Anti-coagulation after surgery

[bbb]

Hello,
I am due for an aneurysm repair and bav valve replacement, probably St. Jude's at Cleveland Clinic Nov. 30th. Do they put you on the Coumadin immediately after the surgery? And how long does it take to stabilize the dose in the hospital?

Then what am I looking at once I get back home, how often will I need to go to the clinic? I suppose I will have a pretty regular appetite once I get home? And if I want green veggies to be a part of my diet, do I eat a consistent amount from the get go of being home so I can have the coumadin adjusted to my diet?

Anything else I will need to know about those first weeks/months of being on coumadin?

THANKS! Betsy

 

[Ross]

Betsy it will take a bit get you stable. They start you after surgery, providing you don't have a bleed somewhere, then you should be in INR range within 4 to 5 days. Your not going to have an appetite and food is going to taste terrible for about 5 weeks, so a combo of poor diet, much less activity then normal will lead to a small amount of warfarin to keep you in range. Once your apetite comes back and you become more active, you'll need more warfarin to keep you in range.

For a while, you may go to get tested weekly and then eventually monthly.

Eat your normal diet as you always do and don't let them tell you can't. You'll go back to that diet anyhow in a matter of time, so why not adjust for it now.

Really there isn't much more. It's wait and see as you recover.

 

[ALCapshaw2]

There are several schools of thought on anti-coagulation following surgery.

I suspect most surgeons start your Coumadin the night of your surgery, recognizing that it can take several days to come up to theraputic INR levels.

This is where it gets tricky. There are Faster (and Shorter) acting anticoagulents, namely Lovenox (injections) or Heparin (IV Drip). These are often used to "bridge" Coumadin patients until their INR is in range. There is no interaction since these anti-coagulents work on a different part of the anti-coagulation chain. There is some (small) additional risk with these medications (mostly in how each patient reacts which your nurses will need to watch for).

The BIG question is "When to begin" the Bridging medication to balance the Risk of Stroke versus the Risk of Bleeding. Some surgeons do NOT Bridge, but simply wait for the Coumadin to reach theraputic level. I expect every surgeon has his own philosophy and experience with this issue. It's a good question to ask your surgeon.

'AL Capshaw'

 

[Marty]

The "hand off"

The "hand off"

In days past heart surgery patients were in the hospital at least two weeks post op aand the surgeons could get the ACT stabilized before discharge. Now patients are discharged post op much earlier. I went home AM the fourth post op day. My surgeon was no longer responsible for the ACT, I was never told but presumed my cardiologist was now in charge. However they are busy people saving lives in the ER and ICU so ACT is way down on their list of concerns. Their nurses do it any how. My surgeon told me they operate on patients from all over, some hundreds of miles from home. He is not sure who gets the "hand off" much of the time. My advice ; discuss the "hand off" with your surgeon and also discuss before the operation with your PC or cardiologistjust how they intend to work it. Mine didn't work well at all. When the surgeon checked me at the routine 2 wk post op my INR was 8 and I had a chest full of blood. It had to be aspirated and I still remember all the little bottles of blood the tech pulled out. It never reaccumulated and about that time my cardiologest ordered a Coaguchek for me and I've been doing it myself ever since.

 

[bbb]

Marty,

My cardiologist has said I would probably see him about 3-4 weeks after I am home from Cleveland, and beforehand I would be going to the coumadin clinic. I will have to discuss with Cleveland how soon I go to the local coumadin clinic once I am home. If all goes well I am home on a Friday. How soon does one go to the clinic after surgery?
Are coumadin clinics open on weekends, or is it usually a Mon-Fri. operation?

I think since I am having surgery in Cleveland, I will not see a surgeon again, unless I need to. After hearing what happened to you, that makes me a little nervous. Should I consider seeing the cardiologist sooner? Did you have any symptoms of having the blood in your chest?

