Interesting stuff!

When I went for a consult to have my upper wisdom teeth removed a few years ago, the oral surgeon said that he doesn't recommend bridging because of the bleeding risk, that he'd rather have my INR below 1.5 instead because that seems to be a lesser risk than bridging itself. I ended up not having the procedure because it seemed unnecessary and because the idea of trying to get my INR to that very specific level the day of surgery seemed ridiculous to me.

I wonder a couple of things about the findings, like I wonder if the bleeding occurred post procedure, so that maybe the issue is starting lovenox too soon after surgery. Or, were the patients older or had other health issues. I sometimes think that needs to be taken into consideration too.

When I had a colonoscopy not long ago, both my Internist and my Pulmonologist advised that I go off of Warfarin for 3 days and resume taking it after the procedure. I exercised & tried to keep fairly active those days that I was off of Warfarin. It took awhile to get my INR back in range.

I was diagnosed with DVT & a PE 12/11 with no known cause.

I get a colonoscopy yearly and I have to be off warfarin 5 days before but I do bridge with Lovenox. But if I have polyps removed, I usually am instructed to hold both warfarin an Lovenox for a week to 10 days post procedure due to bleeding risk.

I think this is an interesting article and subject, for sure. I've seen the change in how doctors are handling procedures over the past few years. I think there are some gaps in the information, like rmb mentioned, or at least in the article here, maybe the scientific article in its entirety addresses some of those things, like when the bleeding occurred and such.

Personally, I think this is the kind of thing which just needs to be taken on a case by case basis and the decision individualized for each patient and each procedure. I know that certain "standards" are going to be recommended, but from the experiences I've had, I believe that we should, as always, advocate for ourselves and come to an agreement with our doctors regarding each procedure we have done.

I don't myself really see much need for the bridging before surgery. I mean, they basically ask for 5 days off warfarin to normalize your INR. I think the chances of someone getting a clot in those 5 days is very small, especially if the concern is a DVT history. A different underlying medical issue such as atrial fibrillation or a mechanical heart valve, well that would be a different situation because the risk of complication during those five days seems like it would be higher. At the same time, I don't really see where having bridged before surgery would really increase your bleeding risk in any significant way, as long as the bridging is done correctly and lovenox stopped at the appropriate time.

I think the trickiest part of the equation is the post-op period. Because here you have someone already with a known risk factor since they're already on anticoagulation, then you've added the surgery as another risk factor for clotting. But obviously, that's also going to be the most delicate time in terms of a bleeding complication. So, what to do? I think it just needs to be assessed individually for both the patient's history and the procedure itself.

For instance, when I had the heart catheterization, I asked repeatedly about bridging and was told by more than one doctor that it wasn't necessary, just stop the meds 5 days pre-procedure and start again the same day of the procedure. Well, what do you know, lucky me clotted and lost the artery due to not bridging after the procedure. And although I have continuing problems with that arm now, I'm not sure that not bridging was the wrong decision. I mean, when we have a clotting history, it's always going to be a little bit of a gamble, whatever we decide to do. I mean, the flip side of my problem is that if I had bridged, I could have started bleeding out of the artery rather than have it clot, and I'm sure it was that concern which lead my doctors to their recommendation. It seemed less likely I would clot than bleed, so we played the odds but I lost anyway. Which is worse? I'm not really sure. If I'd have gone the other way, I might have lost that one too and just had a different set of problems. Though if I had lost my hand (a concern at the time since the circulation in it was quite poor), I'm sure I would be much less generous in my assessment of the situation.

However, as a result of that incident, I have very specific recommendations for ME, that aren't normal protocol, but my doctors are just trying to best serve my individual needs and apparent clotting vs. bleeding issues. And the recommendations are different for different procedures. Really, I think that's how it should be for everyone whenever possible, even if we have to make the doctor stop and think about it. I try not to be pushy or tell the doctor his job, but I also refuse to be moved along like a number in a line at the deli, every decision made according to protocol for the masses. The decision to bridge or not is actually really important, and I think that neither we nor the doctors should consider it a one size fits all scenario, as it's often considered.

From sources, the result of the NIH bridge trial will be published in about four week in the NEJM and will also be discussed at ISTH Toronto.

The article mentioned in your link will be one of the consideration along with other resources used in that trial. I'm curious of the pendulum will swing the opposite direction in regards to bridging high risk patients. Also curious if the overall findings back each other up or if there were any conflicting results. Guess we'll see in a few weeks.

To be continued....

this is very interesting. i have had a number of minor procedures over the last few years. Due to my clotability the surgeons have kept me on warfarin but like my inr around 2.5.
I can only guess its different for everyone and what the dr decides is the best for the individual.
It used bother me a little. I had a procedure earlier this year in a different state and asked the surgeon what he thought. He said so long as it was at my usual level it didn't worry him and that i would bruise a lot (I did). my incision site bled heaps but as it was a minor surgery this didn't bother him either.
This does seem different from what I've read here but I'm not sure.

Mj568, do you mean that you've been kept on warfarin during the procedures themselves or just that you're usually on warfarin? That seems very unusual if you stay at a 2.5 INR for surgical procedures, although maybe they were procedures with very little bleeding risk. For example, my hematologist recommended (and the other doctors involved in my care have agreed) that whenever I have a colonoscopy, better to just stay on warfarin for it, and if they do happen to find something which needs removed, just schedule that separately, since most people actually don't need anything done. I haven't had one yet, and I'm not so sure whether that's what I'll do. But I will admit it would concern me to be at 2.5 for something where they're cutting into me, so you're braver than me!

Shilosmommy I stay on warfarin for the procedures, so far colonoscopies, endoscopy, hysteroscopy, a tooth removed (under GA) and most recently a loop recorder inserted. Minor procedures but all done at 2.5. it disturbed me initially but I think what worried me the most was that it didn't overly concern the surgeon that I was on warfarin. the anethetists do seem more bothered generally but go with the idea that if the surgeon is comfortablr then they are fine. when I had the recorder put in the incision site bled heaps but the cardiologist came in and simply changed the dressing and gave me more dressings in case it bled when I got home (it did). I was supposed to have carpal tunnel surgery and the plan was to do this on warfarin as well. I don't know about brave though:)