IN hospital 7 days waiting for INR to go up

[bturner972]

My husband had AVR last Tuesday, 8/19. He has had little pain, is walking a lot, and feels pretty good. They are keeping him in the hospital because they want his INR up to 2.0 before they discharge him. He is 6'7" and weighs 315 (a big guy!) We have been told that he may require higher doses of coumadin because of his size. Does anyone have experience or information re how long it may take to get the INR to climb up? I know there is a delay between ingestion and when it is reflected in the INR. They may relesase him today and give him injections (in the stomach) once we get home. I'll know more soon.

Thanks, I love this website.

 

[Karlynn]

First let me suggest that if you haven't already, go to the top of this Anticoagulation forum and read and view the stickies. Make sure you educate yourselves on Coumadin management (it's not hard) rather than solely relying on the "experts" to do what's right.

How aggressive are they being on increasing his dose? Many doctors fear bleeding much more than they fear clotting, so this may cause them to be very cautious in raising his dose. And don't worry about the amount he ends up on. There's no danger for those of us needing to take higher doses to keep in range.

If you know what his INR has been and what his doses are, it would be helpful for us to know. We can then tell if they are being aggressive enough or being too cautious. And it's important that you and your husband keep track of it.

 

[Ross]

....and if he's in the hospital, they are probably sabatoging him by giving him boost, ensure, or something along that line that has lots of Vit K in it.

 

[Lisa in Katy]

I echo what others have said, but want to add one thing that I didn't know for a few years. The stomach injections (Lovenox) will help prevent clotting, but won't affect his INR. Only the Warfarin they are giving him will affect his INR. So, when Warfarin is given in conjunction with Lovenox, a low INR doesn't necessarily mean that he is prone to clots. Lovenox has a short half-life, so as soon as his INR is in range, they will discontinue the injections, so as not to over medicate him. The process takes a lot of patience in the beginning.

 

[Bina]

Hello. I was in hospital for 16 days getting the INR up (and I'm small). After one week at home it still went down and I had to go to the ER for adjustment and I got one Lovenox needle to take at home. I've been stable ever since.

 

[catwoman]

Activity level, other Rxes and OTC meds, sensitivity to warfarin, illness/physical condition and diet have more of an affect on INR and dosage than physical build.

The more active the person, the greater amount of warfarin needed to achieve a given INR range. That's because you metabolize warfarin through the liver and the more active you are, the faster warfarin is filtered through the liver, leaving less behind to prevent clotting.
As a person recovers and increases his/her normal activity level, a greater dosage will be required to achieve the desired INR range.

The rest can increase or decrease the effects of warfarin.

 

[Freddie]

Gee, I was sent home after 4 days with an INR of 1.6 with no injections to take home. My range is 2.5 - 3.5.

But I'm glad to hear that the doctor is keeping a close eye on this. Makes me think that I wasn't really being watched.

All this will take time and patience (and lots of it) as the others have said. But don't despair, relax and take one day at a time.

 

[ALCapshaw2]

There is a relatively New Genetic Test that can determine if a patient is a 'Fast Metabolizer' or 'Slow Metabolizer' of Coumadin / Warfarin which is useful as a guide on how much Coumadin will be needed to reach his prescribed INR Range.

Without that test, it is a 'cut and try' routine of giving a dose, testing, adjusting the dose, test, etc. until the appropriate INR is reached.

You may also want to educate yourself (and your husband) by reading AL Lodwick's Website, www.warfarinfo.com

AL Lodwick is a Registered Pharmacist and Certified AntiCoagulation Care Provider who recently retired as Director of his own Coumadin Clinic in Pueblo, CO. He is a well known author, consulatant, and Seminar Leader on the subject. His "Dosing Guide" is the Best $5 investment you can make as an AntiCoagulation Patient. (order online from his website)

'AL Capshaw'

 

[LUVMyBirman]

Yes, beware of Boost, Ensure, etc. I had to firgure that one out on my own. This out of sheer boredom sitting around waiting for my INR to come up. It's loaded with Vit. K. Which will conteract the Warfarin.

Good luck.

 

[Alistair]

They are keeping him in the hospital because they want his INR up to 2.0 before they discharge him.

I had pretty much the same experience as your husband. I had my surgery on a Friday and by Monday evening, I wanted to go home (my recovery was fast and relatively painless). But they kept me until Thursday trying to get my INR to its proper level. I left the Hospital on Thursday evening and had my first INR test the following Monday. During that time, it dropped from 2.5 to 1.4.

It is definitely a trial and error period which can be frustrating. With every test, my dosage changes, then again, it has only been 18 days since my surgery.

I am by far the least patient Patient.

