Platelet count CESI

[thecentral09]

What is the lowest consistent platelet count you have been willing to go for cervical epidural steroid injection. I still use an 18 gauge touhy with CLO. Currently have a patient at 85 and is stable, labs taken today

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[willabeast]

What is the lowest consistent platelet count you have been willing to go for cervical epidural steroid injection. I still use an 18 gauge touhy with CLO. Currently have a patient at 85 and is stable, labs taken today

It depends for most docs as to why the platelet count is down as to what is a good number. BUT...an epidural hematoma is a possibility in any patient. To be safe, suggest writing down the results of a phone call to the patient's hematologist regarding risk. ITP bleeding risk is more than just a platelet count.

 

[SommeRiver]

25g spinal needle here, and since I switched over it has made my life easier.

For cervical ESI I'd be okay at 85. I would prefer 100, but if the pt is miserable I'd do it.

 

[lobelsteve]

I've done an SCS trial with platelets at 22k. No bleed. Found out a week later what the numbers were.

 

[DOctorJay]

DJ Kennedy mentioned at AAPM this year that the interlaminar CESIs that led to epidural hematoma were all with 18 gauge needles. I believe he said this came from claims data.

I use a 20 gauge tuohy.


Sent from my iPhone using SDN

 

[deleted880510]

Do you all check/review platelet counts on all patients prior to a cervical epidural? i dont

 

[SSdoc33]

25g spinal needle here, and since I switched over it has made my life easier.

For cervical ESI I'd be okay at 85. I would prefer 100, but if the pt is miserable I'd do it.

this is about right

 

[soccrwz]

50K was the absolute limit for OB, 75k was the relative limit for most. Its not just the one number, the trend matters, as does the function and other modifiable factors

 

[Laryngospasm]

20g tuohy here. I cut off at 75k. Not because I believe it’s dangerous below but the opposite. I know 75k is safe. And how many are you going to cancel for being below 75k?

 

[strike5858]

25g spinal needle here, and since I switched over it has made my life easier.

For cervical ESI I'd be okay at 85. I would prefer 100, but if the pt is miserable I'd do it.

What is your technique?

 

[Laryngospasm]

Clo with little puffs of contrast as you get close is what many are switching to.

 

[SommeRiver]

CLO at 45ish and when I get to the interlaminar space I attach extension tubing. I put a tiny amount of contrast and watch it track posteriorly, advance a tiny amount and put another small amount of contrast, still posterior, advance a small amount and more contrast but now it is epidural. Go ahead and inject steroid and 2cc NS.

PLT count - CESI is an elective procedure that works for a length of time, is not curative of stenosis, and radic commonly recurs. I'd inject at 85 but I'm not personally going much lower. I've done lumbar TF in the 60s, but I don't equate the two at all.

 

[drusso]

40K

 

[painfree23]

I've done an SCS trial with platelets at 22k. No bleed. Found out a week later what the numbers were.

What compelled you to do this? If something happened how would you defend it? Perc trial?

 

[lobelsteve]

What compelled you to do this? If something happened how would you defend it? Perc trial?

Trail in office. A week later he was in ER for flu. CBC then showed platelets.

 

[lonelobo]

What compelled you to do this? If something happened how would you defend it? Perc trial?

Who regularly checks Platelets before a procedure?

 

[Ducttape]

DJ Kennedy mentioned at AAPM this year that the interlaminar CESIs that led to epidural hematoma were all with 18 gauge needles. I believe he said this came from claims data.

I use a 20 gauge tuohy.


Sent from my iPhone using SDN

that might reflect more historical data and the fact that the preponderance of esi in the past were with 18 gauge Touhy needles...

 

[thecentral09]

Who regularly checks Platelets before a procedure?

Depends on the procedure. Scs trial and kypho, 100%. CESI- only if he of bleeding tendency. The patient in question has significant psych issues, he of thrombocytopenia 2/2 to NASH, and a cervical disc hern. I can canceled due to psych component and platelet count of 80k. More so because she’s the type of person shows up to the ER for fun

 

[paindoc007]

Depends on the procedure. Scs trial and kypho, 100%. CESI- only if he of bleeding tendency. The patient in question has significant psych issues, he of thrombocytopenia 2/2 to NASH, and a cervical disc hern. I can canceled due to psych component and platelet count of 80k. More so because she’s the type of person shows up to the ER for fun

100%? CBC and Coags are routine for your stim and kypho cases? I’ve never ordered routine labs pre-op for that stuff

 

[ctts]

For patients with ITP, in whom platelet levels can fluctuate quite a lot, how recent would you require the platelet count to be for ESI? My cut off is 70k, but I have seen a patient who fluctuates a little above or below. If it is over 70k one week ago, I am not sure that I would trust that it is still over 70k today. Should I require one within 24 hours in this case? Or maybe 48 hours?

