Coumadin and post surgical complications_ wow!

[sylviayasgur]

hi all!
i have missed being here and all of you so very much....
leave it to a crisis to bring me back!!
some of you have read that my dad, 71 y.o. in chronic afib had a st. jude's valve put in about 4 1/2 years ago.
although i have some idea about how coumadin works since he and i talk all the time, i am really learning the intricacies of it these days and appreciate all you who have taught me new things in just the last 2 days_ thank you.

my dad had a hernia removed laparoscopically last monday (nov.22). they took him off his coumadin before it and the surgery went well.
they put him back on his coumadin about 12 hours post surgery and again, all was well. he went home two days later, instructed to receive lovenox shots to bring his inr levels back up, which he was doing (and turning black and blue all over his pelvis, but surgeon_remember it was thanksgiving!_said this was "normal").

saturday and sunday he complained of feeling faint and a lot of pain in his abdomen... again the surgeon said "normal". my mom rushed him to the er on sunday night because he was so weak and we think she saved his life by doing this.
his bp was 70/40, he was severely dehydrated and his kidneys were about to shut down, he was severely anemic (crit of 14) and they admitted him immediately to icu. they called me to come down sunday night at 11 pm incase things got worse.

they have hydrated him with iv's, given him several blood transfusions, given him frozen plasma to coagulate the hematoma (bleeding) in his pelvis, and keep him stable. he was stable yesterday (no bleeding even though his inr was at 2.3), so decided to give him heparin to elevate his inr a bit. unfortunately they had to stop that after 4 hours because his crit levels dropped and this indicates that he is once again bleeding.

they just informed us that they will be moving him out of icu today (even though his bleeding might not be under full control yet) and we are quite concerned. i just spoke to my mom and she says they may be giving him more frozen plasma to stop the bleeding. i can't understand how they can keep going back and forth this way_ frozen plasma, heparin, and so on.
his cardio seems calm and not too worried but i think we need to talk with him.

i am amazed that a little (normally out-patient) procedure can turn into such a complicated life/death situation with just the additional factor of coumadin!
in any case, i can't thank you all _ especially allodwick, you were so speedy to answer my questions, thanks!_for all your help, support and knowledge.
makes me see how much i truly miss you all.
hope you are all doing well. i'll keep you posted.
all the best, sylvia

 

[Karlynn]

Sylvia, we have missed you and I'm so sorry to hear about the many problems with your Dad. I've had those calls to hurry to be with my parents and it is an upsetting and stressful time.

When you have the time, I would be very interested in knowing what you have found the reasons to be for so many problems arising. I know we all could learn from it. Would also like to hear what questions you asked Al and what his explanations were. Maybe this would help those of us on Coumadin prepare for the unexpected.

I hope and pray that your Dad recovers well.

 

[Nancy]

Sylvia-

I am so sorry to hear about your dad.

Joe had a similar scary incident when he had gallbladder surgery. He was not on Coumadin at the time, but was on Lovenox as bridge therapy pre-surgery. He had a complete bleedout post surgery and had 33 units of various blood products to try to stop the bleeding and to save his life. He also was on vitamin K. He was in the ICU for many days and then for many more in the regular part of the hospital.

This is one of the times when he came very close to departing this world.

It took him the better part of almost a year to recover. When sent home, he was still in shock with an extremely low bloodpressure, and his stomach was so swollen from everything that had happened, that he looked 10 months pregnant. The wounds in his stomach took forever to stop draining and to close. And he had Visiting Nurses for several weeks.

In thinking back, I have many doubts about the use of Lovenox for him as bridge therapy. I know he will NEVER allow that again. He will only allow Heparin and in-hospital IV, better control, even though it's a pain to be in the hospital.

Your dad, no doubt will have a rough go of it for a while. But healing does take place, once he is over the initial shock to his system. It just takes a long, long time.

Wishing him all the best and please tell him that he has an "almost" twin who is doing OK now.

 

[LUVMyBirman]

Hi Sylvia,


We missed you as well!

