alcoholic for CESI

[PinchandBurn]

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A female in her late 50s. Being referred for CESI. She has h/o of drug abuse and Alcohol Abuse. She states she's been 'clean for 4 mo". However, her LFTs are still elevated (in the 200s), three months ago.

She's tried all the conservative stuff already: PT (improved), TCAs, anti-convulsants, etc. None has really helped. Neuro did an EMG apparently which does show a C7radic. Neurosurg requesting CESI to 'maximize' conservative tx options before surgery.

Denies any easy bruising, spont bleeding.

How many of you would get a PT/PTT/INR, plt count, and repeat LFTs before proceeding with a cESI. Would you get them if she did have easy bruising?


oh by the way she's requesting 'sedation' for a CESI....I almost never do sedation for cervical procedures. But she's quite nervous and I'm concerned she will move, therefore, considering 5mg po valium (but concerned of prolonged effect d/t likely liver dysfunction). If she requires too much, may just say Risks vs Benefits, patient not a candidate for awake CESI and refer to someone that does 'heavy sedation' for CESI.

 

[lobelsteve]

A female in her late 50s. Being referred for CESI. She has h/o of drug abuse and Alcohol Abuse. She states she's been 'clean for 4 mo". However, her LFTs are still elevated (in the 200s), three months ago.

She's tried all the conservative stuff already: PT (improved), TCAs, anti-convulsants, etc. None has really helped. Neuro did an EMG apparently which does show a C7radic. Neurosurg requesting CESI to 'maximize' conservative tx options before surgery.

Denies any easy bruising, spont bleeding.

How many of you would get a PT/PTT/INR, plt count, and repeat LFTs before proceeding with a cESI. Would you get them if she did have easy bruising?


oh by the way she's requesting 'sedation' for a CESI....I almost never do sedation for cervical procedures. But she's quite nervous and I'm concerned she will move, therefore, considering 5mg po valium (but concerned of prolonged effect d/t likely liver dysfunction). If she requires too much, may just say Risks vs Benefits, patient not a candidate for awake CESI and refer to someone that does 'heavy sedation' for CESI.

Option 1: punt to guy down the street who doesn't give a crap.
Option 2: Get PT/PTT as these are effected in hepatic disease. No problems with steroids and contrast in this case. Use your usual sedation protocol. IV is better than PO and is controllable and readily reversible. If she isn't going to hold still give her 2/2 ahead of the prep.

Only you can decide as you have met her and evaluated her.

 

[drf]

No reason to not check labs if the surgeon hasn't already. I spend extra time thinking about ordering a new MRI or a CT myelo. I dont scratch my ead too much when ordering Some basic labs with liver disease before a neuraxial procedure.

 

[Gauss]

I would get labs, PT/PTT/INR, cbc and chem, lfts. if anything happens down the road you have pre CESI labs to look at
Is she in AA, counseling, rehab? What does "clean" mean to her? Completely dry or only a few shots a day instead of a bottle? did she fall off the wagon or has she been sober for long periods of time?

 

[PinchandBurn]

I would get labs, PT/PTT/INR, cbc and chem, lfts. if anything happens down the road you have pre CESI labs to look at
Is she in AA, counseling, rehab? What does "clean" mean to her? Completely dry or only a few shots a day instead of a bottle? did she fall off the wagon or has she been sober for long periods of time?

yes she's been in AA. did counseling,etc...

but claims she had 'one slip' the other day.

Exactly.....given questionable history, thats why I want labs......

Despite her recreational history, it does look like she may have a legit issue.

 

[PMR 4 MSK]

Valium is rather long-acting, consider Xanax or other short-acting benzo. However, I would warn her that benzos have an effect on the brain almost identical to alcohol, and this can trigger a relapse.

Given her liver dysfunction, I agree with getting PT/INR and PTT, as well as platelet count.

What is the Dx for the CESI? What, where and how are your injecting? E.g. don't even think of doing a TFESI.

Realize this is just a "known" alcoholic. Statistically 10-20% of your patients are alcoholics and/or addicts, and that's without even counting the smokers.