-Alistair

 

[Ross]

Well it helps if those in charge understand Coumadin and pursue dose changes aggressively enough to bring one in range, but as we all know, that almost never happens.

 

[lance]

Recent hospital INR experience

Recent hospital INR experience

My husband received a stent and was discharged from the cardiac unit on 2 mgs of warfarin per day.

I tested his INR at home because I thought 2 mgs. wasn't enough. It wasn't. On day 5 his INR was 1.2. Ten mg per day brought him into the 2-3 recommended range.

So the cardiac specialists in a cardiac ward of a hospital performing open heart surgery had no idea how much warfarin to prescribe.

It sure does help when doctors know about ACT otherwise it's a game of Russian Roulette.

 

[Ross]

I see no reason and no excuse for these physicians to not be up to speed. It really ticks me off when they refuse to take ownership that they are part of the problem. They'll blame it on everything except the themselves.

 

[LUVMyBirman]

That was almost 10 years ago for me with the Ensure. Pointed it out to the rounding GP...she said "OH, had no idea about the Vitamin K content in there. Duh. I was new to the game and had a better handle on it!

Will be going in for a non heart related surgery next month. I will post more later. About my expereince with managing the coumadin, heparin and lovenox. that is. I usually bleed when my levels come back up. Not looking forward...but it is necessary.

 

[ALCapshaw2]

My husband received a stent and was discharged from the cardiac unit on 2 mgs of warfarin per day.

I tested his INR at home because I thought 2 mgs. wasn't enough. It wasn't. On day 5 his INR was 1.2. Ten mg per day brought him into the 2-3 recommended range.

So the cardiac specialists in a cardiac ward of a hospital performing open heart surgery had no idea how much warfarin to prescribe.

It sure does help when doctors know about ACT otherwise it's a game of Russian Roulette.

Did you TELL the Doc that Rx'ed the 2 mg dose about how your INR dropped to 1.2?

If you did NOT, please do so.

These guys NEED something to force them to get Up to Date on AntiCoagulation Management, otherwise, it will just be More of the Same for other patients, on and on and on. Witzkey's Cardiologist* with his "30 years of doing this" is a perfect example. *Hold for 3 days for an INR of 4.4 - YIKES! When will they ever Learn?

'AL Capshaw'

 

[Marty]

Beware the "hand-off"!

Beware the "hand-off"!

As my surgeon explained to me- in the "old" days post-op heart patients were kept in hospital 2 or 3 weeks. This gave the surgeons time to find the proper warfarin dose and stabilize the patient. Now heart patients are discharged in 3 or 4 days. I was out the AM of the 4th day. So everything depends on the "hand-off". These handoffs as expected can vary. My handoff to a cardiology group didn't go well. We finally got through it but there were some bumps in the road-one was pleural effusion with six pints of blood sucked out of my chest at 2 week visit to surgeon. INR at 6.5. I think its good that they do not rush the patients out of the hospital every where.

 

[ALCapshaw2]

That was almost 10 years ago for me with the Ensure. Pointed it out to the rounding GP...she said "OH, had no idea about the Vitamin K content in there. Duh. I was new to the game and had a better handle on it!

Will be going in for a non heart related surgery next month. I will post more later. About my expereince with managing the coumadin, heparin and lovenox. that is. I usually bleed when my levels come back up. Not looking forward...but it is necessary.

Be sure to have your Surgeon talk Directly with your Cardiologist. Then have someone (usually your Coumadin Clinic Manager) come up with a Bridging Schedule, reviewed by your Cardiologist for his concurrence, then presented to the Surgeon.

The 'tricky part' is balancing the Bleeding Risk vs. the Stroke Risk AFTER Surgery. I asked 3 Heart Surgeons about their usual Bridging Procedure and got 3 different answers! The one I liked Best was to start Coumadin the night of the surgery (6-12 hours post procedure), then start Lovenox 24 hours (more for higher bleeding risk surgeries) after the procedure. (Just MY Non-Professional opinion)

'AL Capshaw'

 

[lance]

Did you TELL the Doc that Rx'ed the 2 mg dose about how your INR dropped to 1.2?

If you did NOT, please do so.

These guys NEED something to force them to get Up to Date on AntiCoagulation Management, otherwise, it will just be More of the Same for other patients, on and on and on. Witzkey's Cardiologist* with his "30 years of doing this" is a perfect example. *Hold for 3 days for an INR of 4.4 - YIKES! When will they ever Learn?

'AL Capshaw'

Yes, I tried--did the best I could anyway. Husband waiting for appointment with said cardiologist and definitely tell him then. I thought holding for 3 days was absolutely absurd too. I prefer to adjust with 1/2 doses so there is some carryover. Witzkey was lucky.