So sorry to hear about your father. It's a catch 22 isn't it? I can totally sympathize with the post surgical bleeding. Every time I have had a procedure post MVR....this happens. I feel it is a combination of the Lovenox and Coumadin. Recently after some simple dental surgery (3 days later) I was back in with a bleeding hematoma. It's that third day that always concerns me.

We will keep your family in our prayers

Take care.

 

[sylviayasgur]

thanks so much, all

thanks so much, all

just out the door to the hospital. they moved my dad to a surgical floor (out of icu) and just discovered his inr to be 1.3 ish.he is exhausted which i can imagine he must be,but i am very nervous and want to rush over to see what's going on there... his cardio started his coumadin in the hospital today in the hopes of a higher inr, but slower than the heparin so that maybe the bleeding won't be started again (that is, if it has stopped!)... gotta go advocate for my dad... thank God for all your help and support; i'd be lost without it.
karlynn, i will post the im's i sent to al and his responses when i return tonight.
again, i am so indebted to each and every one of you.
stay well, sylvia

 

[catwoman]

Sylvia:

Will be praying for your dad -- and your family, too. Hope everything is looking up....

 

[Granbonny]

Hi Sylvia

Hi Sylvia

I hope you find your Dad doing better..Let us know soon.....I don't understand why..if his INR was 2.3..didn't they just up his coumadin a tad??..I'm trying to find out more about Lovenox and Heparin?..Never had to use them before..just tweaking my coumadin dose ..will put me back in range.........Hope you get some answers...and Daddy is feeling better. Bonnie

 

[sylviayasgur]

PM's exchanged with allodwick... hope they help others as well

PM's exchanged with allodwick... hope they help others as well

Originally Posted by sylviayasgur

hi al!
i haven't been on much at all lately, but could really use some feedback from you....
i'm not writing about joey, but about my father who had avr 4 1/2 yrs ago (st. jude's mechanical)and has chronic afib and has been on coumadin for about 5 yrs as a result of this.
my dad, a young 71, had laparoscopic hernia surgery last monday (a week ago). he was admitted to the hospital to be heparinized and taken off coumadin the day before his surgery.
all went smoothly and after 12 hours or so they started him back on (assuming it was coumadin) bloodthinners. he was discharged two days later.
he complained of discomfort which progressively seemed to get worse. he was also being given lovenox shots twice a day to get his levels up.
he called the doctor almost daily, complaining of swelling in the area and swollen testicles, but they said it was normal. he turned totally black and blue in the area, but again..."normal".
he complained of lightheadedness and distension of the abdomen and wound up in the ER late last night. his BP was down to 70/44, he was totally dehydrated and has internal bleeding.

my worry right now is that he is in ICU and they are giving him frozen plasma to bring his coumadin levels down to "normal" (and to coagulate the bleeding hematoma). they feel that the internal bleeding needs to be halted first and foremost... i am so nervous (and so is he) because we are worried about clotting and his valve. although his cardiologist felt that the coumadin was of utmost importance, the icu staff overrode his suggestions and are going this route....
i would love some feedback from someon knowledgeable like you.... i know there is a safety window that you can be off the coumadin, but given that he is receiving coagulants, doesn't that decrease the time and put him at risk of a stroke?
we are all so upset about this... i could certainly use some expert advice..
thanks for your time,
sylvia

Response from Al:
This is one of the hardest questions to answer. The talk that I gave at the Denver reunion was on this very topic. Obviously the doctors were trying to not have him off the warfarin for very long before his surgery. But this probably caused him to bleed after the procedure. Most valve people come out well when this method is used. But,the people that this happens to wind up having the most problems after surgery are those who bleed in the first few days after surgery. Still the vast majority of these people wound up coming out of the hospital in good shape but they had a struggle.

You have correctly stated the problem about there being a window when it is OK to be without warfarin, but the window is smaller when warfarin has to be reversed. However, the aortic valve is a better type to have than a mitral when this has to be done.

The bleeding problem is of more concern in the short term than his valve. That problem has to be dealt with first.

