bridging

[jax]

well last month i was getting all prepared to start bridging when my appointment for my procedure was cancelled. the machine they use broke so they had to put it off a month. Last week i called to see if they had gotten it fixed and they scheduled me in for the 22nd. My pcp who takes care of my coumadin has an outline of how i am to bridge for this procedure. it says that my inr should be 1.5 =< she had me stop coumadin last night which is 5 days before and start lovenox this morning and continue on that that twice a day. i will have to get my inr checked wednesday morning to make sure that it is low enough or else take some vitamin k. it then states that if hemostasis is good day of procedure i may restart my coumadin. then continue bridging till i hit 2. the only problem is that my procedure is on thursday and she wants me to get my inr checked on day two after procedure which will fall on the weekend. i don't much mind waiting until monday to go in and get it checked and that is what i am going to have to do. i just figure that there will be a better chance that by the time i get into the hospital on the monday after my procedure that i will be able to stop with the lovenox hopefully. don't really know if i have too many questions about all of this except. would my inr drop that quickly over night after not taking coumadin last night? i am worried about the bruise that i will get from todays shots. the last time i gave myself a shot and my inr was above 2 it was so big and nasty and hurt every time my clothes brushed up against it.

 

[ALCapshaw2]

It is quite common to stop coumadin for a day before starting the Lovenox so you 'should be OK' with that protocol.

The bigger issue is When (or IF) to resume Lovenox after your procedure (I don't remember what you are having done). Here, it is necessary to find the right balance between Risk of Bleeding vs. Risk of Stroke.

Ross had Serious Bleeding issues from Lovenox following having ALL of his teeth extracted. He ultimately had to discontinue Lovenox and just let the Coumadin build up over the next few days.

Some Surgeons actually prefer to Bridge BEFORE surgery but NOT to use Lovenox after, just allowing the Coumadin to slowly raise the INR back to the recommended range.

You may want to discuss this with your PCP and Cardiologist and then have them confer with your surgeon.

'AL C'

 

[jax]

it is a leep procedure done at the ob/gyn's it is outpatient and i do believe it is a fairly quick procedure. it is done under a local anesthetic and from what someone else had posted on another thread i had on this is they thought the ob/gyn was being overly cautious. i am pretty sure that my pcp called cleveland clinic to ask how to bridge properly as she said that she needed to do her homework before letting me know how to go about it. she is a new pcp and i liked the fact that she was going to consult with my cardio over how to properly bridge since she has not had to deal with my coumadin therapy for very long. i need to look at my paperwork she gave me but i am pretty sure it says i am on lovenox until my inr hits 2.

 

[kfay]

Jackie, I don't take coumadin and have only occasionally had to be on it, so I am certainly no expert. However, I did have a leep procedure done years ago and literally had no true bleeding. A little weeping or oozing, yes, but bleeding, no. Unless they have changed how this procedure is done since I had it done, they don't "cut" you in a traditional sense. I think after they take away that tissue that is abnormal, they basically cauterize any area that may be bleeding which is probably why I didn't have any bleeding at all afterwards. So, I would be surprised if you run a high risk of bleeding afterwards.

Best of luck with your procedure. It really isn't a big deal at all.

Kim

 

[jax]

Thank you for information on the procedure Kim. Although I have been a little nervous about having to get this done I know it has to be and you have put me more at ease. I just want to get it over and maybe get a break from doctors for a little while.

Al I just looked at my outline on how she has me bridging she has me bridging morning and night of course. The day before the procedure she has me only doing the lovenox in the morning and not at night. Then the day of the procedure I am to only do a shot at night. So there will basically be nothing for 24 hours or more. That's a bit scary. Then after that she has me doing morning and night until I reach 2.0. Does this sound about right? Or should I look into it further with her holding the lovenox for more than 24 hours? Thanks for all the input.

 

[Faye]

I have had to bridge several times. This is what my cardio recommends:

• Stop Coumadin 4 days prior to procedure
• Start Lovenox (every 12 hours) when INR hits 1.8. (For me it takes 2 days to drop from being in range to 1.8)
• Stop Lovenox 12 hours before procedure.
• Start Coumadin and Lovenox 24 hours after procedure.
• Continue Lovenox until INR is above 1.8 (For me, it takes about 3 days to get there)

I home test so it is easy to monitor my INR.

It sounds to me like the advice from your doctor is right on target. Be thankful she was willing to do her homework!

Good luck with your procedure and bridging!

 

[jax]

Thanks faye. I am very grateful she did her homework on this. I have not taken coumadin since saturday night so I am hoping the bruise I get from the needle I did this morning won't be too bad. I'm still waiting for my monitor. QAS is working with my doctor because she forgot to write in a diagnosis and just checked off mechanical valve so my inr has to be checked at the hospital for the time being is tested at the hospital. So by the time I go in monday morning I am hoping that I will be high enough to discontinue the lovenox that night.

 

[ALCapshaw2]

After reading some of the Bleeding Stories with Lovenox when taken shortly after various types of surgery, I've become more comfortable with the idea of holding Lovenox for 24 (or even 48) hours following surgeries to allow time for the surgical sites to begin to heal and lower the risk of bleeding.

Remember, some Surgeons do NOT Bridge After Surgery, relying only on Coumadin to bring the INR up *gradually* over 3 or 4 days. I've not heard of any problems with this protocol.

'AL C'

 

[jax]

Thanks for all the answers. It has definitely made me more comfortable as I am still learning about this bridging idea. Man I have real nasty bruise from the shot this morning. Glad put it lower than my waist line as I think it would have been sore if my jeans were rubbing up against it.

 

[jax]

WelL I had my procedure yesterday morning. And truly the worst part of the whole thing was having to bridge with lovenox. I was able to start back on my coumadin last night. And also had to give myself lovenox. And ofcourse I have to continue that through til my next blood draw for inr on monday. Just hoping my inr goes up enough that I can stop the bridging monday morning.

 

[jax]

Went to get my inr checked yesterday morning. I was hoping that it would be high enough to get off the lovenox. But it came back at. 1.62 which isn't so good. I have to retest on friday and continue the lovenox until then. So my inr is climbing but not as fast as I would have thought. Wasn't quite so tired yesterday as I was last week. Seems as though when my inr is low that. I just feel exhausted all of the time and can't seem to get enough sleep. I would think by friday I should be able to get off the lovenox. I will be back on my coumadin for a whole week by that time.