Bridging controversy

[warrenr]

Lot of talk here lately about bridging. It seems that most of you think that if your doctor bridges you for a procedure that everything will be fine. Here is my point. Most of the procedures everyone is talking about are low bleed risk procedures ie. ablation, root canal, screening colonoscopy, mole removal, etc. In fact, most of the procedures you will face for the rest of your lives will be low bleed risk procedures. It seems that when the doctor tells you to stop coumadin and he will bridge you then you think this doctor know's what he/she is doing when in fact he/she doesn't. The written standard's for these low bleed risk procedures is to have them done without stopping coumadin. Why even take the chance of bad outcome with bridging when coumadin shouldn't be stopped to begin with. If the doctor doesn't feel comfortable performing the procedure fully anticoagulated when the standard say's no need to stop coumadin then in my opinion the doctor is incompetent and you should go to a competent physician. If the standard for a particular procedure is to do it anticoagulated then damit take charge of your care and get someone that know's what they are doing.

That is my 2 cents worth

 

[Guest]

I agree with that.

 

[tommy]

I have all the respect in the world for you Warren, and am very sorry for what you and your father have been through. However, I think that the use of the word "incompetant" is a bit strong.

In my area (Dallas), bridging for colonscopies is the norm. I suppose that I could convince my GE to do a scope without adjusting Coumadin, but this would be purely an investigative scope. If any polyps are discovered, I would need to go "under" again to ship them. That merely delays the "bridge" question.

I also suppose that I could shop for a GE that would snip without adjusting Coumadin, but I choose not to look any further beyond the best GE in the Dallas area (that I already use). Is he an expert in anti colagulation? No! But my cardio gets involved every time.

I also bridged for hernia srepair surgery. Again, I used a top notch surgeon and anticoagulation guidance from my cartdio.

..my 2 cents.

 

[Karlynn]

Warren or Al, do either of you know where I can get the protocol for the anticoagulant patient undergoing a D & C Hysteroscopy? I've been look, but I'm not the best web searcher in the world.

 

[Nancy]

I have a BIG suspicion that insurance bean counters will be putting their two cents into the scenario of doing two colonoscopies in a row, one with anticoagulation and one with bridging.

I think they have much more say in all of this than any of us will ever know.

 

[Ross]

Just to throw a wrench into this whole thing, there are folks who are as proactive as it gets and are stuck with the Doctors they have and cannot see someone else without incurring expenses that they can't afford. (HMO's)

Honestly, everything is true and I couldn't agree more. I just wish it weren't so hard for people to be able to pick up and search for another physician.

 

[Guest]

If the world were perfect then we wouldn't need doctors.

The table would be a little crowded at dinner with everyone from Adam and Eve on down all elbowing their way up.

 

[Ross]

If the world were perfect then we wouldn't need doctors.

The table would be a little crowded at dinner with everyone from Adam and Eve on down all elbowing their way up.

Nah, we'd just have to build a bigger planet!

 

[Guest]

I wonder how hot it would get from greenhouse gasses.

 

[lance]

I have all the respect in the world for you Warren, and am very sorry for what you and your father have been through. However, I think that the use of the word "incompetant" is a bit strong.

In my area (Dallas), bridging for colonscopies is the norm. I suppose that I could convince my GE to do a scope without adjusting Coumadin, but this would be purely an investigative scope. If any polyps are discovered, I would need to go "under" again to ship them. That merely delays the "bridge" question.

I also suppose that I could shop for a GE that would snip without adjusting Coumadin, but I choose not to look any further beyond the best GE in the Dallas area (that I already use). Is he an expert in anti colagulation? No! But my cardio gets involved every time.

I also bridged for hernia srepair surgery. Again, I used a top notch surgeon and anticoagulation guidance from my cartdio.

..my 2 cents.

Please outline "bridging" you received for hernia repair.

 

[warrenr]

links

links

Warren or Al, do either of you know where I can get the protocol for the anticoagulant patient undergoing a D & C Hysteroscopy? I've been look, but I'm not the best web searcher in the world.

karlynn,

Hope these links help. I will send more links later.

http://64.233.167.104/search?q=cach...cological+perioperative+anticoagulation&hl=en

http://64.233.167.104/search?q=cach...cological+perioperative+anticoagulation&hl=en

http://www.fpnotebook.com/HEM176.htm

 

[warrenr]

is a little strong

is a little strong

I have all the respect in the world for you Warren, and am very sorry for what you and your father have been through. However, I think that the use of the word "incompetant" is a bit strong.

In my area (Dallas), bridging for colonscopies is the norm. I suppose that I could convince my GE to do a scope without adjusting Coumadin, but this would be purely an investigative scope. If any polyps are discovered, I would need to go "under" again to ship them. That merely delays the "bridge" question.

