High Risk Surgery

[lance]

On warfarin because of mechanical valve.

Need abdominal surgery soon (high risk).

Is it better to have this done at a large city hospital with an anticoagulation clinic on site or in the local small city hospital?

Warfarin withdrawal is the elephant in the living room (at least for now).

 

[Ross]

I don't think large or small is the issue, but whether or not whomever knows what they are doing. I've seen bad in large and small as well as good at both.

 

[lance]

High Risk surgery

High Risk surgery

I don't think large or small is the issue, but whether or not whomever knows what they are doing. I've seen bad in large and small as well as good at both.

Thanks Ross, point well taken.

I will find out all I can about the withdrawal procedure so I can discuss it in depth with the person in charge.

 

[RCB]

GI surgeon

GI surgeon

Look to a GI surgeon at teaching hospital which also offer a cardiology fellowship. Then ask him what his experience is with people who have your medical problems, or who he would recommend. The best drs. like a frank and to the point discussion. Good luck!

 

[ALCapshaw2]

If the surgeon (or some other doctor on your case) does NOT know how to manage BRIDGE THERAPY (going off Coumadin with either LOVENOX injections at home or hospital administered HEPARIN DRIP) for 3 or 4 days BEFORE and AFTER surgery, then FIND ANOTHER DOCTOR. Coumadin Clinic staff nurses 'usually' know how to administer and monitor Lovenox injections.

'AL'

 

[Nancy]

Lance-

I just have to mention Joe's experience with gallbladder surgery. He almost died. He had a total bleedout and had to have 33 units of various blood products to stop the bleed, plus he had to have a second surgery to clean out the clots and fluid which was pressing on his heart. His recovery time from this fiasco was about 9 months. He came closer to seeing angel wings after this surgery than he has ever been.

His cardiologist used Lovenox bridging therapy, and it was felt that Lovenox contributed to the bleed. Joe will NEVER use Lovenox again or Fragmin either, and if he needs bridging he will go into the hospital with a Heparin drip. Much more controlled.

The FDA had recommended that Lovenox not be used for valve patients. That was a while ago, and I'm not sure how it stands now.

Last time we knew, his former cardiology group had stopped using Lovenox for bridging.

Also look up posts from Sylviasgur regarding her dad. He had an almost identical thing happen, and is now still recovering.

 

[Guest]

The usual rankings for outcomes are:
1. People who have bridging and have no complications tend to do the best.
2. People who have bridging and bleeding do worse. Usually because they bleed and then have to hold everything and often clot. It seems that because they are being closely managed when this happens.
3. The worst outcomes are people who are told to just stop the warfarin. The longer the stop, the worse the outcomes.

What we have learned after people like Joe's experience is that Lovenox and Fragmin tend to accumulate in people who have poor kidney function. Some may not have had poor kidney function when they were started on Lovenox but developed it during the surgical process. It is true that you can reverse heparin better than Lovenox but this tends to place them in category 2 when it has to be done. The best study about this was done with Fragmin so the truth is that this should be the standard of care but Lovenox is so well established in most hospitals that they are reluctant to change. I think that now the best outcomes would be expected with Lovenox or Fragmin ALONG WITH kidney function monitoring.

 

[Nancy]

It may be interesting to do some research on people who have congestive heart failure and have to be on heavy doses of diuretics, since much of the time they have compromised kidney function of one degree or another.

I do know that Joe's kidney function tanked after this surgical mishap, and they were even considering dialysis for him, but somehow, he avoided that.

So the accumulation of Lovenox may be one of the contributing things.

But--how does one determine who will get into trouble and who will not, especially if kidney function tests out OK prior to surgery.

Very tricky stuff.

We would prefer to err on the side of caution.

 

[John & Joann]

Joann went off Coumadin at a local hospital to have the original pacemaker installed. We both agree that she will NEVER go off Coumadin unless it is at a facility that totally understands the risks, coumadin management, and has a large cardiac surgery department.

The pacemaker was replaced (old wires) at Cleveland Clinic hot. They can not do it hot if the wires DO NOT need replacing.

You need to make certain that the general surgeon is WELL informed on the issues. This is NOT likely at a small facility. I would ask your original cardiac suergeon to make recommendations if you respect him.

 

[Guest]

Use this formula

CrCl = (140 - age) x IBW / (Scr x 72)

Age is in years

IBW is Ideal Body weight figured by
Males: IBW = 50 kg + 2.3 kg for each inch over 5 feet.
Females: IBW = 45.5 kg + 2.3 kg for each inch over 5 feet.

The Scr is the serum creatinine - one of the values gotten from drawing blood at 4AM every day in the hospital.

For women you multiply the answer times 0.85. Because the "average" woman has 85% of the muscle mass of an "average" man. Creatinine is a product of muscle breakdown. If it is accumulating, the the person probably isn't removing some drugs from their body very well either.

If the answer comes out to be 30 or less, you are approaching needing dialysis and will not clear the Lovenox or Fragmin from your body very fast and will be at in increased risk of bleeding.

This is one of the things that pharmacists do in hospitals every day. At our hospital the pharmacists get a list of everyone whose Serum Creatinine is 2.5 or higher and a list of people who are on drugs that tend to accumulate if they have kidney failure. They calculate this for each of the people who are on both of those lists and then put notes on the charts of people who need to have doses adjusted because of poor kidney function.

 

[ALCapshaw2]

AL Lodwick -

What is CrCl in the formula you presented above?

'AL Capshaw'

 

[Guest]

Sorry - Cr Cl = Creatinine Clearance.

Muscle is continuously breaking down and being replaced. Creatinine is one of the breakdown products. The serum creatinine (in your blood) should be somewhere around 0.9 to 1.5. If it goes higher than that it means that your kidneys are not getting the substance out of your body. There can be several reasons such as dehydration or excessive muscle wasting. If you solve the dehydration problem then this should come back to near normal. If it does not, then it usually indicates a degree of kidney failure. Obviously if you have a 400 pound man who has a high fat content or a 120 pound woman who lifts weights then the numbers don't fit very well. It is again a case of treating the person and not the number - just like INR guidelines.

If the Cr Cl is above 50 - your kidneys are normal
If it is 30 to 50 then you have mild or moderate kidney failure
If it is 10 or below you are probably on dialysis (or will be real soon)