Anti-Coagulants and peripheral injections

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PinchandBurn

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So I know neuraxial anesthesia and anti-coagulation has stirred some controversary on here in the last year or so. Of course the ASRA guidelines are mainly for neuraxial injections.

What about for things like TPIs, Greater Troch Bursa injections? I hold anti-coag for them now, I'm thinking of converting to doing these injections while on coagulation. I use a 27G needle for TPIs and use a 25G for Bursa. I suppose I could tell them about the potential for a hematoma. THe issues is, can't hematomas themselves hurt really bad?


Wht about for intra-articular injections--hips, knees, shoulders I figured I would still hold anti-coagulation for them since hemarthrosis is a concern.

What do you guys think?
 
So I know neuraxial anesthesia and anti-coagulation has stirred some controversary on here in the last year or so. Of course the ASRA guidelines are mainly for neuraxial injections.

What about for things like TPIs, Greater Troch Bursa injections? I hold anti-coag for them now, I'm thinking of converting to doing these injections while on coagulation. I use a 27G needle for TPIs and use a 25G for Bursa. I suppose I could tell them about the potential for a hematoma. THe issues is, can't hematomas themselves hurt really bad?


Wht about for intra-articular injections--hips, knees, shoulders I figured I would still hold anti-coagulation for them since hemarthrosis is a concern.

What do you guys think?

Never heard of any PMR or Ortho that holds for peripheral joints or TPI's. I have been consulted by black hats to review case where guy had MI and dies while holding anticoags for a hip injection. We have another long thread on this with a lot of good back and forth arguments. I believe the risk of MI/CVA is greater than and with much worse consequences than the risk/consequences of a hemarthrosis or hematoma. The spinal canal is a different beast.
 
Walgreens doesn't hold anticoagulants for flu shots do they? Then why hold for a tpi?
 
Walgreens doesn't hold anticoagulants for flu shots do they? Then why hold for a tpi?


Walgreens also doesnt ask what a person is doing with 3-6 Vicodin scripts a month.

that being said, your example is correct. no reason to hold anticoagulation, especially since the proceduralist can just hold pressure for 5 min-23 hours to make it stop.
 
I don't have them stop anticoagulants for peripheral injections. I have had 4 patients over the years who have had MI/stroke while coming off anticoagulants and waiting for a procedure. And Walgreens probably doesn't ask any questions except, "how would you like to pay for that"?
 
Okay, okay shouldn't have brought up Walgreens. Substitute the PCPs office if you prefer.

Point is if it is non spine and can hold pressure I do not hold ac. It becomes risk versus benefit like anything else.
 
+1, the risks are too great to come off the meds.
 
Okay, okay shouldn't have brought up Walgreens. Substitute the PCPs office if you prefer.

Point is if it is non spine and can hold pressure I do not hold ac. It becomes risk versus benefit like anything else.


its not that im hating on Walgreens or any of these pharmacies that are going to start with an inhouse provider...

wait a min, it is that im hating on them 🙂
 
So I know neuraxial anesthesia and anti-coagulation has stirred some controversary on here in the last year or so. Of course the ASRA guidelines are mainly for neuraxial injections.

What about for things like TPIs, Greater Troch Bursa injections? I hold anti-coag for them now, I'm thinking of converting to doing these injections while on coagulation. I use a 27G needle for TPIs and use a 25G for Bursa. I suppose I could tell them about the potential for a hematoma. THe issues is, can't hematomas themselves hurt really bad?


Wht about for intra-articular injections--hips, knees, shoulders I figured I would still hold anti-coagulation for them since hemarthrosis is a concern.

What do you guys think?