The odds are that your father will come out OK but it will take time.

 

[sylviayasgur]

thank you for your well wishes

thank you for your well wishes

today's update on my dad...
he was moved to another floor where they barely know he exists. in fact, i had to make a big stink to have the doctor come in and make sure he was well hydrated. they gave him a fleet drink in the icu before sending him down to another floor, but neglected to remind the nurses that he was not ingesting any food or fluids and was receiving minimal iv fluids. so he had diahhrea, no additional fluids, his pressure started to drop, he was very very tired and weak... i really let the doctors have it and after that they became a bit more attentive.
he is running a low grade fever and is now receiving fluids and tylenol.
they are restarting his coumadin tonight since his inr was around 2.4 today.
i hope the fever goes away and he starts to feel stronger and maybe sit in a chair or take a short stroll tomorrow.
it's so difficult to see my dad like this_ he is rarely one to sit still or be too tired for anything.
thanks for your prayers, thoughts and support. i printed up these posts and read them to him. he felt so much better knowing it wasn't exclusive to him.
i will keep you posted as he comes along...
be well, sylvia

 

[Nancy]

Hi Sylvia-

Just tell your dad to hang very tough throughout this and also tell him to trust in the healing properties of his body. This is a very rough thing to have to go through. It hits every part of the body and he will be understandably weak. One day at a time.

The body heals cell by cell, but he WILL get there.

Joe's doing well, his stomach is flat now, his bloodwork is good, his cheeks are pink. He's a warrior and so is your dad.

I'll be thinking of him and you and your family. It is very, very difficult to witness such things.

NEVER give up!!!

 

[ShezaGirlie]

Hi Sylvia and Daddy...

Hi Sylvia and Daddy...

So sorry you have all this on your plate just now, but hope as each day passes that your Daddy gets better and better and he will.

Isn't our own Mr. Al just the nicest guy...!

Just wanted you both to know I'm thinking of you. And Sylvia, keep being the advocate and straighten out those doctors and nurses...

 

[Marty]

Bleeding into leg muscle

Bleeding into leg muscle

Sylvia,I'm sorry to hear about your Dad but it looks like he is going to make it. I really identify with his problem because I am having a similar problem , my first coumadin complication since mitral valve replacement six years ago.
Sunday November 21 I took a hard fall on the golf course trying to get down in a steep sand trap. I hurt all over after the fall but it was the last hole and I was able to drive home. After supper that evening, I began to feel a cramp in my left thigh which progressed to severe pain. The leg was tight , white, and cold. Consultation with orthopedics suggested possible "compartment syndrome". MRI showed diffuse bleeding anterior compartment.INR day before was 3.6. Cardiologist advice.. hold Coumadin 3 days and retest. He said there was no data that going on Lovenox was indicated and it might do harm. Next test INR 1.6. Leg still painful but not as bad. Blood broke out of compartment and now leg a beautiful purple. Advice-"gingerly" reload Coumadin. Three days later INR 1.9. Yesterday I upped dose and will try to maintain INR near 2.5. Leg still hurts but I think bleeding has stopped. We're hoping that Coumadin does not allow it to start again.Thanks to Coaguchek I can test frequently without vein stick and trip to hospital.

 

[sylviayasgur]

hi all!
i have been printing up these responses and reading them to my dad; he feels so reassured by your posts_ thank you!

marty,
i'm so sorry you have to go through this. i now realize how complicated life can become in a mere instant once you are a "coumadin-er". scary!!
hope you feel better and this problem resolves itself soon_ sounds like you're already on your way, thank G-d.

jamie,
yes, al is incredible. we are so fortunate to have him among us here.

nancy,
we got my dad a private nurse yesterday, since he is so weak and the hospital is so short-staffed. you are right, it seems_she says_ that this recovery is a really slow one and may take weeks and weeks.