 

[painfree23]

For patients with ITP, in whom platelet levels can fluctuate quite a lot, how recent would you require the platelet count to be for ESI? My cut off is 70k, but I have seen a patient who fluctuates a little above or below. If it is over 70k one week ago, I am not sure that I would trust that it is still over 70k today. Should I require one within 24 hours in this case? Or maybe 48 hours?

I would just do the CESI if the lab was a week old.

 

[lobelsteve]

I'd do 50k.

 

[Gnarvin]

I must be more conservative than most. Since I consider a CESI a purely elective procedure, my general cut off is 100k. If the patient is super miserable I would consider 80k but would have a very very thorough risks and benefits discussion and document the crap out of it.

I use an 18g Tuohy with CLO. If there is any doubt I give contrast early. My reason for using the 18g Tuohy is that I find the LOR more crisp and immediate than with 20g. May be user error.

 

[deleted875186]

I also use 70k as my general cutoff for neuraxial. In cervical I would be more conservative, above 100k I would be happy, 70-100k I would hold off if there were any other risks factors, otherwise I would do it.

20G toughy, COL at 50 degrees, hanging drop, will occasionally do LOR to saline, confirm with contrast, low threshold to use puffs of contrast if any change in resistance or uncertainty.

 

[nvrsumr]

Haven’t heard “hanging drop” in a decade. No shade. Ur confirming with contrast so whatever.

I doubt I was anywhere near the epidural space when I did blind hanging drop cesi as a fellow.

 

[deleted875186]

Haven’t heard “hanging drop” in a decade. No shade. Ur confirming with contrast so whatever.

I doubt I was anywhere near the epidural space when I did blind hanging drop cesi as a fellow.

Lol, another guy in my practice does hanging drop too

 

[Laryngospasm]

Hanging drop works great for blind thoracic while sitting. I don’t use when imaging is a available. It’s best at getting rid of false LOR which is a bitch in blind thoracic. Also frees up both hands to put a lot of force on the needle while also preventing inadvertent rapid advances.

 

[lobelsteve]

25g 3.5" spinal needle for all my epidural procedures (except SCS).
Not as concerned about hematoma as I would be with the big stick.

 

[Laryngospasm]

Not sure why you rolled your eyes at that Steve. Have you done a lot of thoracic catheters for difficult patients after they were converted to open thoracotomy and are impossible to position laying on an ICu bed in the pacu? Or have you never done OR anesthesia and don’t understand that it works very well in this difficult circumstance? I wasn’t talking about doing it in clinic

 

[paindoc007]

Just noticed, what did sommeRiver get banned for?

 

[lobelsteve]

Not sure why you rolled your eyes at that Steve. Have you done a lot of thoracic catheters for difficult patients after they were converted to open thoracotomy and are impossible to position laying on an ICu bed in the pacu? Or have you never done OR anesthesia and don’t understand that it works very well in this difficult circumstance? I wasn’t talking about doing it in clinic

Completely different. Operative anesthesia is not outpatient pain. Do you ever add ropi and fentanyl to your epidurals for radic? You test dosing lido in your tfesi?

 

[Laryngospasm]

Completely different. Operative anesthesia is not outpatient pain. Do you ever add ropi and fentanyl to your epidurals for radic? You test dosing lido in your tfesi?

I understand it is different as I have done and still do both but thanks for educating me on something you have never done. I was just talking about a technique and did not specify. The snarkiness was uncalled for. I will continue to give you a thumbs up if you describe a technique that is new to me because I appreciate the viewpoints that come from other experiences.

Edit: I did specify indirectly as I said without imaging. Anyway: have a great weekend.

 

[deleted875186]

Completely different. Operative anesthesia is not outpatient pain. Do you ever add ropi and fentanyl to your epidurals for radic? You test dosing lido in your tfesi?

Why don’t we add 50 mcg epidurally to an outpatient ESI? Sounds like a study waiting to happen.

 

[deleted875186]

Also, could imagine there would a people lined up to get into that study …. Very easy sell to patients

 

[lobelsteve]

Why don’t we add 50 mcg epidurally to an outpatient ESI? Sounds like a study waiting to happen.

There are folks putting in fentanyl, clonidine, sarapin, varied local anesthetics. I'm a salt water and steroid kinda guy.

