NOACs and operations : a warning

This is a warning that medical staff, outside Cardiology, may well have a poor

understanding of anticoagulation beyond warfarin so we need to be aware.

I am shortly to have 2 discs removed from my neck so I attended a pre-op assessment on Friday at one of the best rated neurological hospitals in the UK.

First I was interviewed by a specialist nurse who was tasked to check my history. I had written a list of my medication and handed it to her.

2x 150mg Pradaxa NOAC. 1x2.5mg Bisoprolol. 1x20mg Atorvastatin.

She thought that I took 300 mg of Pradaxa in one go and I had to explain that one capsule was taken per 12 hours. She then said that I was to stop taking it 7 days before the operation. I explained that I had already discussed this with the spinal surgeon and his instruction was to stop the Pradaxa 72 hours before the operation.

I think that this goes to show that we must all be aware that general knowledge of NOACs is poor.

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31 Replies

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  • Thank you jennydog, you are so right.

    What I find stunning about your experience is that a nurse, even a specialist one in a specific area, would give advice in an area which is so obviously outside her expertise. Makes me wonder how many previous patients followed this dangerous advice.

    Best wishes with your op - I hope all goes well for you.

  • Finvola I agree and I thought it worthwhile to recount the experience. I really would not like to be off Pradaxa for a whole week.

    Thank you for your good wishes. I will end up minus 2 discs and plus 2 plastic wedges with a titanium plate to hold them in place. It seems minor compared to what friends have gone through having hip and knee replacements.

  • It's not! Best wishes, interested to hear how it goes.

  • Had to have some damaged tissue removed from both eyebrows (rugby and boxing damage not for looking pretty!)

    On rivaroxaban and was told stop a minimum of 24hrs before and after

    Looked like I done 18 rounds with Sonny Liston for a while after though.

  • Thank you Jennydog.You have raised a very important issue.I am not quite sure yet how we can resolve it...that is to say how we can make the professionals aware of the advice they give re. ops. and NOACs...and for them to consistently get it right so that we patients feel safe in their hands.

  • Easy - don't rely that 'professionals' know best - be informed and don't except everything you are told verbatim......I think The Donald is a perfect example.....

    No professional can know everything and because medicine is now so specialised, many know nothing or very little about diseases outside their speciality. There are over 60,000 dysfunctions of the body, no doctor or nurse could ever know more than a small percentage.

    I am a firm believer in response ability - I think the danger is for those older people who may not have the awareness and be of a culture who did rely on professionals to know better........I think this is why I admire geriatricians so much as they are the only speciality that do seem to be far more global in their thinking.

  • Well Done Jenny, at least you have the eye on the ball. My best wishes for the operation.

    Kind Regards

    Barry

  • I recently had a skin cancer removed from my face.

    The surgeon told me to stop Apixaban two days before the operation. Therefore because the procedure was in the late afternoon I was without the med for three days in total!

    I guess all surgeons have different requirements etc.

    I checked with my cardiologist to see if it was ok to be off Apixiban for that long and he said yes.

  • Hi Jenny

    Terryfing isn't it, I wrote about a similar experience prior to my knee op, you'd really think that a pre-op nurse would have come across these drugs any times, but the one that interviewed me was very poor.

    Be well

    Ian

  • We have to be expert patients. Aware of the guidelines and questioning our management in thr nicest possible way

  • Did anyone stop anticoagulants and then go on low molecular weight heparin injections as I did therefore still anticoagulated

  • Yes - if you look at my last post I argued the case when I was told to stop warfarin, and eventually was bridged with Fragmin. No problems at all.

  • Hi Irene,

    That's interesting - I'm on Warfarin and when I had my partial knee surgery in Nov 2015 I was told to stop Warfarin 1 week prior to surgery = which I did. No Bridging anticoagulant at that point.

    I went under the knife at about 11 am and came back to my room around 1 pm - then I was given Fragmin. That evening I just continued my usual dose of warfarin as usual for that day.

    Like you - no problems at all.

    John

  • I did for several procedures

  • When I had my colonoscopy nobody could / would tell me if I should stay on or come off apixaban. In the end I looked up the Nice guidelines which said to miss one dose and took a print out with me on the day of the procedure. Why couldnt my G.P. have done that ? My G.P. said she was not prepared to advise me. When I rang the hospital there was no one who could speak to me. If I hadnt taken it into my own hands I would probably have been sent home. X

  • Now that is worrying.....

