Hernia Repair Surgery & Will Be Without Coumadin for 3-5 Days, Should I be Worried?

[Warfarinking]

Hernia Repair Surgery & Will Be Without Coumadin for 3-5 Days, Should I be Worried?

Hi, as title states, I will be without coumadin for 3-5 days so I can have my hernia repaired. I'm extremely nervous and pretty scared about being without coumadin. Doctors mentioned possibly having to take the shot that will help out with not being on coumadin for the days but I'm just unsure about everything. How dangerous is being without coumadin for that long and has anyone had the shots done? thanks

 

[pellicle]

I have twice had surgery after my mechanical valve and twice been without warfarin for 3 to 4 days ... it is such a normal thing in the hospitals here that no one blinks. You just get heparin shots till after you resume warfarin and your INR is back to normal range.

There have been ladies here do last stages of pregnancy on heparin and been off warfarin for 20 or so days.

 

[AZ Don]

Being without coumadin does not mean that you need to be without anti-coagulation. Your reference to the shots I assume refers to heparin which is also an anti-coagulant. If it would put you more at ease perhaps you can confirm what the plan for your anti-coagulation is, and ensure that your Cardiologist is on board with it. Switching to heparin is normal for surgery. My Uncle was told to stop coumadin (don't know specifically why he was on it) by a dentist for a dental procedure. He just stopped, no coumadin, no heparin, nothing. He had a severe stroke as a result.

 

[pellicle]

Holy Smoke Don

My Uncle was told to stop coumadin (don't know specifically why he was on it) by a dentist for a dental procedure. He just stopped, no coumadin, no heparin, nothing. He had a severe stroke as a result.

Was that from a single missed dose or how long did he stop for?

@Warfarinking

Don rightly points out that the "shots" you mention are anticoagulation therapy, so you are just changing types. I had assumed that you must have known that.

Heparin is a good, anticoagulant perhaps the gold standard, but its injected and thus less desirable than a small tablet

Best wishes with the hernia operation.

PS can I ask why you chose your name? Seems at odds for a guy who seems to know nothing about warfarin.

 

[AZ Don]

Was that from a single missed dose or how long did he stop for?

It was at least a few days that he stopped, maybe more. I have no idea why he didn't check with the Dr. that prescribed coumadin.

 

[pellicle]

It was at least a few days that he stopped, maybe more. I have no idea why he didn't check with the Dr. that prescribed coumadin.

Jeeze Don, as we say here in Australia - "Bloody Nora"

The multiple layers of failure in that process to manage your Uncle is astounding. How could anyone at the dentist be unaware of his needs? Time and time again I read things which reenforce to me the need to manage yourself and be your own advocate.

I hope he has recovered after the stroke.

To anyone reading this I have been to the dentists for sub gingival bleeds on a number of occasions and the dentist and hygienists have both commented that they have expected more bleeding. That if I had not told them I was on warfarin they would not have picked it. To me this speaks of my closely managed INR (average 2.6) and the likely poor management of other patients (likely higher).

 

[Warfarinking]

Hi all, a little update. I will be without Coumadin for 5 days, my INR was 4.1 when I had it checked on Sept 17th (my range should be between 2.5 - 3.5 so it was a bit high). They also said i will not be taking any heparin shots either. How risky is this?? My operation is on Thursday so I will be without Coumadin Saturday, Sunday, Monday, Tuesday, Wed and back on Coumadin after surgery on Thursday unless doctor says not to. They also mentioned the aortic valve is less prone to strokes and things to go wrong. I would really appreciate more feedback because I'm stressing. Thanks!

 

[pellicle]

Hi

I will be without Coumadin for 5 days, my INR was 4.1 when I had it checked on Sept 17th (my range should be between 2.5 - 3.5 so it was a bit high).

