D
DrAllan
I am a retired surgeon and thought I would share my experience and feelings regarding surgery and anticoagulation. My reading of this board and others is that there is confusion amongst patients and sheer stupidity in the medical profession regarding the issue. Your primary care doctor has little appreciation of the nature of surgical bleeding and tends to panic with the idea of Coumadin and any bleeding. Your surgeon, depending on the site of the surgery and past experience may or may not be knowledgeable. Let me try to elucidate.
For instance, if you are having coronary artery bypass, or correction of a carotid artery stenosis, all of which involve large blood vessels, you are routinely anticougulated with heparin type drugs to prevent clotting during the procedure. The reason for this is that the blood supply to the affected vessels is clamped off, and when this degree of stasis occurs, clotting can happen. The reason the surgeon does not worry about bleeding is that they are controlling the vessel.
When doing many other kinds of surgery, during the dissection to get to the affected region or organ, tissue plans are separated. There are always various sized blood vessels that get cut during this procedure. The larger ones require being sutured, tied, or cauterized. The smaller ones in non-anti coagulated patients clot by themselves, or do so with some pressure. This is no different than what one does to an abrasion to the skin which is damaged, such as a “skinned” knee. Needless to say if on anticoagulants, this does not stop as quickly. A got comparison is the bleeding that may occur from a finger stick with home INR testing, or the venipuncture at the lab, which requires a ‘band-aid’. These small blood vessel areas are referred frequently to by the surgeon as “oozers”, and unless significant are ignored while other work is being done. Sometimes the area is packed off with a pressure type bandaged wedged into place to apply pressure. However, when the pressure is removed the bleeding can start again relatively immediately, or later when the tissues move and rub against themselves as the patient moves while awake. If these areas or close to the surface so that another bandage type material can be applied to apply pressure than oozing can be safely tolerated. If the area is not accessible, say inside your colon, bladder or brain, then it is not a good idea to leave the area capable of bleeding.
Further complicating the issue is that during the healing process, the body has the tendency to dissolve clots that form in blood vessels, and the areas that are tied or cauterized have a tendency to slough off and leave a raw area that can bleed. Again, this is more of a problem when anticoagulated.
The advantage of “bridging” therapy is that heparin (or low molecular heparin such as Lovenoix) acts rapidly and can be rapidly reversed.
Statistically, the majority of embolic strokes in patients stopping well-controlled Coumadin occur between the 4-5th day after stopping. Thus is you stop therapy 2 days prior to surgery and take 4-5 days to return to control INR on oral Coumadin, you are at great risk from the day after surgery for another 5 days. Tell that to your physician. Inform your family, and send a note to your malpractice attorney.
I hope that this adds some information to the bleeding surgery issue and will provide you with a format to carefully question the medical professionals caring for you.
For instance, if you are having coronary artery bypass, or correction of a carotid artery stenosis, all of which involve large blood vessels, you are routinely anticougulated with heparin type drugs to prevent clotting during the procedure. The reason for this is that the blood supply to the affected vessels is clamped off, and when this degree of stasis occurs, clotting can happen. The reason the surgeon does not worry about bleeding is that they are controlling the vessel.
When doing many other kinds of surgery, during the dissection to get to the affected region or organ, tissue plans are separated. There are always various sized blood vessels that get cut during this procedure. The larger ones require being sutured, tied, or cauterized. The smaller ones in non-anti coagulated patients clot by themselves, or do so with some pressure. This is no different than what one does to an abrasion to the skin which is damaged, such as a “skinned” knee. Needless to say if on anticoagulants, this does not stop as quickly. A got comparison is the bleeding that may occur from a finger stick with home INR testing, or the venipuncture at the lab, which requires a ‘band-aid’. These small blood vessel areas are referred frequently to by the surgeon as “oozers”, and unless significant are ignored while other work is being done. Sometimes the area is packed off with a pressure type bandaged wedged into place to apply pressure. However, when the pressure is removed the bleeding can start again relatively immediately, or later when the tissues move and rub against themselves as the patient moves while awake. If these areas or close to the surface so that another bandage type material can be applied to apply pressure than oozing can be safely tolerated. If the area is not accessible, say inside your colon, bladder or brain, then it is not a good idea to leave the area capable of bleeding.
Further complicating the issue is that during the healing process, the body has the tendency to dissolve clots that form in blood vessels, and the areas that are tied or cauterized have a tendency to slough off and leave a raw area that can bleed. Again, this is more of a problem when anticoagulated.
The advantage of “bridging” therapy is that heparin (or low molecular heparin such as Lovenoix) acts rapidly and can be rapidly reversed.
Statistically, the majority of embolic strokes in patients stopping well-controlled Coumadin occur between the 4-5th day after stopping. Thus is you stop therapy 2 days prior to surgery and take 4-5 days to return to control INR on oral Coumadin, you are at great risk from the day after surgery for another 5 days. Tell that to your physician. Inform your family, and send a note to your malpractice attorney.
I hope that this adds some information to the bleeding surgery issue and will provide you with a format to carefully question the medical professionals caring for you.