 

[epidural man]

A female in her late 50s. Being referred for CESI. She has h/o of drug abuse and Alcohol Abuse. She states she's been 'clean for 4 mo". However, her LFTs are still elevated (in the 200s), three months ago.

She's tried all the conservative stuff already: PT (improved), TCAs, anti-convulsants, etc. None has really helped. Neuro did an EMG apparently which does show a C7radic. Neurosurg requesting CESI to 'maximize' conservative tx options before surgery.

Denies any easy bruising, spont bleeding.

How many of you would get a PT/PTT/INR, plt count, and repeat LFTs before proceeding with a cESI. Would you get them if she did have easy bruising?


oh by the way she's requesting 'sedation' for a CESI....I almost never do sedation for cervical procedures. But she's quite nervous and I'm concerned she will move, therefore, considering 5mg po valium (but concerned of prolonged effect d/t likely liver dysfunction). If she requires too much, may just say Risks vs Benefits, patient not a candidate for awake CESI and refer to someone that does 'heavy sedation' for CESI.

+/- on labs

Stick with IV sedation - as steve says - more titratable - easily reversed.

 

[Jcm800]

+/- on labs

Stick with IV sedation - as steve says - more titratable - easily reversed.

1) get labs, no harm

2) IV sed AT THE FACILITY not your office. dont surprised when the 4 of valium and the 200 fentanyl later, she is asking for the sedation...
i just put stuff in the IV and do the procedure.
"doc are you going to sedate me?"
"Yes, i am giving more as we speak" as the additional saline flush goes through...

3) and i like steves option, punt... but in all reality, she will likely do fine, if she jumps up, just make sure your hands are OFF the needle haha...

 

[lobelsteve]

1) get labs, no harm

2) IV sed AT THE FACILITY not your office. dont surprised when the 4 of valium and the 200 fentanyl later, she is asking for the sedation...
i just put stuff in the IV and do the procedure.
"doc are you going to sedate me?"
"Yes, i am giving more as we speak" as the additional saline flush goes through...

3) and i like steves option, punt... but in all reality, she will likely do fine, if she jumps up, just make sure your hands are OFF the needle haha...

In training we had a few "jumpers"

Rule 1: do not let the patient pith themselves with a Tuohy needle and an image intensifier.

I have put a good amount of pressure on the back of someone's head to keep this from happening. Left arm to occiput, right hand to pull out needle. Alternatively, with steady pressure using your forearm on their skull, advance with the right hand slowly. Or go lateral as soon as you get off lamina and walk in with nothing overhead. We never got enough laterals in fellowship.

 

[Jcm800]

In training we had a few "jumpers"

Rule 1: do not let the patient pith themselves with a Tuohy needle and an image intensifier.

I have put a good amount of pressure on the back of someone's head to keep this from happening. Left arm to occiput, right hand to pull out needle. Alternatively, with steady pressure using your forearm on their skull, advance with the right hand slowly. Or go lateral as soon as you get off lamina and walk in with nothing overhead. We never got enough laterals in fellowship.

before the oblique thing, i did the vast majority of the procedure under lateral, crazy not to... thanks to this board, no more lateral. all contra-lateral oblique.

 

[PinchandBurn]

before the oblique thing, i did the vast majority of the procedure under lateral, crazy not to... thanks to this board, no more lateral. all contra-lateral oblique.

recent convert to the contralateral view as well. I think it's starting to be a good thing....

 

[epidural man]

before the oblique thing, i did the vast majority of the procedure under lateral, crazy not to... thanks to this board, no more lateral. all contra-lateral oblique.

👍

It takes some getting used too. I think an early mistake is not going lateral enough to resolve the lamina (looking at a "dot shot" of the contralateral lamina) - or perhaps going to far.

I'm certainly getting better at getting that nice stair step pattern to look good. I'm using this view frequently now for my lumber SCS trials as well.

I used it at the epiducer course recently and people looked at me like I was nuts. (Also, I did my LOR with the blunt, not with saline or air in a syringe - and again people looked at me like i was from another planet)

 

[bedrock]

👍

(Also, I did my LOR with the blunt, not with saline or air in a syringe - and again people looked at me like i was from another planet)

Some people would say that Idaho is another planet.....😀