    Did you ask your GP why she was not prepared to advise you?

    In my job if something was beyond my competence level I would say so and then say 'I will find out or refer you'.

    As you say, just verifies that we must become experts.....sigh..... x

  • I did ask and she saidshe wasnt qualified to give me that advice. She did ring the hospital for information but she couldnt get anyone to speak to her either. It was a Friday afternoon whatever that had to do with it......

  • Mmmm.... I wonder, did she have a computer in front of her? NHS have a secure site for queries - I know that is what my GP does if she's not sure on meds, procedures etc.

    That must have been very difficult for you at a time when you, or anyone facing a procedure, are going to be anxious and want information and reassurance.

  • This discussion just shows how important this wonderful site is.

  • Yes Jennydog, over the last few years of AF consultations and any other medical matter I have made it clear to one and all (incl my wife who thinks It's OTT) that I am one of the medical team with my notes/past test results and opinions; no longer sit back and do as you are told. My GP and cardiologist accept this and we now have a good working relationship as 'colleagues'.

    Occasionally of course you are spoilt with someone who is clearly super competent and knowledgeable and when that happens it is immediately apparent and I back off.

    Best wishes for your op and recuperation!

  • At one time I would have been like your wife, no longer...........

  • I'm a GP and I agree with you. You should be part of the team and not hold health care professionals in so much high regard that you leave your own knowledge and common sense at the door

  • Thank you for posting this information and forewarning us to check up on the treatment/drug therapy we are receiving. In this busy life I think we assume that the "experts" know what they are talking about! Good luck with your operation. Keep warm and let us know how you get on. Anne

  • jennydog, you are SO right. Three weeks ago I was having my medical history taken in hospital. The nurse asked me which medications I was on and I said Rivaroxaban and Ramipril. I told her Rivaroxaban was an anti-coagulant and she then asked me what my last INR reading had been. I had to tell HER that INR tests are not used with NOACs. That is the second time it has happened recently. Surely it's not such a difficult piece of information to pass on to nursing staff. I do wonder how competent some nurses are . I had a test done in my GP surgery and the nurse had to work out the mid point between 1.1 and 1.5 She thought it was 1.25!!! I had to tell her it was 1.3 and then explained how she could work that out in future. Bit worrying.

  • That would be the advice for aspirin!

  • I'm having a pre - op assessment today. Will report back later. I take apixaban.

    Marion

  • Marion62 I'll be interested to see how you get on. Good luck.

  • Hi.

    Pre- op assessment went very well. I am having a procedure under GA next Thursday. I was told to take my last apixaban Tuesday evening as it would be out of my system by Thursday and restart Friday morning. I did query the Friday morning restart and she thought it would be OK. I will check that date again before I leave hospital.

    I haven't had a GA for over 30 years - not looking forward to it at all.

    Marion

  • Marion62 thank you for that. I'm glad the pre-op went well. I had a GA for my ablation 2 years ago. When I woke up I felt absolutely atrocious for all of 2 minutes and then I was fine. I don't think that nausea is the problem that it used to be.

    It takes up to 6 months to get over the tiredness caused by the GA so be prepared for that.

    Good luck with the operation.

  • Thanks jennydog,

    Last time I was sick after my op - but have been assured that things have greatly improved since then.

    I hope I recover quite quick from the op as I belong to a walking group. My husband suffered for many many months - after having two GAs in 7 weeks.

  • orchardworker. The patient is one of the colleagues. Exactly. And we have a multidisciplinary team where each participant has valued contributions.

    I live in a country where the local doctors are totally phased by this. I teach my students that every patient has at least the following rights and duties:

    1. Check the spelling of every medicine. There is a world of difference between Coversyl and Coversal. The pharmacist mis-read it, and that could have been nasty

    2. Check the doses. Unusual needs justification

    3. Check for every medicine if extra tests are needed eg Urea level. This information is normally hard to find. Even the British National Formulary hides/ignores it.

    4. Check and recheck drug interactions. Use more than one source of information

    5. Stress to the doctor, when looking at lab tests etc, that it is not the absolute level of the result that matters. It is change that matters. Something as simple as having a temperature. Some people almost never react with an increase, so 38C is serious. For others, 38C is routine.

    6. Try to introduce new medicines, one at a time. With new medicines ask the question: Do I have to?

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