Anticoagulation guidelines for pain procedures?

[Ligament]

Hi All,

I've been revising my guidelines. I've taken the most conservative guidelines I can find from various regional anesthesia societies.


I used the following AWESOME document which compares the recommendations of all the major anesthesiology societies for the data:

http://forums.studentdoctor.net/attachment.php?attachmentid=10098&d=1207112173

I'd appreciate your thoughts on the below document. If you like it, feel free to use it:

PAIN MANAGEMENT PROCEDURE INSTRUCTIONS FOR PATIENTS USING “BLOOD THINNERS”

Certain drugs MUST be discontinued prior to pain management procedures, as they cause abnormal bleeding and clotting. It is your responsibility to check with the prescribing physician of the below medications whether it is OK for you to stop these medications temporarily. DO NOT STOP THESE MEDICATIONS WITHOUT CONSULTING THE PRESCRIBING DOCTOR FIRST!

• Coumadin/warfarin MUST be discontinued 5 days prior1 to the procedure after obtaining approval from the physician that prescribes this medication to you. In addition, you MUST obtain a PT/INR level the day before your pain injection procedure and provide the numbers to us before the procedure so we can verify it is safe to proceed. In general, your INR needs to be 1.2 or lower. It is your responsibility to coordinate this with the physician that prescribes this medicine to you as well as the coumadin clinic if you are involved with one. Please hand-carry or fax your PT/INR level to this office before your procedure!

• Aspirin or aspirin containing products MUST be discontinued 3 days prior2 to the procedure after obtaining approval from the physician that prescribes this medication to you. Aspirin-containing products include but are not limited to: “Baby” aspirin, Bufferin, Excedrin, Anacin, Asciptin, Ecotrin, Empirin, Midol, Pepto-Bismol, Sine-Off, Sine-Aid IB, Nuprin, Dristan Sinus.

• Aggrenox (aspirin/dipyridamole) and Persantine (dipyridamole) MUST be discontinued 7 days prior to the procedure after obtaining approval from the physician that prescribes this medication to you.

• Plavix (clopidogrel), and Pletal (cilostazol) MUST be discontinued 7 days prior1 to the procedure after obtaining approval from the physician that prescribes this medication to you. These medications may be restarted 3 hours after the procedure is completed.

• Ticlid (ticlopidine) MUST be discontinued 14 days prior1 to a procedure after obtaining approval from the physician that prescribes this medication to you.

• Aggrastat (tirofiban) and Integrilin (eptifibatide) MUST be discontinued 8 hours prior1 to a procedure after obtaining approval from the physician that prescribes this medication to you.

• ReoPro (abciximab) MUST be discontinued 48 hours prior1 to a procedure after obtaining approval from the physician that prescribes this medication to you.

• Unfractionated Heparin MUST be discontinued 24 hours prior to a procedure after obtaining approval from the physician that prescribes this medication to you. Heparin may be restarted 3 hours after the procedure is completed.

• Low molecular weight heparin, such as Lovenox (enoxaparin), Fragmin (Dalteparin), and Normiflo (Ardeparin) MUST be stopped 24 hours prior1 to the procedure after obtaining approval from the physician that prescribes this medication to you. Lovenox may be restarted 24 hours after the procedure is completed.

• Arixtra (fondaparinux) and Orgaran (danaparoid) MUST be stopped 7 days prior to the procedure after obtaining approval from the physician that prescribes this medication to you. These medications can be restarted 24 hours after the procedure is completed.

• Iprivask (desirudin), Refludan (lepirudin), Angiomax (bivalirudin), Novastan (argatroban), Exanta (elagatran/ximelagatran) MUST be stopped 14 days prior to the procedure after obtaining approval from the physician that prescribes this medication to you.

Unless otherwise noted, you may resume the above medications within 3 hours after the pain procedure.

If you have any questions about any of the above information, please call the office at least 7 days in advance of your appointment. We strive to make this a safe and pleasant experience for you.

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[lobelsteve]

http://home.comcast.net/~lobelsteve/forms/pre.pdf

Just getting a website started- I'll have to transfer it over to the main office server when done.


