair scientists (who don't have science degrees) but I'm ok with that (mostly because I've already put them on my ignore list).

My surgeon was happy for me to be around 1.5 during shoulder surgery.

The INR needs to be low to aid the healing process as well as to mitigate against bleeding.

leadville said:

My surgeon was happy for me to be around 1.5 during shoulder surgery.

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its indeed interesting that guidelines suggest INR of 1.4 yet then go on to directly talk about ceasing warfarin


(ref doi:10.1093/eurheartj/ehab395)

... it just leaves me scratching my head.

Thanks for the comments

leadville said:

My surgeon was happy for me to be around 1.5 during shoulder surgery.

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Hi Leadville,

So they did not bridge for shoulder surgery, just had you bring INR down around 1.5?

@Chuck C

hey,

I have had 2 surgeries in the 12 years i have been taking warfarin.

I found it depends on how the Surgeon feels about the situation.

#1 surgery, dose down to ~ 1.5 with no bridging needed.

#2 Surgery, dose down to 1, stop warfarin and bridge with Heparin ( classic method )


#1 surgery i was prescribed Heparin as a precaution however. i never needed it.

Of the 2 methods i would prefer to lower my warfarin dose as opposed to stopping completely, but just to reiterate ;
the surgeon needs to be on the same page.

Anything really invasive, I stopped warfarin and bridged. Second heart surgery for example.

Gall bladder and appendix was kind of a rush. I got to the hospital on a Wednesday with pain, they stopped Warfarin right away then did surgery when INR was low enough. But they had time, and it was laparoscopic. I imaging a ruptured appendix might have called for more drastic measures. My gallbladder was what brought me in and we all agreed to take the appendix while I was there to avoid such an emergency on Warfarin as Appendicitis is rather prevalent in my family.

Superman said:

Anything really invasive, I stopped warfarin and bridged. Second heart surgery for example.

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hard to get more invasive than that

leadville said:

Of the 2 methods i would prefer to lower my warfarin dose as opposed to stopping completely,

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I share this preference. The surgeon who handled my recent thyroid procedure prefers this as well.

I had my follow up appointment with him yesterday and we discussed this. He indicated that there seems to be a shift happening with many surgeons preferring to lowerering INR modestly, rather than bridging. But, it really comes down to individualized medicine; the patient's particular risks and the specific procedure.

Chuck C said:

He indicated that there seems to be a shift happening with many surgeons preferring to lowerering INR modestly, rather than bridging.

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this is frankly great news.

But, it really comes down to individualized medicine; the patient's particular risks and the specific procedure.

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of course ... as Superman suggested "OHS" and other very invasive processes will probably not benefit from such a technique.

Thanks for posting

Two years ago had knee replacement surgery. Have mechanical heart valve. Was told to bridge and was told to stop warfarin on Sunday for a Thursday surgery and to do lovenox shots twice Tuesday and only Wed morning. Was told at time of surgery on Thursday morning my INR was 1.07. My first reaction was too low. Had surgery and they held off lovenox shots but had me start warfarin Thursday evening with my normal 5 mg dose. Had rehab late morning on Friday. Nurse came in to check on me after rehab and found I was confused. She called doc and he determined I was having a stroke. They called my wife who showed up to room with an ambulance crew in hallway with stretcher. She was asked to approve the use of the TPA clot buster drug and if no improvement, I was going to be taken to a stroke specialty hospital 15 miles away. I remember none of this and woke up in ICU the next morning. Ended up in hospital for another 5 days and after many tests, it was determined they caught it and no lasting issues from stroke. There were 3 CT scans and one MRI over 2 days. I am told by my cardiologist that I am more susceptible to clots and they will be more hands on next time I have to bridge.

I may need another knee replaced in a few years, for other knee, and my shoulder is falling apart and I am told plan for a reverse shoulder replacement in the future. So will be needing to bridge again in the future.

It is hell to get old. But the alternative is not too good.

pellicle said:

of course ... as Superman suggested "OHS" and other very invasive processes will probably not benefit from such a technique.

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I’ll further add the risk of a clot forming in my mechanical valve is pretty low when my mechanical valve is removed and my heart is stopped. So a little different.

Superman said:

I’ll further add the risk of a clot forming in my mechanical valve is pretty low when my mechanical valve is removed and my heart is stopped. So a little different.

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Good point. But, the moment the new valve is stitched into place, off the machine and blood flowing through the heart again, a little risk of clot with each beat.

Superman said:

I’ll further add the risk of a clot forming in my mechanical valve is pretty low when my mechanical valve is removed and my heart is stopped. So a little different.

