Steroid injection w/ESRD and CHF

[clubdeac]

So I was referred a trainwreck today. 65 y/o WF with a PMH sig for ESRD on HD, CAD s/p CABG, DM II and h/o spontaneous epidural abscess who was referred for left shoulder, knee and buttock pain. Basically she's got bone on bone shoulder and knee OA along with adhesive capsulitis and probably discogenic left buttock pain. Last ortho she saw said he couldn't give her any steroid injections b/c it would send her into CHF. Her nephrologist told her no synvisc?? Would anyone here consider steroids? I'm not even sure if her nephrologist would allow me to try voltaren or flector. I was thinking suprascapular nerve blocks followed by RFA if successful. Not too worried about muscle weakness as she hasn't ranged her shoulder in years. Also was thinking about genicular nerve blocks for the knee pain followed by RFA if indicated. Any thoughts?

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[PinchandBurn]

So I was referred a trainwreck today. 65 y/o WF with a PMH sig for ESRD on HD, CAD s/p CABG, DM II and h/o spontaneous epidural abscess who was referred for left shoulder, knee and buttock pain. Basically she's got bone on bone shoulder and knee OA along with adhesive capsulitis and probably discogenic left buttock pain. Last ortho she saw said he couldn't give her any steroid injections b/c it would send her into CHF. Her nephrologist told her no synvisc?? Would anyone here consider steroids? I'm not even sure if her nephrologist would allow me to try voltaren or flector. I was thinking suprascapular nerve blocks followed by RFA if successful. Not too worried about muscle weakness as she hasn't ranged her shoulder in years. Also was thinking about genicular nerve blocks for the knee pain followed by RFA if indicated. Any thoughts?

the spontaneous abscess in the epidural space makes me weary. I'd first get a CRP and mk sure there's no current abscess (get a MRI).

You could always just do a local anesthetic only ESI, just ask Lax:

 

[Pacman27]

For the knee you can do genicular blocks followed with RFA if you want the article PM me

 

[joshmir]

You could do Grey Rami block and RF for discogenic pain if abscess is cleared; also if abscess had a positive culture identifying it and its susceptibilities thats comforting

Not sure steroids would send into CHF if you did the injection right before dialysis; how long will fluid retention from steroids take to happen?

In ESRD if they are not making any urine nephrology may let you do systemic nsaids

I think the concern of of cardiologists with NSAIDs is increased afterload from fluid retention, but not sure that is a risk with dead kidneys no longer making urine and dialysis three times weekly

 

[Pacman27]

Low