I ditched aspirin precautions after reviewing the literature in the last few months. I made coumadin and Plavix both seven days to ease the info on staff and patients. I have a full lab so getting a stat PT/INR is easy. I have a Cardiologist down the hall who likes to chat-I can walk into his office and get the skinny on what to do (what he wants done) for valve replacement, low EF, etc patients.

 

[joshmir]

1) do you guys book procedures for mondays? if so, how do you get the coumadin checked?

2) anyone else hold aspirin for CESIs?

3) are your guidelines different for MBBs and TPIs than for other injections?

4) do you guys want your handouts to tell them to stop herbals, too?

 

[lobelsteve]

I do not stop any meds for MBB's or RF or joints.

Only epidural, discal, sympathetic blocks get the Plavix/Coumadin stoppage.

 

[Tenesma]

your dipyridamole is a bit too strong - i just tell them to hold it for 3 days...

and coumadin is 5 days with INR check for epidural,transforaminal, and cervical MBB/RF and Lumbar RF and 3 days with NO INR check for lumbar MBB, SI joint, etc...

after speaking to a bunch of orthopods i no longer hold plavix for peripheral injections - none of them hold plavix/coumadin for any of their injections and really haven't had any problems (plus they use 22 gauge needles and I use 25g or 27g needles)...

 

[Ligament]

your dipyridamole is a bit too strong - i just tell them to hold it for 3 days...

and coumadin is 5 days with INR check for epidural,transforaminal, and cervical MBB/RF and Lumbar RF and 3 days with NO INR check for lumbar MBB, SI joint, etc...

after speaking to a bunch of orthopods i no longer hold plavix for peripheral injections - none of them hold plavix/coumadin for any of their injections and really haven't had any problems (plus they use 22 gauge needles and I use 25g or 27g needles)...

Thanks tenesma. I don't remember locating any good published guidelines on dipyridamole. Do you recall where you picked up this recommendation?

 

[PMR 4 MSK]

I ditched aspirin precautions after reviewing the literature in the last few months. I made coumadin and Plavix both seven days to ease the info on staff and patients. I have a full lab so getting a stat PT/INR is easy. I have a Cardiologist down the hall who likes to chat-I can walk into his office and get the skinny on what to do (what he wants done) for valve replacement, low EF, etc patients.

If you use seven days, that could place the patient who is on coumadin at risk for a clotting event. Since The standard seems to be 5 days, you seem to be stating that you give them 2 extra days of risk for "ease." Being defensive,I'd worry about legalities of that. You might cover yourself by getting the prescribing physician to agree to it in writing. If I'm seriously concerned about a clotting event, I require it in writing from the other doc.

1) do you guys book procedures for mondays? if so, how do you get the coumadin checked?

2) anyone else hold aspirin for CESIs?

3) are your guidelines different for MBBs and TPIs than for other injections?

4) do you guys want your handouts to tell them to stop herbals, too?

1) STAT coumadin level 1st thing in AM, don't do the procedure until you know.
2) no, I don't stop ASA for anything currently, nor NSAIDs
3) TPI's - I don't hold anything. MBB's I do.
4) Not until we know which ones to seriously worry about.

Also, in your original document, Ligament, some of your guidelines say when to restart, some don't. Is there any consensus on restarting? I tell mine to restart the next day. A risky coumadin I restart that day, as it's 1-2 days before it takes effect and several to full anticoag.

 

[Ligament]

Also, in your original document, Ligament, some of your guidelines say when to restart, some don't. Is there any consensus on restarting? I tell mine to restart the next day. A risky coumadin I restart that day, as it's 1-2 days before it takes effect and several to full anticoag.

Good question. I address this in one of the last lines of the document:

"Unless otherwise noted, you may resume the above medications within 3 hours after the pain procedure."

However, there are some clear guidelines on some medications and some not clear guidelines...advice appreciated...

 

[lobelsteve]

If you use seven days, that could place the patient who is on coumadin at risk for a clotting event. Since The standard seems to be 5 days, you seem to be stating that you give them 2 extra days of risk for "ease." Being defensive,I'd worry about legalities of that. You might cover yourself by getting the prescribing physician to agree to it in writing. If I'm seriously concerned about a clotting event, I require it in writing from the other doc.