his cardiologist came by today and feels that "heart-wise" he is ready to go home. we feel that when he is able to walk by himself he will be ready.
he is still very weak, can't get up or stand alone yet, is more alert (more time awake and less dozing off), etc. then he'll be ready to go home.
he still has great discomfort in his abdomen from the hematomas (one was 14x16 cm, the other a mere 4x7cm!!!) .

life is so fragile. you can blink and a second later it can change forever.
i feel so blessed to know that my mother took him to the ER in the nick of time and saved his life in doing so.
i also feel so blessed to have such a wonderful family as you all.
i pray each day for G-d to keep you all well and safe.
thank you, thank you, thank you.
-sylvia

 

[Nancy]

Sylvia-

One of the things that has to be weighed about staying in the hospital for any length of time, when being home is feasible, is hospital-bourne illness. Joe developed "C. Dif" diarrhea which is absolutely horrible. It took him about 3 months to get over that one after his bleedout. It is hospital-bourne. It can sap your strength seriously and will require the services of a gastro man. Nasty-nasty stuff!

So, make sure that your dad disinfects his hands frequently while in the hospital and you do as well, and all of your family members Get him some Purell. And make sure that all that have contact with him disinfect too, no exceptions!

No matter how well they clean the rooms, there is always some kind of germ lurking about, chair arms, cusions, bedrails, call buttons, TVs, food trays, radiators, you name it. I've found dried blood on many hospital surfaces, and no doubt there are other body secretions as well. Not to gross you out, but your dad is in precarious condition right now, and has to be extra careful.

I'm very glad you have a private duty nurse with him.

 

[LUVMyBirman]

Hi Marty,

What are we going to do with you my friend? Hope you are doing much better today.

Take care and watch out for those large holes

 

[Marty]

Sylvia,
Sounds like Dad is hanging in there but he had one of the worst bleeds I've heard of in recent years in an anticoagulated patient. Back in the 1950's we were still learning how to dose patients and we saw bad bleeds every day in every area of the body. The amount of bleed in your Dad makes me think the surgeon must have nicked a major vessel.Let us know how they plan to return his INR to the therapeutic range. Is he still on heparin drip? Nancy is so right. Try to get him out of the hospital as soon as possible. They are dangerous places.
Gina, its just one damn thing after another isn't it? Remember gettin' old ain't for sissies, particularly if you're taking warfarin. However I go back to work with my limp Monday. My biggest worry now is , when if ever will I get back on the golf course? I already know ,Alice ordered a new hybrid 5 wood from Riley as my Christmas gift. Will I ever get to use it? I'll keep you posted.

 

[Nan]

Sylvia, I was so sorry to hear what has been happening with your Dad. But it sounds like things may be getting a little bit better for him. I sure hope so. When we hear what has happened to Nancy's Joe, then we know your Dad can get through this!

You are being an excellent advocate!

Marty- here's hoping you get back on that golf course soon. You have been through a lot. You enjoy that new wood!

Best to you both.

 

[Nancy]

Marty-

I'm sorry to hear about your leg situation. That needs a little time to heal as well, so be good and don't go making it any worse.

I had a HUGE hematoma on my calf caused when I fell through some ice (which rebounded and nailed my leg) of our frog pond, while trying to rescue our little (then) puppy who had fallen into the pond.

It took a year before I couldn't feel the lump anymore.

Golf will be so much sweeter with that new wood.

 

[Marty]

Nancy and all, You are so right. this will take a long time to resolve. The pain has decreased but locomotion still difficult. Last INR 2 days ago 2.1.
This is a slow rise. I'm still on reduced dose from before. My usual dose to keep INR at around 3.5 was 21 mgm/wk. I think I'm going to settle down around 18-19/wk and keep the INR near 2.5 from now on even though I am a mitral. No one really knows but I think there is less chance of a bleed at this level . Who knows for sure but I think the chance for clot is only slightly increased. Every warfarin patient should know themselves and self dose with the help of a home monitor. Testing in a lab every six weeks is not adequate in my view.

 

[Nancy]

Sylvia-

Haven't seen any posts in the last couple of days, I've been thinking about you and your dad. hope all is going along OK.