I'd agree that its a little high (you are mechanical Aortic valve aren't you??) but given that you're about to have surgery I think its a bit higher than it should be. In my (quite tissue disruptive) surgeries I went off warfarin the day before the surgery (from something like 2.7) and commenced heparin after surgery ... so my INR went to something like 1.5 for about a day. I would need more data (daily dose, INR) to make any assessment for you but I'd say that you'll be at a normal INR by the third day. So essentially un-anticoagulated ... or prime for a problem. Problems could be a clot or could be greater thrombosis formation on the valve, which can (and does) lead to valve obstruction.

They also said i will not be taking any heparin shots either. How risky is this??

In my opinion its a greater risk than I'd be willing to take. I'd be asking serious and voiciferous questions and asking for justifications. Where is this? Like is this a developed country? Do they not have any duty of care there?

They also mentioned the aortic valve is less prone to strokes and things to go wrong. I would really appreciate more feedback because I'm stressing. Thanks!

well it is less prone to strokes than (say) a mitral, but really, that duration is too long. You will also essentially be totally off warfarin at that point and need to recommence with the normal recommencement protocols of care to reduce risks.

For me every red light is on on my dash.

 

[Warfarinking]

Hi



I'd agree that its a little high (you are mechanical Aortic valve aren't you??) but given that you're about to have surgery I think its a bit higher than it should be. In my (quite tissue disruptive) surgeries I went off warfarin the day before the surgery (from something like 2.7) and commenced heparin after surgery ... so my INR went to something like 1.5 for about a day. I would need more data (daily dose, INR) to make any assessment for you but I'd say that you'll be at a normal INR by the third day. So essentially un-anticoagulated ... or prime for a problem. Problems could be a clot or could be greater thrombosis formation on the valve, which can (and does) lead to valve obstruction.



In my opinion its a greater risk than I'd be willing to take. I'd be asking serious and voiciferous questions and asking for justifications. Where is this? Like is this a developed country? Do they not have any duty of care there?




well it is less prone to strokes than (say) a mitral, but really, that duration is too long. You will also essentially be totally off warfarin at that point and need to recommence with the normal recommencement protocols of care to reduce risks.

For me every red light is on on my dash.

I'm not sure if I'll be able to sleep good tonight knowing this now. Tomorrow will mark my 3rd day without Coumadin. I plan to go to my doctor and see what they say about having heparin shots. I usually take 6 or 9mg a day. My Coumadin doctor tested my INR and saw that it was 4.1, she said to take only 6mg sept 17th and 18th then stop till Thursday Sept 24th. What do you recommend I do? could I literally have them give me the heparin shots?

 

[pellicle]

well keep in mind I'm not an anticoagulation specialist, and even among them opinions vary

...What do you recommend I do? could I literally have them give me the heparin shots?

well I'd recommend you speak firmly about this with them (don't be a passive patient) and lay clear your concerns. Mention risk of thrombosis formation on the valve and the risk of free blood thrombosis (clots) and ask them to explain why you are not on heparin when this is actually required protocol for surgery.

For instance in Australia:

http://www.australianprescriber.com/magazine/23/1/13/6

[FONT=open_sansregular]Introduction
The most common indications for long-term oral anticoagulation with warfarin are venous thromboembolism, mechanical cardiac valves and atrial fibrillation. When patients with these conditions need surgery, the perioperative management of their warfarin therapy poses a major problem. Withholding warfarin increases the risk of thromboembolism, particularly in the context of surgery which itself increases the thrombotic risk. To minimise the risk of perioperative thrombosis, alternate anticoagulation with heparin is often used. Perioperative anticoagulation is accompanied by an increased risk of postoperative bleeding. There is no consensus on the optimal approach to anticoagulation in the perioperative period. In each individual patient, rational decisions must be made after weighing up the haemorrhagic and thrombotic risks.[/FONT]
[FONT=open_sansregular]Risks of temporarily withholding warfarin
The risks are difficult to quantify due to the lack of randomised trials examining this issue. They vary according to the indication for the warfarin therapy.[/FONT]

my underline ...

so to be clear, its a bit like crossing the road without looking. Getting hit by a car is directly related to the traffic density.

