Invasive procedure perioperative management of INR (extended)

[Habana58]

Here is a video from the Clinical Trials Unit (CTU) at the London School of Hygiene & Tropical Medicine that explains how Tranexamic Acid works.
https://www.bing.com/videos/rivervi...=2567367CB8CB495D97DF740A722E53AE&FORM=VRDGAR

This other video is very informative about it

https://www.bing.com/videos/rivervi...421A4FAD34671B0BA03B421A4FAD34671B&ajaxhist=0


Have to see my dentist 2 weeks before the procedure, will ask her about this product, sounds like a good safe gard for the just in case , thank you

 

[3mm]

Have to see my dentist 2 weeks before the procedure, will ask her about this product, sounds like a good safe gard for the just in case

Warning - it cost over $100 US dollars. Also, it is a specialty item which only 1 area medical lab could make for me. Fortunately, my bleeding started on a weeknight, so the oral surgeon and the medical lab were both open the next morning.

 

[pellicle]

Warning - it cost over $100 US dollars

I know almost nothing about this subject, so take what follows as being just what I looked up out of interest the other day.

I looked it up here and found a chemist shop sells Cyklokapron 500mg Tablets 100 - (Tranexamic Acid) for $40 obviously this isn't for topical. So I looked around and found:

https://www.nhs.uk/medicines/tranexamic-acid/how-and-when-to-take-tranexamic-acid/

which also mentions oral taking ... so I wonder if there are other forms which are beneficial / substitutable for your purpose.

It would seem that for those of us on anticoagulation therapy that's perhaps not ideal and may even be a contra-indication (so I checked that too)

¯\_(ツ)_/¯

HTH

 

[3mm]

oral taking ... so I wonder if there are other forms which are beneficial / substitutable for your purpose.

My prescription was liquid. I was told to hold it in my mouth for 2 minutes and then spit out the excess. The bottle also read "DO NOT SWALLOW". Repeat 4 times each day.

After 2 minutes I spit the acid out onto a piece of gauze, which I jammed into the space left by the missing tooth. I kept the gauze there for perhaps 30 minutes while I went about other activities.

It would seem that for those of us on anticoagulation therapy that's perhaps not ideal and may even be a contra-indication

I agree regarding PILLS containing tranexamic acid. That is why I used the liquid and did not swallow it. Tranexamic acid works at the location of a clot to strengthen the fiber in the clot, so putting the liquid form in my mouth should not affect clotting anywhere else in my body, assuming I do not swallow the tranexamic acid.

Thank you for the link to the NHS article; it provides good information.

I am NOT an expert, and I am a sample of 1. I actually only used the tranexamic acid for 1 day until the bleeding stopped.

 

[Eva]

…. He indicated that there seems to be a shift happening with many surgeons preferring to lowerering INR modestly, rather than bridging. But, it really comes down to individualized medicine; the patient's particular risks and the specific procedure.

I hope so!

 

[Eva]

Two years ago had knee replacement surgery. Have mechanical heart valve. Was told to bridge and was told to stop warfarin on Sunday for a Thursday surgery and to do lovenox shots twice Tuesday and only Wed morning. Was told at time of surgery on Thursday morning my INR was 1.07. My first reaction was too low. Had surgery and they held off lovenox shots but had me start warfarin Thursday evening with my normal 5 mg dose. Had rehab late morning on Friday. Nurse came in to check on me after rehab and found I was confused. She called doc and he determined I was having a stroke. They called my wife who showed up to room with an ambulance crew in hallway with stretcher. She was asked to approve the use of the TPA clot buster drug and if no improvement, I was going to be taken to a stroke specialty hospital 15 miles away. I remember none of this and woke up in ICU the next morning. Ended up in hospital for another 5 days and after many tests, it was determined they caught it and no lasting issues from stroke. There were 3 CT scans and one MRI over 2 days. I am told by my cardiologist that I am more susceptible to clots and they will be more hands on next time I have to bridge.

I may need another knee replaced in a few years, for other knee, and my shoulder is falling apart and I am told plan for a reverse shoulder replacement in the future. So will be needing to bridge again in the future.

It is hell to get old. But the alternative is not too good.

Sorry for what you went through, but glad you’re okay.
Do you self-test at home? If so, what was your INR Thursday night? You may have needed more than 5 mg! I wonder who/why you were instructed to hold off the Lovenox. Normally, after surgery, Lovenox and warfarin are restarted together, and Lovenox can be stopped once your INR is back within your normal range.

If you have to go through this again, make sure:
(1) You’re prescribed the right dose of Lovenox. Dosage is based on the patient’s weight. Doctors (even top-notch doctors) can make mistakes even when they know your weight! (This happened to me, but luckily I caught it before starting the shots, since I had Lovenox before.)
(2) Confirm with your cardiologist when to stop the Lovenox after surgery.

Best of luck.