TPI's & soft-tissue injections are analogous to EMGs. Here is what the AANEM says:

What are the risks associated with performing an EMG on a patient taking Coumadin?
Bleeding and hematoma are potential risks of needle EMG in patients with or without disorders of hemostasis. There is limited data regarding the incidence of clinically significant bleeding complications from needle EMG and additional risks in patients who are receiving antiplatelet or anticoagulant therapy or who suffer from thrombocytopenia or clotting factor deficiencies. Additionally, the use of subcutaneous partially fractionated heparin (e.g. Lovenox®) is becoming more commonplace. The degree of anticoagulation is not readily measurable, which may also result in increased risk of hemorrhagic complications. Some practitioners utilize vapocoolant spray to improve hemostasis, although there are no studies assessing the utility of this technique. Likewise, no data indicates that various needle parameters (e.g. gauge, monopolar vs. concentric, etc.) present different risks for bleeding complications. In a retrospective, uncontrolled study of patients who were not receiving anticoagulants, 14 asymptomatic paraspinal muscle hematomas were identified by MRI in 5 of 45 muscles. In a survey of 47 electrodiagnostic laboratories with ACGME-approved fellowships, 3 laboratories reported a single instance of serious bleeding complications (requiring intervention) occurring in anticoagulated patients.31 One laboratory reported two instances of serious bleeding complications. In the only prospective study, subclinical hematomas were visualized by ultrasonography in 3 of 209 muscles. There was no statistical difference in hematoma rates in subjects taking anti-platelet or anticoagulant therapy compared to control subjects. 40 There are few published case reports of bleeding complications following needle EMG. These include a 64-year-old man anticoagulated with coumadin (prothrombin time = 28s [control = 12.4s], partial thromboplastin time = 68 [26]). He developed subcutaneous bleeding following needle EMG examination with a drop in hematocrit from 43 to 29%, resulting in angina and requiring blood transfusion.13 There are two cases of hematoma and compartment syndrome affecting the calf27 (73-year-old man with recent aspirin usage) and forearm60 (34-year-old woman with no bleeding risks). There is an additional report of calf hematoma and pseudoaneurysm in an 81-year-old woman with an INR = 2.5. 53 The risks and benefits of needle EMG examination should be considered in patients with known disorders of hemostasis, and needle EMG should be performed with added caution. Each case should be considered individually with regard to the potential benefits of the study relative to the risks of intramuscular hemorrhage or other bleeding. If the decision is made to perform needle EMG in such a patient, it is advisable to first examine small, superficial muscles to watch for bleeding problems. Prolonged pressure over the needle site will usually produce hemostasis.
Excerpt from the AANEM position statement


Intra-articular joint injections - shoulder, hip, and knee - are different. The risk of a hemarthrosis, while small, is nevertheless real. Because the evidence on what to do doesn't exist we should probably use 'shared decision making' and leave the choice to the patient/family about whether or not to bridge them prior to the injection. Not documenting the offer to bridge in your consent, IMO, a sin of omission in the event of a hemarthrosis.

I've had both a knee hemarthrosis and significant hematoma formation with an EMG.
 
TPI's & soft-tissue injections are analogous to EMGs. Here is what the AANEM says:

What are the risks associated with performing an EMG on a patient taking Coumadin?
Bleeding and hematoma are potential risks of needle EMG in patients with or without disorders of hemostasis. There is limited data regarding the incidence of clinically significant bleeding complications from needle EMG and additional risks in patients who are receiving antiplatelet or anticoagulant therapy or who suffer from thrombocytopenia or clotting factor deficiencies. Additionally, the use of subcutaneous partially fractionated heparin (e.g. Lovenox®) is becoming more commonplace. The degree of anticoagulation is not readily measurable, which may also result in increased risk of hemorrhagic complications. Some practitioners utilize vapocoolant spray to improve hemostasis, although there are no studies assessing the utility of this technique. Likewise, no data indicates that various needle parameters (e.g. gauge, monopolar vs. concentric, etc.) present different risks for bleeding complications. In a retrospective, uncontrolled study of patients who were not receiving anticoagulants, 14 asymptomatic paraspinal muscle hematomas were identified by MRI in 5 of 45 muscles. In a survey of 47 electrodiagnostic laboratories with ACGME-approved fellowships, 3 laboratories reported a single instance of serious bleeding complications (requiring intervention) occurring in anticoagulated patients.31 One laboratory reported two instances of serious bleeding complications. In the only prospective study, subclinical hematomas were visualized by ultrasonography in 3 of 209 muscles. There was no statistical difference in hematoma rates in subjects taking anti-platelet or anticoagulant therapy compared to control subjects. 40 There are few published case reports of bleeding complications following needle EMG. These include a 64-year-old man anticoagulated with coumadin (prothrombin time = 28s [control = 12.4s], partial thromboplastin time = 68 [26]). He developed subcutaneous bleeding following needle EMG examination with a drop in hematocrit from 43 to 29%, resulting in angina and requiring blood transfusion.13 There are two cases of hematoma and compartment syndrome affecting the calf27 (73-year-old man with recent aspirin usage) and forearm60 (34-year-old woman with no bleeding risks). There is an additional report of calf hematoma and pseudoaneurysm in an 81-year-old woman with an INR = 2.5. 53 The risks and benefits of needle EMG examination should be considered in patients with known disorders of hemostasis, and needle EMG should be performed with added caution. Each case should be considered individually with regard to the potential benefits of the study relative to the risks of intramuscular hemorrhage or other bleeding. If the decision is made to perform needle EMG in such a patient, it is advisable to first examine small, superficial muscles to watch for bleeding problems. Prolonged pressure over the needle site will usually produce hemostasis.
Excerpt from the AANEM position statement


Intra-articular joint injections - shoulder, hip, and knee - are different. The risk of a hemarthrosis, while small, is nevertheless real. Because the evidence on what to do doesn't exist we should probably use 'shared decision making' and leave the choice to the patient/family about whether or not to bridge them prior to the injection. Not documenting the offer to bridge in your consent, IMO, a sin of omission in the event of a hemarthrosis.

I've had both a knee hemarthrosis and significant hematoma formation with an EMG.

Thanks 101

That was a helpful article. I didnt know you PMR folks did EMGs on anti-coag pt. That is reassuring!

I agree with you I think I'm now comfortable with using a small gauage needle and doing a TPI/bursa injection. I probably wouldnt do a knee/hip because of the hemarthrosis issue....

question, when they say "vapocoolant' sprays, they are referring to Ethyl Chloride probably right?
 
TPI's & soft-tissue injections are analogous to EMGs. Here is what the AANEM says:



Intra-articular joint injections - shoulder, hip, and knee - are different. The risk of a hemarthrosis, while small, is nevertheless real. Because the evidence on what to do doesn't exist we should probably use 'shared decision making' and leave the choice to the patient/family about whether or not to bridge them prior to the injection. Not documenting the offer to bridge in your consent, IMO, a sin of omission in the event of a hemarthrosis.

I've had both a knee hemarthrosis and significant hematoma formation with an EMG.


A follow up. What are you doing for a patient for Intra-Articular SI joint injections and lateral sacral nerve injections? Technically these are neuraxial.

My concern I suppose for the Lateral Sacral Nerve Injections is probably just not warranted as you could likely compress that area.

However, for intra-articular SI joint injctions, isnt there a r/o of a hemoarthrosis (just like the one you mentioned for a hip or knee joint)?
 
A follow up. What are you doing for a patient for Intra-Articular SI joint injections and lateral sacral nerve injections? Technically these are neuraxial.

My concern I suppose for the Lateral Sacral Nerve Injections is probably just not warranted as you could likely compress that area.

However, for intra-articular SI joint injctions, isnt there a r/o of a hemoarthrosis (just like the one you mentioned for a hip or knee joint)?

I don't worry about SIJA.
 
Heres a recent article in the American journal of medicine.

I choose not to stop anticoagulants for knees and shoulder, especially since ive been doing them under ultrasound . Still on the fence for hips...

Hope this helps.

