Warfarin and surgery

[Jade]

I am due minor surgery soon and am wondering about your experiences of coming off warfarin and bridging. What's the normal system?

[Manofmendip]

Hi Jade

When I had heart surgery I started Fragmin and stopped Warfarin one week before surgery and started Warfarin the afternoon on the day I had surgery in the morning. I kept the Fragmin going until my INR was back in target, or so I thought, but my self test machine was giving false readings after surgery so I should have had lab blood tests instead.

Dave

[Jade in reply to Manofmendip]

Dave it's interesting they let you start warfarin on the day. I have had 2 minor procedures done under local and been told I cannot have ibuprofen or aspirin for pain. This was not said because I am on warfarin it's on all their literature.

[nyctapdancer in reply to Jade]

I take advil when i need it. drs are clueless

but my hemo has APLS and he takes advil too. we both take high dose coumadin

[MaryF Administrator]

Hi, I have never needed this, not being on Warfarin, but several people have had this on here, it is best that they share their experiences with you, your hospital/clinic will have done it before and will follow recommended protocol. MaryF

[Jade in reply to MaryF]

I know the hospital will have a system, but I really don't trust hospitals at all. I have self tested for 10 years with no support as I have come across docs who wanted to undo prof Hughes good work. So I have hidden as long as I can.

[jetjetjet]

I have had 2 mayor surgeries in the last 3 years and also dental extractions.

I am an 80% risk factor from the start.

they taper down the warfarin testing everyday 3 days prior . then i go off warfarin totally but stay on Hydroxy.

1 day post surgery i start 40 mls enox. 2 or 3 days then 120 mls and then start warfarin again .testing every day then 2 days etc. .

one surgery i stayed on enox for 9 weeks as they wanted test protein S & C which can't be done while on warfarin .

I believe every one is a little different . as our target and warfarin schedule 's are.

any thing else you may have i would be happy to help if i can in my own opinion.

I go for tests Friday the 2 nd my self-- blood --ultra sound office visit @ gastro - endocrinology

then a fribro scan . this is all for my Fatty Liver-- my platelets count has plummeted and this is a major concern for serious liver disease.. if this doesn't work another process will be done that i don't want to even think about !!

[jetjetjet in reply to jetjetjet]

The other process i didn't want to speak of was the transjugular liver biopsy. 4 of my 5 top Dc's were against any biopsy's.

how ever the fibroscan was a 100% success .. top results.

results were conclusive although not good for me. the fatty liver has me at stage 3 cirrhosis. i have gained 8 pounds which isn't good so i need to get slimmer :-).

retest with blood , ultra sound . fibroscan ,in six months-- hoping for a special test to see if i am clotting in the liver in the near future --i brought this to my gastro specialist only 2 days after all my tests on January 2 nd. .- I asked why it wasn't done and she admitted that she hadn't even knew about this -- the info i gave her was from APS/ action .she is looking into it more but i think she will find what i am asking for is a great step for me. some times we have to take the controls and steer these dc's in the right direction. she is starting to come to me on this BUT it has taken 2 years { every six months }.

so in six months god willing i may have more for you guys on this .

Keep smiling -- Chin up -- best foot forward and all those things.

Casey and Jim here in N.H. USA

[daisyd]

I didn't have any problems at all, you could always contact the staff who deal with your INR, if it were me I would take paracetamol for any pain

[Elaine77c]

I was scheduled for a liver biopsy where they were going to go in through the neck. I started Heparin and came off Warfarin 5 days before. However no one told me until I got to the hospital that they expected me to come off Heparin as well and be completely non-anticoagulated for at least 12 hours! I had a very tense conversation with a consultant as I refused to come off heparin unless Rheumatologist said that risk of another stroke was low. She couldn't say this, only that I would probably be okay - Hepatologist could not get radiography people to do procedure with me on it, so no liver biopsy! Hepatologist was not my consultant but he is now, obviously doesn't mind people arguing with him, and they found other ways to look at my liver! In future, I will not allow them to get that far without an in depth discussion of exactly what they want to do, why and a full review of the risks vs benefits. It will then be me who decides what happens, it is after all my body and my brain that could be damaged by a stray clot!

[nyctapdancer in reply to Elaine77c]

I'm with you. I DON'T TRUST ANY DOCTOR BUT MY OWN - ever

what most of them know about APLS and Coumadin would fit through the eye of a needle

[Andrewl]

Hi Jade, I am not long out of hospital. I too am high risk for surgery due to being a very high thrombotic risk. I didn't get surgery this time, as too risky, but it will have to happen at some point soon. They were going to take me off warfarin, and put me on heparin infusion, and monitor with K19 vit whilst in surgery. Then gradually back onto warfarin after surgery. The aim was to be off warfarin as short a time as possible, and to get inr back to target as fast as possible after procedure. Your haematologist (or whoever is in charge of your condition) should be contacted, and they will keep the department doing your surgery well informed of dangers to be aware of etc for people like us. JetJetJet is not long out of surgery and a hardened aps person, who has been through a lot, his info will be valuable.

