ASRA Screwed me

Recently, I had a patient for an AV Fistula who wanted to be awake for the entire procedure. She had a long list of medical problems like COPD, hx MI, 3 Cardiac Stents, Mild Memory loss/early dementia, CHF (diastolic dsyfunction), Renal Failure, Obesity, etc. The list seemed endless.

The patient asked if I could do a "block" using local and she wanted no sedation of any kind. I reviewed her medication list (long list) and she was still on her Plavix (last dose yest) and baby aspirin.

I remembered ASRA's recommendation on Neuraxial techniques and assumed the latest update was similar to previous recommendations. I was wrong. Here is the 2010 ASRA recommendation:

"These recommendations focus on patients receiving neuraxial and peripheral techniques. The practice settings include inpatient (eg, operating rooms, intensive care units, postoperative surgical floors, labor and delivery settings, or hospital wards) and ambulatory facilities such as pain clinics. The recommendations are intended for use by anesthesiologists and other physicians and health care providers performing neuraxial and peripheral regional anesthetic/analgesic blockade. However, these recommendations may also serve as a resource for other health care providers involved in the management of patients who have undergone similar procedures (eg, myelography, lumbar puncture)."


Since this patient was on Plavix and Aspirin I was going against ASRA's recommendation by giving this patient a block. Even if I used U/S or was the greatest Regional Anesthesiologist who ever lived I still couldn't perform a block on this patient.

I discussed my predicament with the patient. She still wanted a block and no sedation. She needed that AV Fistula and waiting another 6 days for the Plavix to wear off wasn't an option. So, despite ASRA making my life more difficult by including Peripheral nerve blocks in their latest recommendations this patient got a nerve block. Fortunately for both of us the block was easy and there were no complications.

Are you all aware of these new recommendations? Do you agree with them? Will you now NEVER do a peripheral nerve block on patients taking any of the forbidden medications? Why lump a peripheral nerve block in with Spinal/Epidural anesthetics?

ASRA has really put the screws to me for this year. I hope the next "recommendation" is more like previous ones.

The Austrian Society explicitly differentiates between neuraxial, deep peripheral and superficial nerve blocks.141 The latter blocks such as axillary plexus block, femoral nerve block or distal sciatic nerve block may be performed in the presence of aspirin or anticoagulants.



Well this isn't Austria now is it?

Idiopathic said:

Im unclear as to how ASRA screwed you? Recommendations are what they are, they are not guidelines or protocols. I would consider any regional technique in any patient on any medication if it was the right move for the patient. With that said, I would tend to avoid intervention on the difficult to compress areas (supra/infra)

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Anything that makes life easier for the malpractice lawyers and harder for me to practice my specialty is putting the screws to me. The ASRA recommendation has done just that. With malpractice lawyers at every corner I won't usually go against any REASONABLE published recommendation by a well recognized society of experts in the field.

Sorry, but I can assure you the vast majority of Anesthesiologists in my State won't be doing any nerve blocks on these types of patients.

ASRA should have used restraint and gone the Austrian route.

Look at this example:


49 year old male with strong family history of CAD. He has one Drug eluting stent placed 12 months ago by his Cardiologist. His only medications are Plavix, ASA and Liptior. 6'1" 183 pounds. He runs 20 miles a week.
He presents for Rotator cuff repair via scope. Ortho Surgeon is aware patient is still taking Plavix and ASA per Cardiologist recommendation.

Patient requests Interscalene block for post op pain relief. Will you do it? Is it even an option considering ASRA's recommendations?

If this same patients presents for a Total Knee and requests a continuous Femoral nerve catheter will you do it? How about a single shot Femoral block with Bupivacaine and 8 mg of Decadron?

ASRA is supposed to be helping us and the patient. They are doing neither with these "recommendations" by lumping nerve blocks in with Neuraxial blocks. The only nerve block which belongs with Spinals/Epidurals is the Lumbar plexus block (IMHO).

nitroglycerine said:

Do the guidelines say anything about why there has been the change? And according to another guidelines this surgery should be postponed till after 12 months post DES implantation.