1) STAT coumadin level 1st thing in AM, don't do the procedure until you know.
2) no, I don't stop ASA for anything currently, nor NSAIDs
3) TPI's - I don't hold anything. MBB's I do.
4) Not until we know which ones to seriously worry about.

Also, in your original document, Ligament, some of your guidelines say when to restart, some don't. Is there any consensus on restarting? I tell mine to restart the next day. A risky coumadin I restart that day, as it's 1-2 days before it takes effect and several to full anticoag.

Life is full of risks. Some hairs are too small to split. I work in an office with 5 IM docs, 5 FP, cardiology, interventional cardiology, pulmanology, neurology, ortho, ob/gyn, endocrinology, and soon rheumatology. I have good docs to manage every condition and share the minimal risk (if there is risk). In patients at risk for stopping Coumdain, we put them on Lovenox and stop it the night before the procedure. PT/INR is measured the AM of procedure and the Coumadin is restarted and managed by the IM folks starting the night of the procedure. The risk of a thrombotic/embolic/clotting event is documented when taking folks off of their coumadin/plavix.

 

[Tenesma]

agreed

i document in all notes that there is an increased risk of thrombotic/embolic events leading to cardiac or cerebral events...

i also tell all patients to restart their blood-thinners the evening of the procedure date...

 

[mille125]

Aspirin or aspirin containing products MUST be discontinued 3 days prior2 to the procedure after obtaining approval from the physician that prescribes this medication to you. Aspirin-containing products include but are not limited to: “Baby” aspirin, Bufferin, Excedrin, Anacin, Asciptin, Ecotrin, Empirin, Midol, Pepto-Bismol, Sine-Off, Sine-Aid IB, Nuprin, Dristan Sinus.[/LIST]





Where did you get this info and how did you come up with three days? It is not recommended in the ASRA guidelines and can lead to unnecessary thrombotic events........

 

[Ligament]

Click on the link to the article above, it is recommended by

OGARI: O¨ sterreichischen Gesellschaft fu¨ r Ana¨ sthesiologie und Intensivmedizin

It is the most conservative recommendation I could find from a regional anesthesiology society. A lot of docs still require 7 or even 10 days no ASA...

Aspirin or aspirin containing products MUST be discontinued 3 days prior2 to the procedure after obtaining approval from the physician that prescribes this medication to you. Aspirin-containing products include but are not limited to: “Baby” aspirin, Bufferin, Excedrin, Anacin, Asciptin, Ecotrin, Empirin, Midol, Pepto-Bismol, Sine-Off, Sine-Aid IB, Nuprin, Dristan Sinus.[/LIST]





Where did you get this info and how did you come up with three days? It is not recommended in the ASRA guidelines and can lead to unnecessary thrombotic events........

 

[mille125]

A lot of docs still require 7 or even 10 days no ASA



Interesting....As others have said it is all about a risk/benefit ratio and there is some risk to holding these meds. Is the risk of epidural hematoma greater (probably not but there is some risk) These docs would be very sad if their patient developed a thrombotic issue. Do these doctors also hold fish oil and vitamin E. If you are going to hold ASA and NSAIDS then you definitely need to hold these as well. Actually there are several other herbal medicines that can cause bleeding (garlic, kava kava, etc...)



In the end is about perceived risk versus perceived benefit.......

 

[lobelsteve]

The risks are fairly well documented in the Internal Medicine literature.

Atrial Fibrillation- 4% per year CVA risk without Coumadin.
MVR/AVR-
Lupus Anticoagulant-


The risks are understood and need to be weighed against the benefits.

And no, statistically speaking, the risk is not 1/52 x 4% for a CVA by stopping Coumadin for AFIB.

 

[mille125]

The risks are fairly well documented in the Internal Medicine literature.

Atrial Fibrillation- 4% per year CVA risk without Coumadin.
MVR/AVR-
Lupus Anticoagulant-


The risks are understood and need to be weighed against the benefits.

And no, statistically speaking, the risk is not 1/52 x 4% for a CVA by stopping Coumadin for AFIB.

