Warfarin Starting Dose | Dosing Initiation Protocol

Oral anticoagulants especially warfarin are used in most hospitals to decrease the risk of systemic arterial thromboembolism including strokes in patients with atrial fibrillation or flutter or prosthetic valves (Ebell MH, 2005). It is also indicated to prevent recurrent venous thromboembolism in patients with deep vein thrombosis and pulmonary embolism. Besides, it may be used as secondary prevention after myocardial infarction. Over the last 10 years, the use of warfarin has increased substantially particulary within the context of an ageing population (Fitzmaurice DA, 2005).

The INR (International Normalised Ratio) was developed in response to variation in thromboplastin sensitivity and different ways of reporting the prothrombin time across the world. Inappropriate management of anticogulation therapy can lead to subtherapeutic or supratherapeutic INR values which lead to increasing risk of acute or recurrent thromboembolic episodes or bleeding episodes respectively. For most indications, the therapeutic range of INR would be between 2.0 and 3.0. Though, there are exceptions when warfarin is used for secondary prevention after myocardial infarction or for patients with high-risk mechanical prosthetic heart valves, in which case the range would be 2.5 to 3.5 (Heneghan C, Tyndel S et al, 2010).

When starting anticoagulation therapy, it is crucial to review and weight the benefits and potential risks to the patient during therapy. Initial dose of warfarin is typically 5 mg/day in most patients (Ageno W, Steidl L et al, 2003). However, a starting dose of less than 5 mg may be considered for patients greater than 70 years of age, elevated baseline INR greater than 1.1, hypoalbuminemic patients including malnourished, liver disorders, post-operative and others, impaired nutrition (weight < 45 kg), heart failure, known to take medications that increase sensitivity of warfarin, or either induce or inhibit excretion of warfarin (Garcia D, Regan S et al, 2005).

The loading dose for initiation of warfarin has changed from time to time over the years to provide the most effective dose to the patient without compromising the initiation period. Recently, the loading dose was suggested to be 5 mg of starting dose which is close to the average maintenance dose was at least as effective at producing a therapeutic anticoagulation effect by day 4 to 5 as a 10-mg loading dose. In addition, the 5-mg loading dose was associated with lower frequency of unwanted hypocoagulability than the 10-mg dose (Crowther MA, Ginsberg JB et al, 1999). 

Sitz Bath Uses | Definition

Sitz bath is a bath in which a person merely sits in the water covered up to the hips. It is used to relieve discomfort and pain in the lower part of the body by increasing the blood flow to it while keeping the affected area clean. Normally, it is used by patients experiencing pain due to hemorrhoids (piles), inflammatory bowel disease, infections of the bladder, prostate or vagina. Also, it is indicated for patients with anal fissures, uterine cramps, rectal surgery, and perineal pain from episotomy and childbirth, vaginal and vulvar surgeries.

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Sitz Bath Uses | Definition
Sitz Bath Baking Soda / Epsom Salts
Sitz Bath Procedures / Methods | Make your own sitz bath
Sitz Bath Wiki | Instructions

Sitz Bath Baking Soda / Epsom Salts

Sitz Bath Medications

·         bathtub / basin / plastic sitz bath

·         cool / warm / hot water

·         towel

·         salt, baking soda, vinegar (optional)

Warm water: used for relieving the itching, pain and discomfort associated with conditions like hemorrhoids and genital problems.

Cool water: used for easing constipation, inflammation and vaginal discharges or toning the muscles in cases of fecal or urinary incontinence.

Baking soda or epsom salts can be added after doctor recommendation. It is indicated for vaginal or perineal discomforts especially for women after childbirth. The amount of salt added depends on the size of your sitz bath / basin. Besides, vinegar may be added to provide relief from vaginal yeast infections (candidiasis).

Sitz Bath Procedures / Methods | Make your own sitz bath

1)      Firstly, place the sitz bath or basin inside your bathtub and fill it with warm water (temperature should be around 37^oC). Alternatively, you can put your sitz bath on top of your toilet seat. Water should be filled up to about 3 or 4 inches (just deep enough to cover your buttocks and hips)

2)      Then, sit in the sitz bath with your legs out of water. Your part of body that should be immersed in the water is lower abdomen, buttocks, and upper thighs.

3)      Stay in the sitz bath for about 20-30 minutes. 

      Note: An optional step would be filling another sitz bath or basin with cool water where you alternate between hot and cold water (spending 5 minutes in warm water and 1 minute for cold water). Alternate between hot and cold bath up to 3-5 times. A towel soaked in cold water can be used in place of a cold bath.