Clearly wound healing is benefited by coagulation .... but only up to a point, after which coagulation is no longer needed in wound healing. That article goes on to say this:

(note: perioperative means "around the operation"

[FONT=open_sansregular]Do the benefits of anticoagulation outweigh the risks?
The approach to the management of anticoagulation in patients with prosthetic valves undergoing non-cardiac surgery remains controversial. The need for perioperative anticoagulation in patients with mechanical heart valves has been questioned in a recent review. The authors argue that for every 10 000 patients with mechanical heart valves who are given perioperative intravenous heparin, three thromboembolic events are prevented at the cost of 300 major postoperative bleeding episodes.[SUP]3[/SUP] These figures are calculated by assuming an average thromboembolic rate of 8% per year in patients with mechanical heart valves, an anticoagulation-free period of four days and a 3% risk of major postoperative bleeding with intravenous heparin. In light of these calculations, a risk-benefit analysis would preclude the use of full dose anticoagulation during the perioperative period in patients with mechanical valves, except in patients with very recent arterial embolism who have a high risk of recurrence in the absence of anticoagulation. In the absence of recent embolism, the authors recommend, for hospitalised patients, the use of subcutaneous low dose unfractionated or low molecular weight heparin at doses used for prophylaxis against venous thromboembolism, with no prophylaxis for outpatients.[/FONT]
[FONT=open_sansregular]There are limited prospective data to support or contradict these recommendations. The available literature consists mainly of small, non-randomised trials from which no definitive conclusions can be drawn. In one of the few prospective studies, 45 patients with mechanical heart valves underwent non-cardiac surgical procedures.[SUP]4[/SUP] No thromboembolic events were seen in 26 patients with aortic prostheses in whom warfarin was withheld for a total of 6-10 days perioperatively. In 19 patients with mitral prostheses, the warfarin [anticoagulation] effect was reversed with vitamin K on the day of surgery. A heparin infusion was started 12 hours after the operation and warfarin was resumed on the third postoperative day. No thromboembolic events were observed in this group. [/FONT]

[FONT=open_sansregular]Besides being a small non-randomised trial, the other drawback of this study was the lack of long-term follow-up. Valve thrombosis, especially with the tilting-disc (Bjork Shiley) valves, develops slowly and insidiously and may not be evident for 1-2 months. Hence, an uneventful early postoperative period may provide false reassurance that the perioperative anticoagulation has been safe and successful.[/FONT]

[FONT=open_sansregular]A recent review evaluated retrospectively the risk of perioperative bleeding during non-cardiac surgery in 235 patients with mechanical prosthetic heart valves.[/FONT][SUP]5[/SUP][FONT=open_sansregular] A variety of perioperative anticoagulation strategies was used. On multivariate analysis, only a tilting-disc valve in the mitral position and surgery for tumour were found to be predictive factors for a thromboembolic event. Discontinuation of warfarin less than 48 hours before surgery and reinstitution of intravenous heparin within four hours following surgery significantly increased the risk of bleeding. No embolic or haemorrhagic events were detected in 22 patients treated with perioperative low molecular weight heparin.[/FONT]

so the bottom line is : we have no certainty about this ... it may or may not be dangerous.

So just because I am used to what happened to me, does not mean I'm right.

PS: I hope this is not too much info

 

[pellicle]

whats your normal dose?

what valve do you have?

 

[Warfarinking]

whats your normal dose?

what valve do you have?

I had my aortic valve replaced and I just know it's coming from St Jude. My normal dose is M/T/W/F/Sat I take 9mg, which leaves Sunday and Thursday to 6mg. Total of 57mg a week.

 

[pellicle]

I had my aortic valve replaced and I just know it's coming from St Jude

well its a modern bileaflet (not tilting disk) valve which do naturally resist thrombus ... so to me (going back to my risk model) that makes the traffic density low so chances of getting hit crossing the road are lower. I mean that from what I see the chances of a thrombus are lower.

I had not gone outside my own experience before this, and that reading that I posted was new to me. So in reading the "current thought" it seems like there is a foot either side of the fence. As mentioned in the parts I quoted the risk they identified in going off AC was that a valve leaf thrombus was a possibility , but they seem to identify the bjork shelly tilting disk.

