Mech Valve and INR set to Basic 1

[Computec]

An interesting developement I'd ike to share with the group.

I came up with a bleed and endured a hospital admission these past nine days. The bleed wouldn't stop because of the my normal INR of 3.0. I was given vitamin K to lower it so the bleed would clot but no luck right away. Several days later and some blood plasma and the hemoglobin level stopped dropping and apparently the bleeding was stopped. The location of the bleed is near the left kidney. A vascular surgeon was put on standby but was considered a last resort because of the location.

That brings me to where I'm at now. Last night they released me from the hospital and restarted the warfarin at one half my usual dosage. The reasoning being that if it's still a bleeder it will let us know without life threatening consequences. No bridging therapy has been used (Lovenox or Heparin) for that reason. I'm out of the hospital and was told that as we nurse the INR back to normal we'll have some notice if the bleeding continues otherwise I'll be back at normal levels in 5 to 7 more days. Of course there will be hemoglobin level checks and another CT scan in the future too.

I asked one of the doctors about the risk. Yes, he said, it's risky but there's no choice. He also said that being off the warfarin would be deadly if it was for long term because I would stroke out eventually but that the odds of it happening in the short term are acceptable considering the situation.

I might point out that telemetry was used for 5 days and showed no change from normal sinus rhythm at any time. Prior to VR I also had A-Fib. Currently I have no other reasons for the Warfarin than the mech valve.

If this works I'll be a lot less concerned by a low INR than I have been in the past.

Has anyone heard of or had an experience like this? Any thoughts?

 

[Ross]

Somewhat like you only a gastro bleed. There is no choice about stopping. I don't think they should have used Vit K, but plasma only, to lower it because getting it back up after K is difficult. Again, no choice. Risk is small, but with it, the risk could be deadly. Not worth placing your life in danger at this point.

Basically it's your life or a stroke. Life is more important for now.

 

[Karlynn]

Wow, I'm so sorry you had to go through this. Do they know why you had the bleed?

 

[Ross]

Wow, I'm so sorry you had to go through this. Do they know why you had the bleed?

Me too considering what I went through with Lyn a couple years ago.

 

[Computec]

At this point the cause is a mystery aside from the fact that I also had undiagnosed pneumonia. The coughing was such that it could have done it.

Two years ago, before vr surgery, I blew out a vein in the same area by coughing too hard. At that time I had water accumulation from the bad mitral valve. And... I wasn't on ACT.

My rule for now is no more coughing.

 

[Guest]

Hi Computec,
I am a pharmacist who managed warfarin full-time for more than 10 years and now I am semi-retired and just teach seminars on warfarin management. I have not been very active on the site for about 6 months, but now and then a member will contact me when they think that someone has a particularly difficult problem. I used to live in Makiki Heights and worked at Queen?s.

I suspect that you are right about the excessive coughing causing a bleed. It seems that if someone had a prior incident like this then it is likely that it happened again. Here is some truth to the idea that warfarin does not cause bleeding by itself. It causes a weak spot to bleed sooner than it would have happened without warfarin. I did see something similar twice (if I remember correctly) during my active career. The truth is that nobody knows how to treat this situation. I managed about 50,000 patient visits and only saw it twice, so the average doctor would probably not even see it once in an entire career. Vitamin K is generally the first choice when the bleeding doesn?t seem life threatening. This is because it is cheap and causes no threat from diseases that can be transmitted by blood products. But, it takes at least 6 hours to work. So, if they had known that it wasn?t going to stop bleeding easily Fresh Frozen Plasma would have been used sooner.

Being discharged on ½ your regular warfarin dose does make sense. While it is not going to offer much protection from a stroke, it is going to have a minimal risk of causing another hard to stop bleed. The problem with being off warfarin with a mechanical mitral valve is that the pressure change across the valve is fairly low. So the turbulence created by the mechanical valve not being the same shape as the natural valve does not dissipate as fast as it would if it were an aortic valve. Thus, you are at higher risk of a stroke. You are truly between a rock and a hard place. However, the odds are great that you will come through this trying time without serious consequences.

 

[Computec]

Thanks Al. I appreciate the input from you especially since I've noticed that your appearances are rarer here on VR.COM. I hate being the one responsible for interrupting your semi-retirement but I'm glad you're here.

You're correct on the sequence of events. Initially they tried the vitamin K and then (approximately 12 hours later) they tried 2 packs of FFP. Twelve hours later they tried 5 more packs. It's obvious that all during this period the hemoglobin read continued to fall from the 14 when I entered the ER to an 11 just 12 hours later. I could almost see the physicians' hair turning gray. I know that 8.0 is whole blood transfusion area. My reading stabilized at 10.7 on the third day and remains there even now. Since the newly formed hemoglobin cells take 10 days to mature and only show in a (H&H) Hgb/Hct test when viewed microscopicly. I'm probably wrong there but this is what I gather so far.

Given the reading I had it was interesting to see the younger doctors seize upon the idea that I was dehydrated because the RBC was low instead of seeing this as the result of the as yet undiscovered bleed as the more experienced did.

During this ordeal I had consults from dotors from several specialties. Between the lot of them I think they got it right but I had to eat hospital food for 9 days.

On another note... You're more than welcome back in the islands, Al. Maybe you'll return for the renaming of the street in Makiki in your honor. Are you going to wait untill all the warrants are cancelled? Not many leave Hawaii without a good reason. A carreer path would qualify especially if it led to helping as many people as you have. Again, Mahalo Nui Loa for your input.

Jerry