 

[SatoriFound]

So why the heck is the "therapeutic range" 2-3 instead of 2.5-4? Why was the clinic happier with his inr at 2.3 than at 3.3? If the incidence rate is 6.7 at an inr of 2.3 and the incidence rate is 2.4 at 3.3 why wouldn't they WANT his inr at the 3.3? This really confuses me. Even when he was at 4.8 for his inr the incidence rate of 4.7 is lower than the rate for a 2.3 inr.

 

[pellicle]

So why the heck is the "therapeutic range" 2-3 instead of 2.5-4?

so, you seem to assume that INR was set for reasons based on science and evidence ;-)

For whatever reason we seem to live in a world where the patients are verging on hysterical about the number yet actually have no idea what they even mean. This is not surprising to me because (for instance) "everyone" is worried about the price of fuel but drives a fuel hungry car?

¯\_(ツ)_/¯

Why was the clinic happier with his inr at 2.3 than at 3.3?

because that's the number they're given ... do you think they've ever read papers?

If the incidence rate is 6.7 at an inr of 2.3 and the incidence rate is 2.4 at 3.3 why wouldn't they WANT his inr at the 3.3?

personally I keep my INR at 2.5 but steer up at 2.2 ... I notice I bruise less ...

Even when he was at 4.8 for his inr the incidence rate of 4.7 is lower than the rate for a 2.3 inr.

that's what the data says ... but don't argue with "them"

Best Wishes

 

[SatoriFound]

so, you seem to assume that INR was set for reasons based on science and evidence ;-)

For whatever reason we seem to live in a world where the patients are verging on hysterical about the number yet actually have no idea what they even mean. This is not surprising to me because (for instance) "everyone" is worried about the price of fuel but drives a fuel hungry car?

¯\_(ツ)_/¯

Everybody? Not me. Well, I guess you could argue ALL cars are fuel hungry, but I drive a hybrid. My work is way too far away for me to bike there. LOL

because that's the number they're given ... do you think they've ever read papers?

YES! Don't they have to learn this **** to do the job? Why would they not be reading the papers? Is there no degree or training about what it all means required in order to do this job? *shaking my head* I don't know how someone who did this job wouldn't want to know more about the hows and whys of what they are doing. I guess that is just my curious nature though.

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personally I keep my INR at 2.5 but steer up at 2.2 ... I notice I bruise less ...


that's what the data says ... but don't argue with "them"

Best Wishes

 

[pellicle]

...Don't they have to learn this 5h1t to do the job?

you'd think so, plumbers have to learn stuff to touch your sink, but apparently knowing nothing about the drug is quite OK if you're a nurse (who know very little about the metabolism of drugs but something about the administration of a subset of them)

 

[pellicle]

Is there no degree or training about what it all means required in order to do this job? *shaking my head*

on a number of occasions I've wanted to do my PhD in this area, and despite approaching 3 universities (and remember, I'll need to bring in funding) they weren't interested (because there is no prestige in publications in this area).

This guy is both an inspiration to me and a warning ....

https://www.valvereplacement.org/th...ysis-study-focus-on-bleeds-and-cancer.889418/

 

[SatoriFound]

on a number of occasions I've wanted to do my PhD in this area, and despite approaching 3 universities (and remember, I'll need to bring in funding) they weren't interested (because there is no prestige in publications in this area).

This guy is both an inspiration to me and a warning ....

https://www.valvereplacement.org/th...ysis-study-focus-on-bleeds-and-cancer.889418/

Hmmm.... Wouldn't you be able to get do the actual phd in an accepted (related) area, and then do your thesis on this actual topic? Or is the thesis idea what was denied?

 

[pellicle]

Wouldn't you be able to get do the actual phd in an accepted (related) area, and then do your thesis on this actual topic?

that might be the case in some institutions, but a PhD in Australia and the UK is the both proving your proposal, defending it in discussion with peers and a body of original research (not a literature review) which you've personally conducted.

What differentiates it from a Masters (now needing the addition of "by research" because they are now calling post graduate diplomas as Masters) is that a PhD must also contribute to the Academic pedagogy.

 

[TheGymGuy]

@pellicle, thank you for the amazing write up. Those who self-manage should give this a thorough read.

I had a small procedure a bunch of years back for which they had asked me to stop warfarin and resume after. I followed a similar protocol to what you have outlined while measuring daily. Love how detailed your write-ups are.

On the morning of my procedure I added some spinach (its been a while since, but I recall weighing it out) to my morning shake to ensure a slightly lower INR.

I was around 1.7 the night before and 1.6 in the AM. On the evening post procedure I was at 1.5 and next day it was moving back up, with good range achieved 2 days later as well.

Number of test strips used during this experiment is crazy, given that I use 1 per week. Dong 2 tests per day in the AM and PM gave me confidence of the right direction, but heck, its like 10 strip to get to the event, and I nearly ran out.