Thanks, Betsy

 

[Marty]

Betsy,I would check in at the Coumadin Clinic as soon as you get home. Then call your cardiologist with the PT and INR.I'm not sure when all Coumadin Clinics are open. Its all individual. We don't even have any around here in Virginia. If you have one run by a dedicated pharmacist or nurse you are lucky. If not you will have to go to a hospital lab.I don't approve of your cardiologist saying he will see you three or four weeks after you get home from Cleveland. Too much can happen in that interval. See him/her the first week back to make sure you are not fibrillating and that your INR is therapeutic. This should enable the handoff to go smoothly with no surprises. I am sure you will do well, but you have to be a little bit pushy in this situation. As for me, having blood in my chest there were almost no symptoms perhaps a little heaviness. Needless to say I was surprised when they found it with the routine X-ray at 2 weeks. Let us know how it goes with you. We are all interested in you. Marty

 

[MarkU]

I was on a Lovenox bridge after surgery while the Coumadin "kicked in". I had a home care nurse come and give me the shots the first three days I was back at home.
Had my INR tested weekly at the Coumadin lab for the first six weeks until it stabilized and then backed off to once a month for the next year.
Now seven years post-op, I get tested about every six weeks.
My only significant disruption has been going on Lovenox bridges for a couple of colonoscopies - the last time it took me about three months to get my INR stabilized again.
Good luck,
Mark

 

[EVELYN]

Hi Betsy

From my husband, Tyce's, experience. I remember they started him on coumadin the morning after surgery and I believe it was 10 mg. He stayed on that dose until we went home 2 days later....at that time his INR was 1.9 but on the rise.

I have to tell you, the hair on the back of my neck went up when you said 3-4 weeks to see your cardio post op. I know our cardio saw tyce 2 days after he came home from the hospital and then again the following week. If I'm not mistaken, he did an INR test both times....but don't quote me on that because it was 5 years ago and I don't remember. Anyway, Tyce's cardio visits went from once a week for two weeks to once every two weeks to once a month. However, his INR testing stayed weekly for quite a bit.

If at all possible, once you're stable, get a home testing machine. We have the INRatio and test weekly. Tyce eats whatever he chooses....with moderation and consistency and I can tell you from experience, it's alot easier checking every week and making an adjustment than every 2 or 4 weeks.

Good luck with your surgery. You'll be fine, but defintely tell your cardios that you want to see them sooner.

Evelyn

 

[doyo]

Hi, Betsy
Like Marty, my wife did not have smooth "hand off" between the hospital and the cardiologist office. First we got the feeling that her cardio did not want to manage coumadin.
The hospital arranged for the initial home nurse visit for INR check, but the cardio refused to order additional visits and was unresponsive on ACT issues.

When the cardio finally took over, his dose adjustment order actually made the INR drop like a rock to 1.2 in a few days. Before this time, I was arguing with his office on the dose order and testing intervals. It was before I discovered this wonderful community, but even then his coumadin management did not make any sense.

During the 2 week post-op checkup, after hearing the dose adjustment order and 10 day testing interval ordered by the cardio, the RN at the surgeon's office immediately orderd INR check and that's how we found out it was down to essentially zero anticoagulation level (INR 1.2 from 2.3 in 3 days)

Thankfully the surgeon's office took over ACT management temporarily until our PCP took over. I feel my wife's surgeon saved her life twice (surgery and ACT management).
Then I discovered this web site and thanks to help of members including Al Lodwick, Ross and Marty who posted in this thread, she came through.

Her PCP did much better job (he was more knowledgeable than most doctors on this topic) and we now home test and self manage which is the best way to do this stuff. The lab kept making mistakes and my wife's vein was not holding up well.


Here is what I'd do if we had to do it over again.
Talk to your cardio or PCP before the surgery to make sure eveyone knows who will be managing it.
I would definitely ask about testing interval.
Since you will get discharged before INR becomes stable, I would insist on testing more often than once a week during 1st 2 week using the home nurse visits if your insurance covers it. Our home nurse had the portable testing machine so we got the result right away. If not, the home nurse will take the sample to the lab. Make sure your doctor orders INR test with STAT written on the order so your doctor and you get the result on the same day. The lab INR test should always has to be done STAT.

Then you can move to weekly schedule. As you recover, your INR will start dropping fast unless dose is increased, so I would stick with weekly testing for a couple of months. (personally, I will continue with weekly testing, especially with home testing machine).

Maybe you'd want to discuss with your doctors about home testing machine now to get them on the same page....

p.s. Get an accurate Digital bathroom scale before the surgery. You need to weigh yourself everyday (the first thing in the morning to be consistent) to monitor weight gains. The weight gain of 2-3 lb over a few days (cannot recall exact range. The booklet they give you at the hospital had it) could mean you are accumulating fluid around the lungs and heart and needs to be checked out by your local surgeon/hospital and drained. My wife had no symptom but gained 3 lb in 2 days. I took her to the surgeon's office right away and turned out a lot of fulid accumulated in her chest. She was sent back to the hospital right away and stayed for a few days to drain the fluid.


Hope this helps and good luck on your surgery.
EJ