Keep your chin up, and take all the advise you can get.

Hope all goes well

[panda60]

I have had four shoulder operations since being on warfarin. Each time I had to stop warfarin before and go onto heparin for a while after before starting again on warfarin to avoid bleeding in the joint. But that was me and really the best thing you can do is to discuss it with the hospital and your consultant or anticoagulant clinic. It is important to get it right so your op can go ahead.

Good luck

[nyctapdancer]

I had 3 surgeries in 2014 - 2 for ctaracts and one to remove a calcified blood clot from my leg. I was on Coumadin for all of them with no issues

Drs all agreed risks of a clot were too high.

When i had abdominal surgery 5 years or so ago, i came off heparin as i walked into surgery and would have been on it during the surgery if it had lasted more than 3 hours.

it is WAY too dangerous for anyone who has ever had a blood clot to come off coumadin for even one day without switching to heparin.

[GinaD]

First a GRRR moment! Once again -- I try to correct a mis-spelled word and lose the page and my post!

GRRR.

There, I've vented.

I had my hip replaced in Nov 2013 and bridged before and after surgery from warfarin to lovanox and back. NO problems.

The rationale behind the bridging is that warfarin has a half life measured in days (3? I think) while the injectibles have half lives measured in hours. So, the window of time in which your blood is not nice and thin is short. And during that time you are being monitored. Some surgeries are less bleed-prone then others. But most surgeons are going to be very, very wary of taking a knife to anyone on blood thinners. By bridging to heprin, lovanox, etc, the surgeon will be more confident that the patient will not have a major bleed, and by reducing the non-coagulated time the APS patient can be more confident that not much bad can happen in that short interval.

[Hidden]

Hi, not had surgery on Warfarin but like others above have had 2 ops (both c-sections so Warfarin was a no-go regardless pre-op) on Fragmin. In both cases they didn't give me my evening dose of Fragmin and I was first on the lists in the morning and I remained on Fragmin until my INR was back to stable again.

[tim47]

Firstly St Thomas' have a protocol for this problem and it was in line with the advice I had from Prof Hughes before having whole in the heart closed. I have since used it prior to an endoscopy but as an inpatient for a week. Another similar procedure may be coming up and I'll do the same but at home. Also have had oesophageal investigations that carried a risk of accidental bleed so agreed to stop warfarin and go onto Fragmin at home.

I have recently had a conversation about cataract ops and, with other factors, we have concluded benefit at present is not worth the risk.

Frankly we have to get used to having such conversations AND making sure everyone in the team understands their role if we go ahead with appropriate bridging. Cannot emphasis this too strongly.

The protocols is basically to come off warfarin and cover with Fragmin, then straight back on warfarin. fragmin is usually omitted on the day of the procedure before the procedure- but the details must be agreed.

[Holley]

I've had open heart surgery, dental surgery, gall bladder surgery and a few other minor surgeries since being on Coumadin. I go off Coumadin 5 days prior to procedure and switch over to daily injections of Lovenox, since that exits your body in 12 hours. The dose depends on my weight. I hold all meds the night before the procedure and then start both the Coumadin and Lovenox the evening of the procedure day. I "bridge" with the two medications until I'm back in my target range of 2.5-3.5. On average, it takes me about 10 days to get back to that.

[beckyb]

I am going for a bone marrow biopsy next week, for my previous biopsy at a local hospital i did not come off warfarin but for this biopsy in london they have said to stop warfarin for 48 hrs before then start again straight after the procedure. A bit apprehensive about this but the hospital and my gp have said it is standard for some hosps. I get the feeling it varies depending which trust runs the hospital?

In the past when having minor surgery and having to stop warfarin i had heparin injections until 12 hours before the op and until warfarin was stable again afterwards.

[Jade]

Thanks for all the replies. I decided to ring Professor Hughes and get clarification from him. He said come off warfarin 3 days before and start again 2 days after surgery. During that time fragmin except the day of surgery. So there we go. Surgery next Wednesday I will start preparing this weekend.

[nyctapdancer]

I have had multiple surgeries on Warfarin, including a 5-hour shoulder surgery and removal of a kidney stone. I also had a colonoscopy and other procedures on Warfarin - and never, ever, not once had any kind of bleeding issues. Drs have made me get my INR down to 3.0, but that's the lowest it's been on any of these surgeries. I hope your surgery goes well and recovery is fast and complete.