Al, HELP!

[Dee]

I know it's been forever since I've been on. We've had some teenage issues at our house that have taken up all of my time and energy. We think we have things going in the right direction now that he has just returned from a 7 week wilderness camp with a renewed outlook on life, and it's time for me to start taking care of myself again. I'm also dealing with my Dad's lymphoma returning and on and on.....The stress was almost too much to handle.

On Dec. 5th I'm scheduled to have internal hemorrhoids removed using Stapled Hemorrhoidopexy and external hemorrhoids surgically removed and then closed up with sutures. I met with the surgeon today and he said his standard procedure when working with someone on coumadin, is to have them go off 5 days prior to surgery and use Lovenox for bridge therapy. 5 days seems like a lot to me as my levels drop like a rock of just one missed dose. I asked him what he would like my INR levels to be at the time of surgery and he said at the most 1.5, so I asked him since I have my own testing equipment, if he thought I could manage my own INR for the several days leading up to my surgery and have it at that level at surgery? He thought it could be a possibility, but needs to check with my cardio.

I would like your input on this, if you have any experience with patients having a hemorrhoidectomy and how you would handle the coumadin issue and the bridge therapy issue. I'm so scared to have this surgery done with something terrible happening, like a stroke or something, but I have so much pain and bleeding all the time, it's time that I take care of this.

I greatly appreciate your input and want you to know how much I and many others appreciate you being here for us. Thank you!

I look forward to hearing back from you.

 

[JimL]

When I looked into have some minor surgery done a couple years ago (cysts), I was told by one surgeon three days off coumadin before surgery and three days after surgery to get back to normal, thus roughly a week in the hosptal for the surgery. I found another surgeon who would remove the cysts while I was on coumadin.
But your surgery is more serious; you definitely need Al's input on this. I can sure sympathize with the "teenage issues," which we also faced a few years ago; they all lived through, and so did we, and their twenty-somethings now, which seems a definite improvement.

 

[Ross]

Teens and teen issues=

 

[Karlynn]

Yes, 5 days does seem like a lot, particularly if you drop fast. If you take a large dose, one missed does drops you very quickly. I can attest to that. I take 9 and 10, depending on the day. A month ago, I accidentally only took 3 of the 9 mg. in my pill sorter. My INR had been around 3. 3 days later, I tested and my INR was 1.4 (and I had missed no other doses).

 

[Karlynn]

Yes, 5 days does seem like a lot, particularly if you drop fast. If you take a large dose, one missed does drops you very quickly. I can attest to that. I take 9 and 10, depending on the day. A month ago, I accidentally only took 3 of the 9 mg. in my pill sorter. My INR had been around 3. 3 days later, I tested and my INR was 1.4 (and I had missed no other doses).

Although, I will say that I would be much hesitant to got that low intentionally w/out bridge protection.

3 days does seems to be the magic # of when to stop tho. (And the magic # for my post. )

 

[ALCapshaw2]

Hello Dee Dee,

I can relate to your concerns. I just went through an Upper Endoscopy and Colonoscopy with Biopsy while on Lovenox Bridging Therapy. I wasn't thrilled to have to go OFF Coumadin but my GI Doc would not agree to do the procedures while on Coumadin because he wanted to do a biopsy and take care of anything he might find at that time.

I actually learned to give myself the injections which was quite an accomplishment He told me to hold my Coumadin 4 days prior to the procedure and start the Lovenox injections 3 days prior to the procedure, take the last pre-procedure injection 24 hours prior, and resuming the Lovenox injections the night after, for another 4 days after.

Coumadin was also resumed the night after the procedure at an accelerated rate determined by my Coumadin Clinic Nurse and my INR was tested 4 days later. I got through it OK although there was a brief episode of a possible TIA when I checked in for the procedure. It cleared in a minute or two and I was monitored by the nurses for symptoms.

Al Lodwick recently related a conversation he had with an MD who specializes in anti-coagulation regarding Heparin who concluded that Lovenox Bridging was MUCH more consistent and reliable than Heparin.

Lovenox Bridging isn't fun but it's not horrible and it probably is the BEST (i.e. SAFEST) way to go for invasive procedures.

'AL Capshaw'

 

[Dee]

Thanks you guys for the responses so far. I'm anxiously awaiting what my cardio says, but the last time I had a very simple TEE, he wanted me to go off for 4 days prior. After consulting with you guys and not feeling comfortable with it because of my volatile INR, I talked him into just skipping the day before and the day of the procedure. I have a feeling I'm going to have to do some more negotiating with him.

Yes, aren't the teenage years just a joy??? haha. I could write a whole story on what we've been through in the last several months. I guess I'll have to save that for the small talk forum. I was under so much stress and having a lot of chest pains that the Dr. ordered a stress test for me with the IV and scans. The results came back good, but I started to pass out right after the treadmill part...they got me to a recliner and hooked up a bag of fluids to my IV and I started coming around after a little while. Am I out of shape or what???

 

[Guest]

The rankings for risk of complications are from worst to best
stopping warfarin with no Lovenox
stopping warfarin and having bleeding with Lovenox
stopping warfarin and having no problem with either Lovenox or not.

To me 5 days is not too long to be off warfarin if you are on Lovenox. But you should also stay on Lovenox until your INR gets back into the therapeutic range for two days.

 

[kas]

private messages

private messages

Dee. Please check your private messages! Thanks kas

 

[Dee]

Surgery is over and I'm 2 wks. post op today. What we ended up doing with the coumadin is they had me lower my dose a little for a few days and then stop it 2 nights before my surgery, no Lovenox. That's the one nice thing about having a Cougucheck at home, I was able to monitor my INR really close. The surgeon wanted it to be 1.5 the day of surgery, and guess what, I woke up that morning and tested right before I walked out the door and it was exactly 1.5. So that went smoothly! Figuring out how much to take to get back to my normal INR after surgery, was a little more difficult. In fact about 3-4 days post op, I was having a ton of bleeding...it really scared me, I thought something really went wrong. Then I thought I should check my INR before I call the surgeon. It was 4.6!!! No wonder I was bleeding!! I skipped that night and never had a problem with bleeding again.

I'm slowly recovering. I thought it would be a lot quicker than it's going, but that's usually the way things go for me! Of course I want to be 100% with the Holidays coming and so many things to do. There are certain things that just aren't going to happen like usual I guess. We have a house full of company coming, so I guess everyone is going to get to pitch in this year

If I don't get the chance before this weekend, I want to wish all of you a very Merry Christmas and a Happy New Year!!!!!

 

[Guest]

What rank would a hemorrhoid surgeon hold in the Navy?

Rear Admiral.

 

[Dee]

That's a good one Al!!!

There seems to be lots of jokes when it comes to Hemorrhoids and surgery.

When I got to the hospital and the nurse came in to start asking me questions and getting me ready for surgery, she asked me what type of pain I was having and where my pain was. My husband thought I was going to point at him and say "it's sitting over there in the chair and it's a pain in my a**!!!" It's a family joke now.