I also suppose that I could shop for a GE that would snip without adjusting Coumadin, but I choose not to look any further beyond the best GE in the Dallas area (that I already use). Is he an expert in anti colagulation? No! But my cardio gets involved every time.

I also bridged for hernia srepair surgery. Again, I used a top notch surgeon and anticoagulation guidance from my cartdio.

..my 2 cents.

Hosacktom,

Your right, that is a little to strong. Sorry.
It would be interesting to know if these doctor's are aware of the current ASGE standards. They may be very competent but that doesn't mean they are familiar with all of the protocols. It wouldn't hurt to ask them or find out there opinion on the current standard.

 

[Karlynn]

Thank you so very much Warren for taking your time to hunt the references. Unfortunately it didn't cover specifics for me. Most information I've found has to do with Hysterectomy. That's major surgery and I wouldn't question the need for stopping warfarin and using a bridging therapy, or even the need to preadmit to the hospital for the therapy. The procedure I'm having is a simple outpatient procedure. It uses no scalpals, doesn't cut anything. The cervix is dialate and the lining of the uterus is scraped and then, in my case, the uterus will be cauterized (ablation). I believe what I'm having is called a D & C Hysteroscopy (referring to the use of a hysteroscope, which is just a tool that is used to go through the cervical opening and several procedures can be done through it - biopsies, scraping, polyp removal.) followed immediately with a Uterine Ablation.

I do have some time to look into this as I won't be seeing my cardio until 11/15 and I won't have it done before I see her.

I did catch something in one of the references that I question and I'm wondering if it's an old reference because it refers to PT as the test used for assessing warfarin levels.
This is from your 2nd reference. It's just the 1st sentence that made me go
<<Warfarin
Warfarin is rapidly absorbed from the gastrointestinal tract, with peak plasma concentrations being reached 1-4 hours after ingestion. The anticoagulant effect of warfarin becomes visible only after a significant decrease occurs in the concentration of normal vitamin K-dependent clotting factors. After terminating therapy, the anticoagulating effect of warfarin disappears progressively over a matter of days but is rapidly reversible by the administration of vitamin K (long-term effect), fresh frozen plasma, or prothrombin complex concentrate (short-term effect). >>

We've always been told that warfarin absorbs slowly, hence a 3 day lag time between dose and when that dose shows up in the INR.

But maybe I'm confusing different issues.

Anyway - thanks so much again. You are very kind.

 

[Guest]

Yes there are different issues.

The peak plasma time tells how it is absorbed and in many drugs it correlates with the peak effect (pain relievers for example).

But with warfarin what it does is slow the production of vitamin K dependent clotting factors. These take about 3 days to turn over in the average person. So the peak concentration and peak effect are widely separated for warfarin. Heparin on the other hand, does affect the clotting factors already present in the blood, so its peak effect is very fast.

If you think about it, warfarin could not stay in the bowel for three days unless you were chronically severely constipated.

 

[Marty]

Low Risk Procedures

Low Risk Procedures

I liked Dr.Lefraks method for procedures like GI endoscopy. Two days before the procedure check INR. If over 2.5, hold, until procedure and start up again after procedure. Many patients are lower than 2.5 some much lower like Warrens Dad. Don't change their dose but after the procedure try to get them therapeutic.Intuitively this makes sense to me.

 

[Guest]

It sounds reasonable

 

[Marty]

It sounds reasonable

Love it! I wondered what you would say.

 

[Karlynn]

I probably could look this up, but I'm being lazy. Since the more warfarin you take, the faster an INR drops, what would be your educated guess on how fast an INR of 3.0 would drop upon holding doses, when the total weekly dose is 67? If holding 2 days prior - what do you think the INR would be?

I ask this because when I spoke to the dr about my upcoming (date unknown yets) procedure he said he'd have me take my last dose 5 days prior and bridge w/ heparin. When I told him what dose I take, he said he'd go 3 - 4 days then, but would defer to my cardio.

So this protocol is interesting and I was just wondering about how it would apply to larger dose patients.

 

[Guest]

If your level was 3 and you take that much warfarin, I'd guess missing one dose would put down around 2.

 

[warrenr]

2 days prior

2 days prior

I liked Dr.Lefraks method for procedures like GI endoscopy. Two days before the procedure check INR. If over 2.5, hold, until procedure and start up again after procedure. Many patients are lower than 2.5 some much lower like Warrens Dad. Don't change their dose but after the procedure try to get them therapeutic.Intuitively this makes sense to me.

Checking INR 2 days prior and basing decision on that INR level is so critical.
Right on Marty.