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thanks for that research jump off point

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5613602/
Hypothermia is frequently used during CPB for its presumed organ protective effects. Blood viscosity increases with hypothermia and allows maintenance of a higher perfusion pressure despite haemodilution. However, hypothermia reversibly inhibits the clotting factors and platelets. Currently, the data are inconclusive regarding the superiority of hypothermic over the normothermic bypass.[20] Rather than the absolute temperature, the rate of rewarming and cerebral hyperthermia have been shown to be more important to prevent cerebral injury

After 10 years of home testing, and self adjusting my warfarin, through 3 major surgeries, the only time I had a bleeding issue was when I was bridged with Lovenox after knee replacement surgery. My knee surgeon was fine with my INR at 1.4 for the surgery. Unfortunately right after the surgery my surgeon was on the way back to his office and was involved in a bad traffic accident. Another surgeon from the practice followed me up that night and ordered a lovenox shot even though I had already had a lovenox shot 8 hours before, and had resumed my warfarin. All of this caused severe hemorrhaging which took hours to resolve. I have an On-X valve,stopped the warfarin 3 days before the surgery and my INR was 1.4 3 hours before the surgery. I take 12.5mg a day to maintain 2.3 - 2.8 INR. Stopping warfarin drops my INR .4 to .5 a day. In 2 days after starting warfarin from 1.4, I’m not only in the On-X proact trial range in 1 day, but at my comfortable range 2-3 in 2 days. This is all because of knowing my own body and home testing and self adjusting. It has worked for me through the two surgeries ( cervical spine and shoulder surgery for what the surgeon described as a massive tear!) It cuts the Stroke risk significantly from the old recommendations. After the second Lonenox shot and subsequent hemorrhaging, i had to have a blood transfusion and was anemic for a month. Needless to say I’m not a big fan of bridging unless completely necessary. I knew that future surgeries would be problematic because of the medical communities views on surgery for ACT patients. I found this article on surgery and bridging from the Cleveland Clinic dated November 2003. https://www.researchgate.net/publication/8981779_When_patients_on_warfarin_need_surgery even in 2003 they were questioning the safety of bridging and stopping ACT for 5 days. The article was long and covers a lot, but it’s worth a read. By no means do I recommend this for anyone, it has worked for me and my surgeons were onboard with the INR level. Sorry this was so long but ACT shouldn’t be so scary or raise the RED FLAGS with most of the medical community not familiar with the new mechanical valves.

Thanks for your comment, and I hope your surgeon wasn't hurt in that accident.

Gator Chief said:

Sorry this was so long but ACT shouldn’t be so scary or raise the RED FLAGS with most of the medical community not familiar with the new mechanical valves.

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Indeed and my first pass assessment is that its an unintended by-product of the most powerful persuasive tool (fear) which was brought to bear on new starters to ensure compliance. Combined with no methods of self assessment of INR one could predict that it would result in fear of the unknown with no way of looking under the bed to see that there weren't monsters there.

Imagine trying to drive within the speed limits in a car with no speedo.

My dentist told me this week have to get a tooth removed soon, Have read all the good work of Pellicile and Chuck on the subject and it seems that for a tooth extraction i will not need to cancel the warfarin for 2 days but just take half doze for 2 or 3 days; My usual doze is 3mg a day ( i always take notice that most people doze is more than that, but i dont eat much greens, just 1 cup of green tea and some brocolli everyday and that seems to work; not saying is a good food plan; my target range is 2 - 3, and i take 1 asa once/twice a week; Will do a test 2 weeks before the day, to take 1 mg for 2 days, and see how that works; Sometimes i use the labs but lately the labs result show lower than the XS, and i do trust more the XS, just sharing.

Hi

Habana58 said:

Pellicile and Chuck on the subject and it seems that for a tooth extraction i will not need to cancel the warfarin for 2 days but just take half doze for 2 or 3 days;

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you may find this 'experiment' informative as someone I work with to "teach the ropes" of self management to has recently "missed a dose" (error) and decided to go with making data lemonade out of that

The lag and recovery are interesting

yes, their daily dose is 9.5 (right hand axis) and their INR took just two days to reflect that drop and is now on the rise. A more rapid rise (return to previous levels) would have resulted with a bit more of a "bolus" administration ... but the direction was taken for learning.

not too dissimilar to my own results (except I allowed the zero dose to go on too long, thus delaying my return to desired ACT levels



So you can see from that the target of 1.5 (ish) took until the third day (dose taken in the PM) ... by conducting "make lemonade" and documenting these things you can build up (and soon) good data for you

Test and Know Thyself

and i do trust more the XS

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agreed
Best Wishes

Habana58 said:

a tooth removed soon, Have read all the good work of Pellicile and Chuck on the subject and it seems that for a tooth extraction i will not need to cancel the warfarin for 2 days but just take half doze for 2 or 3 days

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I had a tooth pulled in June, and then a dental implant installed in the jawbone in August. They wanted my INR below 2.5. Because my INR is normally between 2.3 and 2.6, I reduced my dose by about 50% for 1 day before the dental procedure. Unfortunately, I had some bleeding after the dental work.

Next time I have dental work like this I will keep my INR in the 2.0 to 2.5 range for a few days after the procedure to allow my gums to seal the wound sooner.

The oral surgeon prescribed Tranexamic Acid 5% to help stop the bleeding. It is a liquid that you hold in your mouth for a few minutes, then spit out. You repeat this several times during the day until the bleeding stops. It works at the bleeding site to help clots form. It is expensive, but it worked.

I hope your dental work goes well!

3mm said:

Tranexamic Acid .... It is expensive, but it worked.

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interesting ... thanks

Here is a video from the Clinical Trials Unit (CTU) at the London School of Hygiene & Tropical Medicine that explains how Tranexamic Acid works.
https://www.bing.com/videos/rivervi...=2567367CB8CB495D97DF740A722E53AE&FORM=VRDGAR