Acute febrile illness; during the course of oral anticoagulation warrants immediate INR check

Oral anticoagulation is needed in many patients like after prosthetic valves insertion, in atrial fibrillation, clots in LA, clots in LV and DVT etc. It is mainly achieved by warfarin sodium which has many interactions with multiple other drugs and its action varies in different other chronic diseased states. to see the response of acute febrile illness on the chronic stable state of INR on a fixed dose of oral warfarin sodium. All the patients with acutely deranged INR who had a stable and controlled INR previously and a fixed dose of warfarin sodium were admitted in the cardiac surgical ward at FIC and their history was explored and recorded. A total of 966 patients were admitted in [CSW] during the period of April, 2012 to April, 2014 with deranged INR. INR was checked twice or sometimes thrice to rule out the laboratory error. 504 patients were female and 462 patients were male, 56 patients had repeated admission for their INR control, most of them were callous regarding taking dose of warfarin so they were excluded from the study. A total of 631 patients had low INR due to missed dose of warfarin sodium. Out of them 13 patients got stuck valve for which emergency redo prosthetic valve replacement was done. 06 patients died in emergency due to late presentation after the prosthetic valve got stuck. Only 279 patients had high INR on the previous dose of warfarin sodium, out of them 216 patients had out of range INR. They were treated by FFP transfusion and holding the Warfarin sodium dose for certain period of time.76% of the patients give H/o acute febrile states 101-103 with rigor and chills [Malaria, enteric fever, pharangitis, cellulitis, boils and UTI etc. etc.] since last 3-4 days for which they had got treatment from some local Gen. practitioners and gave the H/o bleeding gums, general body malaise, bruising, joint aches and pains. 24% of patients denied any acute febrile illness before their INR got out of range 2 patients died in emergency due to intra cerebral bleed after INR got uncontrolled. Any acute febrile illness even of short duration may cause sudden derangement of previously controlled INR on certain fixed dose of warfarin sodium which can create a life threatening situation like intra-cerebral bleed, haem-arthrosis, excessive menstrual blood loss leading to severe anemia. Other less dangerous situation are gum bleed, bruising, joint aches and pains and general malaise. So, it is always advisable and logical to get INR check when ever any acute febrile illness even of short duration is encountered to avoid grave situations

Valvular patients; post operative course, size of the left atrium can predict the cost effectiveness

Cost effectiveness in any surgical procedure is a major contributory factor in the continuation of medical services in developing countries. Limited data is available in assessing the factors related with the duration of ICU stay and treatment after valvular replacement surgeries. Our aim was to see the correlation of pre operative Left Atrial size of the patient and duration of post operative stay in ICU. Observational Study. March 2010 to April 2014. Faisalabad Institute of Cardialogoy, Faisalabad. A total of 550 consecutive patients with valvular lesions were included in the study. Their Left Atrial size was measured echocardiographically pre-operatively and their stay /course in the ICU was monitored. Three categories were identified in regard with the Left Atrial size and the ICU stay. If LA size is below 60 cm2, the post operative course and stay in ICU is normal and lasts for about 1-2 days. If LA size is between 60-65 mm2, the post operative course may be complicated and prolonged by the atrial fibrillation / flutter for which pharmacological cardio version may be needed and the stay in ICU is prolonged and may last for about 2-3 days. And if pre-operative LA size is more the 65 mm2 the patient may behave in entirely different way. His atrial fibrillation persists in spite of electro cardiovertion or pharmacological cardiovertion and his stay in ICU may last up to 4-5 days and thus the cost of treatment is raised. LA size can predict the post operative behavior of the patient in ICU and duration of stay and expected cost of the treatment. Smaller is the size of LA, shorter is the stay in ICU and thus lesser is the post operative cost and vice versa