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You are correct. I apologize for posting a poor, hypothetical example (I changed time to 12 months)
Our 2009 Guidelines from Anesthesiology recommend the following:






Anesthesiology:
January 2009 - Volume 110 - Issue 1 - pp 22-23
doi: 10.1097/ALN.0b013e3181928913
Special Articles

Practice Alert for the Perioperative Management of Patients with Coronary Artery Stents: A Report by the American Society of Anesthesiologists Committee on Standards and Practice Parameters


This Practice Alert reviews published recommendations that address the perioperative management of surgical patients with recently implanted coronary artery stents. The intent of the Alert is to provide the anesthesiologist with information about (1) the increased risk of perioperative myocardial infarction and death in these patients and (2) the relation between antiplatelet therapy and acute perioperative stent thrombosis.
A major concern after successful coronary artery stent placement is the potential for acute stent thrombosis, with subsequent myocardial infarction and death.1 To prevent stent thrombosis in the nonsurgical setting, cardiologists typically recommend dual antiplatelet therapy after coronary stent placement. Dual therapy typically consists of a combination of aspirin and thienopyridine.
Premature discontinuation of dual antiplatelet therapy in patients with coronary artery stents who are scheduled to undergo surgery increases the risk of stent thrombosis, myocardial infarction, and death. This opinion was issued as a 2007 Science Advisory by the American Heart Association (AHA), American College of Cardiology (ACC), Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association.2 This opinion is also supported by the ACC/AHA Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery.3

Back to Top | Article Outline
When Surgery Can Be Postponed

The 2007 Science Advisory and the 2007 ACC/AHA Guidelines make similar recommendations about postponing elective surgery in patients with new coronary stents.
A. The 2007 Science Advisory recommends that elective procedures for which there is significant risk of perioperative or postoperative bleeding should be deferred until an appropriate course of thienopyridine therapy has been completed. The course of thienopyridine therapy associated with this recommendation is as follows:
Bare-metal stents: minimum of 1 month
Drug-eluting stents: 12 months after implantation if the patient is not at high risk of bleeding
B. The 2007 ACC/AHA Guidelines do not recommend elective noncardiac surgery within the following time periods after stent implantation when thienopyridine therapy or aspirin and thienopyridine therapy need to be discontinued perioperatively:
Bare-metal stents: 4–6 weeks
Drug-eluting stents: 12 months

nitroglycerine said:

Do the guidelines say anything about why there has been the change? And according to another guidelines this surgery should be postponed till after 12 months post DES implantation.

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The BMJ has several case rsports of how to handle elective surgery for patients on Plavix and ASA. If Plavix can't be discontinued for 7 days (maintain patient on aspirin if possible) then a bridge therapy should be discussed with Cardiology.

The bottom line is elective surgery and Plavix only go together for "superficial" procedures where bleeding is unexpected or minimal.


FYI, more and more patients are staying on their Plavix for greater than 12 months. If the surgeon thinks he/she can do the procedure on Plavix then elective surgery is permitted provided the waiting period for stents is followed.

the 2007 ACC/AHA Guidelines recommend that consideration should be given to continuing dual antiplatelet therapy perioperatively beyond the recommended time frame in any patient at high risk for stent thrombosis.

nitroglycerine said:

Do the guidelines say anything about why there has been the change? And according to another guidelines this surgery should be postponed till after 12 months post DES implantation.

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In addition my examples are not realistic ones. 99% plus of Ortho surgeons wouldn't do elective surgery on a patient using plavix. The ortho surgeon would want a "bridge therapy" if needed by Cardiology. A more probable scenario is the use of Lovenox the night before the case.

Vascular and Cardiac surgeons seem much more aggressive in doing "elective" surgery on patients still taking Plavix the morning of surgery.