4)      After getting out from your sitz bath, gently pat to dry the affected area with a clean towel. It is noted that avoid rubbing the area dry. You may letting the area air dry or using a hair dryer.

5)      Wash your sitz bath properly after each use and dry it thoroughly.

6)      Repeat the process once or twice daily and you may use it up to several times a week depends on your condition.

Related Searches:
Sitz Bath Uses | Definition
Sitz Bath Baking Soda / Epsom Salts
Sitz Bath Procedures / Methods | Make your own sitz bath
Sitz Bath Wiki | Instructions

Sitz Bath Wiki | Instructions

Sitz Bath - hydrotherapy

Sitz bath is a bath in which a person merely sits in the water covered up to the hips. It is purposed to relieve discomfort and pain in the lower part of the body by increasing the blood flow to it while keeping the affected area clean. Normally, it is used by patients experiencing pain due to hemorrhoids (piles), inflammatory bowel disease, infections of the bladder, prostate or vagina. Also, it is indicated for patients with anal fissures, uterine cramps, rectal surgery, and perineal pain from episotomy and childbirth, vaginal and vulvar surgeries. ^{[1], [2]}

Materials

·         bathtub / basin / plastic sitz bath

·         cool / warm / hot water

·         clean towel

·         salt, baking soda, vinegar (optional)

Warm water: used for relieving the itching, pain and discomfort associated with conditions like hemorrhoids and genital problems. ^{[3], [4]}

Cool water (should not be colder than 20^oC or 68^oF): used for easing constipation, inflammation and vaginal discharges or toning the muscles in cases of fecal or urinary incontinence. ^[4]

Methods ^{[5], [6], [7]}

1)      Firstly, place the sitz bath or basin inside your bathtub and fill it with warm water (temperature should be around 37^oC or 100^oF). Alternatively, you can put your sitz bath on top of your toilet seat. Water should be filled up to about 3 or 4 inches (just deep enough to cover your buttocks and hips)

2)      Then, sit in the sitz bath with your legs out of water. Your part of body that should be immersed in the water is lower abdomen, buttocks, and upper thighs.

3)      Stay in the sitz bath for about 20-30 minutes. An optional step would be filling another sitz bath or basin with cool water where you alternate between hot and cold water (spending 5 minutes in warm water and 1 minute for cold water). Alternate between hot and cold bath up to 3-5 times. A towel soaked in cold water can be used in place of a cold bath.

4)      After getting out from your sitz bath, gently pat to dry the affected area with a clean towel. It is noted that avoid rubbing the area dry. You may letting the area air dry or using a hair dryer.

5)      Wash your sitz bath properly after each use and dry it thoroughly.

6)      Repeat the process once or twice daily and you may use it up to several times a week depends on your condition.

There are some baths with device installed to provide continuous stream of warm water going into sitz bath to keep the water warm. For some being used in the hospital, they may come with a solution bag and a tube which hanging from a hook like an IV pole used. Furthermore, many sitz baths are designed with a vent to prevent overfilling but instead, will empty into the toilet bowel when you sit in. ^{[5], [7]}

Note: Salts can be added after doctor recommendation. It is indicated for vaginal or perineal discomforts especially for women after childbirth. The amount of salt added depends on the size of your sitz bath / basin. Besides, vinegar may be added to provide relief from vaginal yeast infections (candidiasis). ^[7]

Caution: You may feel dizzy when stand up after staying while in the sitz bath.

Images for sitz bath

References:

1.      Parswa Ansari, Norman Sohn. Hemorrhoids (Piles), October 2007. The Merck Manuals Online Medical Library. Retrieved 3 Jun 2012.

2.      Boyden K, Olendorf D, Jeryan C. "sitz bath", The Gale Encyclopedia of Medicine, Detroit, Mich. 2008. Retrieved 3 Jun 2012.

3.      David C. Dugdale. Sitz bath. Medline Plus. Retrieved 3 Jun 2012. (HONcode certified)

4.      http://www.natural-health-restored.com/sitz-bath.html Retrieved 3 Jun 2012.

5.      Barbara Bradley Bolen. How to Take a Sitz Bath. About.com Guide. Retrieved 3 Jun 2012. http://ibs.about.com/od/treatmentofibs/ht/sitzbath.htm (HONcode certified)

6.      Christopher Jacoby. Sitz Bath Recipe. Health Guidance. Retrieved 3 Jun 2012. http://www.healthguidance.org/entry/14749/1/Sitz-Bath-Recipe.html

7.      Theresa Halvorsen. How to Take a Sitz Bath. Retrieved 3 Jun 2012. http://www.howtodothings.com/health-and-fitness/a4540-how-to-take-a-sitz-bath.html