I can understand your anxious feelings, but as I said earlier I'd ask them to explain why you are not on heparin and consider that maybe 48 hours after surgery would be a good time to commence low does heparin as a prophylaxis to thromboembolism.

http://www.uptodate.com/contents/per...anticoagulants

Use of bridging preoperatively – We generally reserve bridging for individuals considered at very high or high risk of thromboembolism (eg, recent stroke, mechanical heart valve, CHADS2 score of 5 or 6) if they require interruption of warfarin.

which to me would suggest that at the very least, after surgery and after they can identify there are no un-identified bleeders, you should consider heparin (which is what bridging refers to)

This document by the Australian State NSW (I live in Queensland) identifies the newer mechanicals as "low risk" of thromboembolism.

Ultimately your surgeon should know more about this than us (me).

good reading also here:
http://circ.ahajournals.org/content/126/4/486.long

Low-risk patients not requiring bridging therapy include the following: AF with CHADS-2 score ≤2 and no previous thromboembolism or intracardiac thrombus; bileaflet mechanical aortic valve prosthesis in sinus rhythm with no previous thromboembolism;

seems in agreement that you're low risk ... I'd still ask my questions

Anyway try to relax and get some rest before surgery, eventually we have to trust our team. I'm not sure if I'm helping or increasing your anxiety ...

Best Wishes

 

[Warfarinking]

A little update: I went in today and spoke to my cardiologist & coumadin doctor. Had my INR tested today and it came out to 1.2 (my normal range is 2.5 - 3.5). They both told me I was a very low risk patient since it's the aortic valve and I don't have any prior history of having strokes, diabetes, and all these other things, therefore, being 5 days without coumadin is totally okay. They told me they would prescribe me 1 Levenox shot just to make me feel better but that I don't need it. I went and got the Levenox but now I'm debating if I should even take it since he said it takes roughly 48 hours to clear from your system and they were also very clear in me not needing it.

 

[pellicle]

Hi

well I'm glad to hear you're felling better. Its been a good question and I've learnt a few things about going off warfarin too. I'd have been concerned about 5 days before this but I guess that the street just isn't that busy for us aortic valvers with modern bileaflet pyrolytic carbon valves.

 

[W. Carter]

Hi, as title states, I will be without coumadin for 3-5 days so I can have my hernia repaired. I'm extremely nervous and pretty scared about being without coumadin. Doctors mentioned possibly having to take the shot that will help out with not being on coumadin for the days but I'm just unsure about everything. How dangerous is being without coumadin for that long and has anyone had the shots done? thanks

First off good luck on your hernia operation. I am 3 weeks recovery for large inguinal hernia surgery and still going through hell. I had to bridge with enoxaparin shots to the stomach for 2 weeks because of being high risk. My incision still has a hole about 1 inch long that won't heal due to bleeding. My whole groin area, upper thigh, and stomach turned purple black that eventually went away. My scrotum is the size of a grapefruit and as hard as concrete which the doc said was a normal complication from the mesh and will eventually clear up. So if your docs say no bridging go for it! The few days after the operation until the warfarin kick in will give you some good healing time. When you bridge the morning after surgery you are already injecting a fast acting blood thinner which makes healing a lot slower.

 

[bocco]

So this thread brings up a question I've had since I got my valve. I was 5 days in the hospital after the valve surgery before starting coumadin. Then I got heparin and coumadin. Seems like that 5 day period would be the same risk as any other 5 days without coumadin.

 

[Warfarinking]

Just wanted to update everyone: It's been roughly 3 weeks since the surgery. I ended up going roughly 5-6 days without coumadin. They gave me a small dose of heparin right before the surgery and the nurse said it was so clots wouldn't build in my leg. The surgeon recommend I start my coumadin 1 day after the surgery, so I did. 2 weeks after the surgery I had to see my coumadin doctor for testing, was in range at 3.2 (my range is 2.5 - 3.5). I feel good and healed now and I'm glad everything is going okay so far!

 

[almost_hectic]

Glad to hear it went so smooth