Anticoagulation for RFA

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buddababa

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Need to implement a policy for my clinic.

ASRA earlier this year posted no need to hold anticoagulation for RFA (lumbar, thoracic) due to low risk. Cervical RFA (intermediate-risk).
My partner pulled up the ASRA app and it says, everything is intermediate risk and blood thinners need to be held.

How can I verify what is correct?

What are you guys doing?

Thanks.
 
Lobel will personally come to your practice and kick your partner’s a** for holding blood thinners for a lumbar RFA.

The ASRA guidelines are still too liberal with holding thinners. If you select “high risk patient” on the app, it will say to hold for everything, which is kinda dumb. What about their high thrombosis risk that also needs to be considered? Haven’t held BTs for any facet procedures in years. I discuss risks with patients, tell them the procedure is on the outside of the spine so damage to the spinal cord from bleeding is extremely unlikely, vs the risk of heart attack or stroke from stopping them.
I have my own spreadsheet that I wrote and I think my partner adopted too, that dictates in general when to hold. But there are a lot of things where the schedulers are instructed to message me for direction if I don’t specify, for example 81 mg ASA for a cervical ESI. If the patient is just taking it because they thought it was good for them, I’ll have them hold it. If they’re taking it because of the 5 stents they had over the past 3 years, definitely continue.
 
callmeanesthesia said:
Lobel will personally come to your practice and kick your partner’s a** for holding blood thinners for a lumbar RFA.

The ASRA guidelines are still too liberal with holding thinners. If you select “high risk patient” on the app, it will say to hold for everything, which is kinda dumb. What about their high thrombosis risk that also needs to be considered? Haven’t held BTs for any facet procedures in years. I discuss risks with patients, tell them the procedure is on the outside of the spine so damage to the spinal cord from bleeding is extremely unlikely, vs the risk of heart attack or stroke from stopping them.
I have my own spreadsheet that I wrote and I think my partner adopted too, that dictates in general when to hold. But there are a lot of things where the schedulers are instructed to message me for direction if I don’t specify, for example 81 mg ASA for a cervical ESI. If the patient is just taking it because they thought it was good for them, I’ll have them hold it. If they’re taking it because of the 5 stents they had over the past 3 years, definitely continue.
Click to expand...
True dat. 2x called to testify against unnecessary withholding of anticoag/antiplatelet. One resulted in patient death. But his hip felt great when he had his MI and died.
 
lobelsteve said:
True dat. 2x called to testify against unnecessary withholding of anticoag/antiplatelet. One resulted in patient death. But his hip felt great when he had his MI and died.
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Held for actual hip inj?
 
What about blood thinners for facet joint cyst rupture? Not sure there is real data out for it…?
 
I withhold for Cervical RFA only. Besides that, Epidurals, SCS, Kypho, Vertiflex. I'm thinking of stopping for CMBB/RFA if everyone here says no reason to withhold.
 
DrSpine said:
I withhold for Cervical RFA only. Besides that, Epidurals, SCS, Kypho, Vertiflex. I'm thinking of stopping for CMBB/RFA if everyone here says no reason to withhold.
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Definitely don’t stop for cervical MBB. RFA I never do but I think it would be reasonable to do it in patients at very low risk of thrombotic complications.
 
PinchandBurn said:
How would you define low risk? Defer to cards?
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AF but younger without multiple risk factors. Plavix beyond one year for TAVR. Anticoagulation for a DVT that was provoked but they just kept the patient on it … etc. generally you can tell if there is a strong indication for anticoagulation, but when in doubt I defer to cards.
 
lobelsteve said:
Never hold for RFA of anything except gasserian. I send my Celiacs to IR for CT guided.
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agree with you, my fear is lawyers - they will start talking about guidelines/standard of care/bring up these organizations with conservative anticoagulation standards - how does one defend against that god forbid a complication were to occur?
 
buddababa said:
agree with you, my fear is lawyers - they will start talking about guidelines/standard of care/bring up these organizations with conservative anticoagulation standards - how does one defend against that god forbid a complication were to occur?
Click to expand...
Complication more likely occur from holding
 
buddababa said:
agree with you, my fear is lawyers - they will start talking about guidelines/standard of care/bring up these organizations with conservative anticoagulation standards - how does one defend against that god forbid a complication were to occur?
Click to expand...
I document my reasoning in the chart, state I beleive the risk of withholding anticoagulation is higher, state that I informed the patient of the relatively smaller risk of bleeding. There’s no way to completely avoid risk. If I truely think someone is high risk I simply don’t offer the injection.
 
MitchLevi said:
You want to kill your pt or deal with a hematoma?
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I agree with you, im just trying to convince my partner to start doing the same, so that we can have a unified clinic policy, its gets too confusing for my staff
 
buddababa said:
agree with you, my fear is lawyers - they will start talking about guidelines/standard of care/bring up these organizations with conservative anticoagulation standards - how does one defend against that god forbid a complication were to occur?
Click to expand...
by being upfront with the patient beforehand - establish good rapport, do a risk/benefit analysis with the patient, communicate well, come to mutually agreeable treatment with reasonable expectations. same thing you do with all your patients.

patients dont generally sue doctors who they really like. and if they dont want to sue, lawyers cant get involved.
 
buddababa said:
I agree with you, im just trying to convince my partner to start doing the same, so that we can have a unified clinic policy, its gets too confusing for my staff
Click to expand...
Or you can be the guy in the group who does all the MBB/RFA for anticoagulated patients. I am sure there are many who can’t hold their plavix due to recent stent. Could be a windfall for you. I am sure after a month or two of not seeing ill effects your partner(s) will change to be like you.
 
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