- Joined
- May 13, 2007
- Messages
- 4,352
- Reaction score
- 738
What do you do when the cardiologist says they cant come off their Plavix or Aspirin since it has been less than a year since the stent was placed?
What do you do when the cardiologist says they cant come off their Plavix or Aspirin since it has been less than a year since the stent was placed?
So facets, but not ESIs?Not stick a needle anywhere that bleeding could be bad...
So facets, but not ESIs?
So facets, but not ESIs?
On Plavix, I don't do anything in the neck except trigger points. Lower than that, I just won't do anything epidural. I will do lumbar facets on Plavix but not on coumadin. It's splitting hairs and kind of arbitrary...
On Plavix, I don't do anything in the neck except trigger points. Lower than that, I just won't do anything epidural. I will do lumbar facets on Plavix but not on coumadin. It's splitting hairs and kind of arbitrary...
Back it up with a logical sentence explaining why....
what about aggrenox?
The low dose aspirin component is not a problem. The persantine has some antiplatelet activity that may increase bleeding risk. I am unaware of any pooled data that would make me hold this medication for a neuraxial procedure.
There are always new and different drugs we need to be aware of: Effient, Jantoven (Coumadin), Trental, Pletal.
Effient would be same as Plavix or Ticlid, but I'm unsure how many days we would need to hold it- at least 7. Trental and Pletal- to hold or not to hold- these would be the only controversial drugs in my book- I'd hold 3-5 days.
are intra-articular facet blocks "peri-spinal"? How about medial branch blocks?no intra-spinal or peri-spinal procedures....
I would stick to your reference-based guidelines, whatever they are. I wouldn't do anything epidural unless the pt meets criteria exactly. Even though it seems like splitting hairs, that's where the hairs are split, at least in my guidelines. And in court, you will have to explain why you did what you did. You will be the greedy doctor, trying to get that 79 dollars at the patient's expense
Lumbar RF 3 levels after MBB x2 at 80C for 90 secs? Heat coagulation via RF? Thoughts.
i had one cardiologist tell me 3 days off plavix should be fine.... i was like "do you have any understanding of how plavix works??"
Any thought from the group about doing transforaminals / SNRBs on Plavix? Technically, the needle tip is outside the neuraxis, although I guess a large psoas compartment bleed could be compressive to the lumbar plexus. Any thoughts about using the Smith & Nephew TruCath for additional safety by keeping the needle tip even more posterior?
FWIW, the only epidural hematoma I know of personally happened to a friend of mine after an easy lumbar SCS trial with a patient on ASA 81mg. No Plavix or Coumadin. ASRA guidelines or no guidelines, sometimes **** happens.
1) i don't get patients off ASA OR NSAIDS - i follow ASRA to the tee
I agree. I dont hold ASA (325 or less) or NSAIDs, i do what ASRA says.
ASRA guidelines have the breath and scope of much greater experience then the pain world. Also the needles are bigger, and the patients are sicker...
so if it is good enough for anesthesia, then i am comfortable, since i generally dont use 17 gauge needles, and i dont go intra-thecal that often, as they (i used to ) do every day.
1) i don't get patients off ASA OR NSAIDS - i follow ASRA to the tee
I agree. I dont hold ASA (325 or less) or NSAIDs, i do what ASRA says.
ASRA guidelines have the breath and scope of much greater experience then the pain world. Also the needles are bigger, and the patients are sicker...
so if it is good enough for anesthesia, then i am comfortable, since i generally dont use 17 gauge needles, and i dont go intra-thecal that often, as they (i used to ) do every day.
In the event of a malpractice suit, they are going to look at what is the "standard of care." That is ill-defined and further defined case-by-case in the court, based on who's lawyer and witnesses are better.
Most every conference and course I've been to, as well as most written recommendations for handling anticoagulation in neuraxial injections are based on ASRA. Those are what I will take in to court with me, should the need arise.
1) i don't get patients off ASA OR NSAIDS - i follow ASRA to the tee
2) technically if you are careful you should not cause a neur-axial bleed.... that being said, a colleague (that i respect) did an RF and it bled like stink from one of the RF sites... he literally held pressure for 40 minutes before it calmed down... 2 hours later the patient develops a radiculopathy (severe pain, weakness and numbness into the foot).... stat MRI shows a HUGE hematoma where the nerve root used to be... patient was on NO anti-coagulation (not even an ASA).... pt admitted, neurosurgery saw and opted to do nothing just some medrol... a few hours later the patient was going completely uncontrollable from the pain and the weakness was very dense... neurosurgery goes in and cleans things up - an artery had been lacerated by RF cannula tip (according to NS)... patient had prompt recovery....
that is why i don't do RFs on anti-coagulated patients....
Wow, that's horrible but a great example of why not to do RF with 20 or 18G sharp RF needles when anticoagulated. I've sometimes debated this as I will do lumbar mbb's while anticoagulated. This confirms it, never gonna attempt an RF while anticoagulated. Thanks for the story.....
So I was at a Bost Sci dinner the other night, round table discussion. There was one ortho spine surgeon in the group who of course took over the conversation. Anyway, he said now the standard of care is to hold plavix 14 days! He said all of his cardiology colleagues recommend this now. WTF? Anyone else hearing this??
So I was at a Bost Sci dinner the other night, round table discussion. There was one ortho spine surgeon in the group who of course took over the conversation. Anyway, he said now the standard of care is to hold plavix 14 days! He said all of his cardiology colleagues recommend this now. WTF? Anyone else hearing this??
i had one cardiologist tell me 3 days off plavix should be fine.... i was like "do you have any understanding of how plavix works??"
Actually, it should be good enough, if the platelet count is 2x what your minimal platelet count would be for a procedure. After 3 days ~1/2 of the platelets have turned over. If platelet count is >150-200 and you are willing to do a procedure at 75-100 then you have 75-100 normal platelets...
Not saying I would do it. But in theory it should be fine (as long as you check platelet levels).
In theory and on the stand going against all published guidelines are two very different things. The science behind he guidelines is there and the ASRA guys are not just making things up.
Thought I'd share this story. Did a two lead stim trial on a patient. Took the needles out and prepared to steristrip the leads down. The guy wouldn't stop bleeding. I literally applied firm pressure for 45 min. Asked the guy about all the possible risk factors and he tells me, "I eat lots of garlic with every meal". I was like great, well let me know if you can't walk or lose bowel or bladder control in the next 24 hrs. Fortunately nothing happened. I now ask most all my patients about garlic, ginseng and gingko.....
He doesn't take Plavix. Just clopidogrel.