Safety of Arthrocentesis and Joint Injection in Patients Receiving Anticoagulation at Therapeutic Levelshttp://www.amjmed.com/article/S0002-9343(11)00785-6/abstract#article-footnote-1http://www.amjmed.com/article/S0002-9343(11)00785-6/abstract#article-footnote-2http://www.amjmed.com/article/S0002-9343(11)00785-6/abstract#article-footnote-3

Department of Internal Medicine, Regions Hospital, St Paul, Minn; and bUniversity of Minnesota Medical School, Minneapolis.

ABSTRACT

BACKGROUND:


Arthrocentesis and joint injections are commonly performed for both diagnostic and

therapeutic indications. Because of safety concerns, there is often reluctance to perform these procedures

in patients who are receiving anticoagulation at therapeutic levels. This study was undertaken to determine

the safety of arthrocentesis and joint injection performed by physicians from different disciplines in

patients who are anticoagulated.

METHODS:


We conducted a retrospective review of 640 arthrocentesis and joint injection procedures

performed in 514 anticoagulated patients between 2001 and 2009. We assessed the incidence of early and

late clinically significant bleeding in or around a joint, infection, and procedure-related pain. We further

compared the incidence of these complications in 456 procedures performed in patients with an international

normalized ratio 2.0 or greater and 184 procedures performed in patients with an international

normalized ratio less than 2.0.

RESULTS:


Only 1 procedure (0.2%) resulted in early, significant, clinical bleeding in the fully anticoagulated

group. There was no statistically significant difference in early and late complications between

patients who had procedures performed with an international normalized ratio 2.0 or greater and those

whose anticoagulation was adjusted to an international normalized ratio less than 2.0.

CONCLUSION:


Arthrocentesis and joint injections in patients receiving chronic warfarin therapy with

therapeutic international normalized ratio are safe procedures. There does not seem to be a need for

reducing the level of anticoagulation before procedures in these patients.

© 2012 Elsevier Inc. All rights reserved.


• The American Journal of Medicine (2012) 125, 265-269

http://www.amjmed.com/article/S0002-9343(11)00785-6/abstract
 
I don't have them stop anticoagulants for peripheral injections. I have had 4 patients over the years who have had MI/stroke while coming off anticoagulants and waiting for a procedure.

Need to consider the relative risks. If the risk of major hemarthrosis or CVA are equal, then u don't hold anticoagulants for a peripheral joint injection. If per that article, the risk of hemarthrosis is really small, then u really don't want to risk a stroke.

As a physiatrist, I'm seen too many patients devastated by strokes to expose them to that risk for anything but a neuroaxial procedure, where u face the risk of spinal cord\nerve damage if they bleed.
(I don't stop anything for SIJ injections/blocks)
 
I can't stand the checkout line at walgreens
 
Last time I went to Walgreens I was buying Augmentin for daughter's teenaged gf who developed strep while vacationing with us. I wrote the script and took it in. The Walgreens
pharmacist - young guy - asked me what my specialty was and when I said PM&R he
told me I shouldn't be writing scripts for ABX. I have a short fuse so what happened next wasn't pretty.

F Walgreens.
 
At ISIS conference just went to lecture by Dr. Endres who suggest not stopping any form of anticoagulation for ANY injections with the exception of Interlaminar ESI, as risk of MI,PE, or CVA much greater than chance of epidural hematoma.

His caveat with transforaminals was physician should use smaller gauge needle and obviously be well-trained in interventional procedures
 
At ISIS conference just went to lecture by Dr. Endres who suggest not stopping any form of anticoagulation for ANY injections with the exception of Interlaminar ESI, as risk of MI,PE, or CVA much greater than chance of epidural hematoma.

His caveat with transforaminals was physician should use smaller gauge needle and obviously be well-trained in interventional procedures


It would be nice if instead of anecdoates like this, someone would mk guidlines. Otherwise, all we have our the ASRA guidelines, which attorneys will use and say that we 'didnt follow the standard of care'.
 
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