 

[lobelsteve]

Not sure why you rolled your eyes at that Steve. Have you done a lot of thoracic catheters for difficult patients after they were converted to open thoracotomy and are impossible to position laying on an ICu bed in the pacu? Or have you never done OR anesthesia and don’t understand that it works very well in this difficult circumstance? I wasn’t talking about doing it in clinic

If rolling eyes is snarky you got thin skin for these forums.

I rolled my eyes at hanging drop. Why don't you til the clear liquid comes out then pull back?
Pain forums: hanging drop has no role in ESI for pain.

 

[Laryngospasm]

Well have to agree to disagree.. I have done way more thoracic epidurals for post op PAIN than most and have never had a wet tap doing hanging drop .how many have you done?

 

[lobelsteve]

Well have to agree to disagree.. I have done way more thoracic epidurals for post op PAIN than most and have never had a wet tap doing hanging drop .how many have you done?

I do 2-3 TESI per year.
Never used hanging drop.
Never added anything but 2cc NSS and 1cc steroid.
Have not used anything but 25g 3.5" Quincke in last 5+ years.

Outpatient pain mgmt is not post-op pain mgmt.

 

[bedrock]

Gotta agree with Steve here. With the availability of flouro In outpatient setting, there is no valid excuse to use hanging drop for any outpatient ILESI, and no valid reason to use anything except steroid + saline for ILESI injectate.

postoperative world is not outpatient world.

 

[fathead88]

I think what laryngospasm is saying is he/she uses hanging drop in lieu of LOR while still using fluoro/contrast in the outpatient setting. Separately uses hanging drop in the perioperative setting as well.

having threaded my fair share of epidural catheters into false loss non-epidural spaces while in residency, I agree with the sentiment that there is no place for non fluoroscopy + contrast procedures in outpatient pain.

 

[deleted875186]

Gotta agree with Steve here. With the availability of flouro In outpatient setting, there is no valid excuse to use hanging drop for any outpatient ILESI, and no valid reason to use anything except steroid + saline for ILESI injectate.

postoperative world is not outpatient world.

Why is it ok to use a 25G needle where all you rely on is your fluoro view, yet hanging drop or LOR with a 20G needle and confirming needle depth with fluoro is inappropriate?

not like I’m advancing a needle blind with hanging drop, advance up in COL, I know I’m a few mm away, hanging drop, confirm with contrast.

 

[BobBarker]

It is basically the same idea as Steve’s puffs of contrast. It is very safe as he is using Fluoro and contrast.

are you using contrast for your drop?

 

[lobelsteve]

Why is it ok to use a 25G needle where all you rely on is your fluoro view, yet hanging drop or LOR with a 20G needle and confirming needle depth with fluoro is inappropriate?

not like I’m advancing a needle blind with hanging drop, advance up in COL, I know I’m a few mm away, hanging drop, confirm with contrast.

If you are relying on LOR or hanging drop to get in then confirming with fluoroscopy you are a danger to your patients. Fluoroscopy before advancing past lamina.

 

[BobBarker]

But Steve he isn’t doing that.

 

[deleted875186]

If you are relying on LOR or hanging drop to get in then confirming with fluoroscopy you are a danger to your patients. Fluoroscopy before advancing past lamina.

I would say as long as your advancing slowly, using COL, confirm with contrast, and patient is completely awake, there’s minimal risk tot he patient. Doesn’t matter what technique or gauge needle you prefer.

 

[lobelsteve]

I would say as long as your advancing slowly, using COL, confirm with contrast, and patient is completely awake, there’s minimal risk tot he patient. Doesn’t matter what technique or gauge needle you prefer.

If advancing slowly with COL, you are using fluoro before it is too late.
Getting in with LOR or drop then shooting a pic to prove you stuck the cord or not is not reasonable.

 

[ctts]

A little off the original topic, but to continue the discussion, just curious, when you are referring to hanging drop above, are you all meaning, some liquid in the hub of needle (whether contrast or not), and advancing without the use of an LOR syringe?

I think has been somewhat discussed in another post in the past, I don't use the above, but I do use a 22G with a modified hanging drop, where one uses the above technique, but combined with LOR. There is only enough contrast to fill the hub, but no additional fluid in the LOR syringe, so it is just air. My thinking is that the added pressure from the LOR syringe will make it more clear when you enter the epidural space, rather than just relying on negative pressure to suck in the fluid. I release the pressure on the LOR syringe as soon as I see the liquid start to drop. Using CLO. Checking fluoro before/during/after ligamentum.

Ok, time to put on my thick skin armor on.

 

[buddababa]

Just noticed, what did sommeRiver get banned for?

Bump