Anticoag status and single shot PNBs

[ethilo]

Hey all,
I stepped in to break another resident on a case recently that left me hungry for answers.

~60s year old female with CAD, just had 1 stent (unclear DES vs BMS) placed 5 months ago for NSTEMI by EKG on positive treadmill test now on apixaban / clopidogrel. Had knee pain, seen in ortho clinic, got an intra-articular injection 2 days prior (Friday) that resulted in septic arthritis brought for culture and washout urgently in the OR on Sunday. Last apixaban dose was 1 day prior (saturday). Surgery team wanted it held for surgery. Patient has continued to take plavix daily.

Patient received a single-shot sciatic and single-shot femoral due to pain being extreme and that she requested to not have GA. A senior resident did the blocks and the junior resident in the OR didn't have a good explanation for why the attending OK'd the blocks in the setting of DAPT.

Just curious, of you all out there, are single-shot sciatics and femorals ok to do with people on 2 agents? I keep getting mixed messages from people about whether it's a catheter vs a single shot, or if it's considered deep or peripheral.

If it were me, I wouldn't have performed blocks on this lady and insisted on GA. It might be a challenging post-op course in terms of pain, but maybe not too bad if they washed it out and started antibiotics.

Anyone have thoughts or opinions about balancing her DAPT with regional anesthesia?

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[AdmiralChz]

Peripheral nerve blocks are safe in just about all areas in the setting of anticoaguation and antiplatelet therapy since they are easily compressible.

In fact, last I checked ASRA had no recommendations at all about holding anticoagulants for this. You could consider avoiding peripheral nerve catheter placement, but even then probably still safe with careful ultrasound-guided technique.

Only site I can see being problematic (for standard blocks) would be infraclaviculars as it’s in a bit of an awkward spot to hold effective pressure with the subclavian artery deep to the clavicle.

This is very, very different than neuraxial recommendations (avoid on active DAPT).

 

[pgg]

Risk & benefit. Guidelines are guidelines, not standards.

From Regional Anesthesia in the Anticoagulated Patient - NYSORA The New York School of Regional Anesthesia :

The most recent ASRA guidelines recommended that the same guidelines on neuraxial injections apply to deep plexus or peripheral nerve blocks. Some clinicians may find this to be too restrictive and apply the same guidelines only to deep plexus and noncompressible blocks (e.g., lumbar plexus block, deep cervical plexus blocks) or to blocks near vascular areas, such as celiac plexus blocks or superior hypogastric plexus blocks. If peripheral nerve blocks are performed in the presence of anticoagulants, the anesthesiologist must discuss the risks and benefits of the block with the patient and the surgeon, and follow the patient very closely after the block.

A lot of us were disappointed that ASRA lumped all PNBs in with neuraxial with regard to the anticoagulation guidelines. I think most of us would be willing to do an ultrasound guided femoral and/or sciatic block on a patient on Plavix, given some reasonable motive to avoid GA.

 

[BobBarker]

Block away. ASRA guide lines are wrong on some things.

 

[nimbus]

Don't hit a vessel and you'll be fine. Even if you do hit a vessel, just get a minion to tamponade it for awhile and you'll be fine. We all poke 22g needles in these patients for other reasons without a second thought. I don't think there's anything special about a nerve block. And if they can get a trochar or an incision in the knee, a 22g needle in the groin or thigh is gonna be okay.

 

[vector2]

Hey all,
I stepped in to break another resident on a case recently that left me hungry for answers.

~60s year old female with CAD, just had 1 stent (unclear DES vs BMS) placed 5 months ago for NSTEMI by EKG on positive treadmill test now on apixaban / clopidogrel. Had knee pain, seen in ortho clinic, got an intra-articular injection 2 days prior (Friday) that resulted in septic arthritis brought for culture and washout urgently in the OR on Sunday. Last apixaban dose was 1 day prior (saturday). Surgery team wanted it held for surgery. Patient has continued to take plavix daily.

Patient received a single-shot sciatic and single-shot femoral due to pain being extreme and that she requested to not have GA. A senior resident did the blocks and the junior resident in the OR didn't have a good explanation for why the attending OK'd the blocks in the setting of DAPT.

Just curious, of you all out there, are single-shot sciatics and femorals ok to do with people on 2 agents? I keep getting mixed messages from people about whether it's a catheter vs a single shot, or if it's considered deep or peripheral.

If it were me, I wouldn't have performed blocks on this lady and insisted on GA. It might be a challenging post-op course in terms of pain, but maybe not too bad if they washed it out and started antibiotics.

Anyone have thoughts or opinions about balancing her DAPT with regional anesthesia?

Might just be me, but in a hypothetical fatty fat fat who was anticoagulated, I would hesitate for a min on a transgluteal sciatic. God forbid they end up being the 1 in 10 kazillion who gets a bad gluteal hematoma or gluteal compartment syndrome, the lawyers would have a field day quoting the ASRA guidelines.

On the other hand, infragluteal or high pop sci- no problem.

 

[ethilo]

...so would you say a "Deep peripheral block" would probably include paravertebral, lumbar plexus, transgluteal sciatic (if really heavy-set individual), and maybe infraclavicular?

My go-to reference for looking up this stuff is the ASRA Coags app and no one really has quite defined deep vs superficial for me other than "a site that's compressible."