I agree...the cardiologist would not have recommended the blood thinner in the first place if it were not indicated....I also agree that the risk of stopping coumadin for 5-7 days is much less than 4% but not 1/52 times 4%...I generally try to maximize all other possible treatments before suggesting that a patient stop their coumadin or plavix (ie I may try long acting opioid trials sooner in this population)...the patients know this and appreciate the discussion

 

[Tenesma]

no more than 325mg of aspirin per day for my patients - i don't make them hold aspirin unless they are over the quota of 325/day

 

[CPAINDOC]

I have been revising my guidelines as well. The literature does not support discontinuing aspirin. However, a lot of pain docs are nervous about this. I have been told by a colleague that baby asa is ok but regular asa is not. I always thought the antiplatelet activity was dose independent, but apparently cardiologists and neurologists feel otherwise.

I stop coumadin 5 days prior and check inr with a meter the day of procedure. If inr is less than 1.2, then proceed.

I stop plavix 7 days prior.

I am struggling with asa concept, whether to keep pts on baby asa, and stop regular asa, 7 days prior. I am leaning to continuing baby asa for all.

The procedures involve interlaminar or transforaminal esi, mbbb, intraarticular facets.

Other such as si joint, tpi, peripheral nerve block are excluded.

Does anyone have any other ideas about asa v. Baby asa?

 

[Tenesma]

my limit is 325mg of ASA per day - and they don't have to stop it for any of my procedures.

especially if they are stopping coumadin or plavix, i'd like to have some ASA on board for their heart/brain...

what i do as part of my practice is FAX out an easy to fill out form letter to the prescribing physician - indicating what i am planning on doing and why, and how often I may consider that type of procedure per year... with areas for them to check off whether we can hold anti-coagulation and whether we can hold it repeatedly and what is the max they are comfortable with it being held per year..... then all that physician's staff has to do is re-fax that form back to us, and that gets filed in their chart...

i have been burned by some patients stopping their meds after "checking" with their doctors (which means they didn't actually check w/ their prescribing doc) and then have a CVA or stent re-thrombosis....

so this process allows me to document everything

oh, and on that form it mentions that the patient understands that there is an increased risk of stroke/heart attack every time anti-coagulation is held...

 

[CPAINDOC]

my limit is 325mg of ASA per day - and they don't have to stop it for any of my procedures.

especially if they are stopping coumadin or plavix, i'd like to have some ASA on board for their heart/brain...

what i do as part of my practice is FAX out an easy to fill out form letter to the prescribing physician - indicating what i am planning on doing and why, and how often I may consider that type of procedure per year... with areas for them to check off whether we can hold anti-coagulation and whether we can hold it repeatedly and what is the max they are comfortable with it being held per year..... then all that physician's staff has to do is re-fax that form back to us, and that gets filed in their chart...

i have been burned by some patients stopping their meds after "checking" with their doctors (which means they didn't actually check w/ their prescribing doc) and then have a CVA or stent re-thrombosis....

so this process allows me to document everything

oh, and on that form it mentions that the patient understands that there is an increased risk of stroke/heart attack every time anti-coagulation is held...

In general, most pts who get stents must stay anticoagulated for approximately 6 months. Therefore, it is unlikely they can have procedures, unless you go through the lovenox drill.

A colleague of mine is keeping people on baby ASA for everything, that is if they are on ASA to begin with. I also have a letter sent to cardiologist having them sign off on pts taking plavix or coumadin.

 

[knoxdoc]

How many reports exist of epidural hematomas requiring immediate decompression after a patient has undergone an axial injection while on coumadin? I had a patient with paroxysmal a fib stroke out last week while waiting for the ESI (6 days out). Makes me wonder if we aren't doing a whole lot of harm by trying to cover our asses in the unlikely event that Mildred gets a hematoma. If it were my back, I'd say keep the coumadin going.

Lets put is this way, whats more likely, a stroke or a hematoma? Follow up question: what would you rather have, a stroke or a much-more-likely reversible hematoma (if patient is educated of the symptoms beforehand).

 

[lobelsteve]

ASA and NSAID's No restrictions
Coumadin 5 days or INR <1.5 (for catheter removal) (I use 1.3 for epidural procedures)

Plavix 7 days
Ticlid 10-14 days (depends on ASRA vs SEDAR guidelines)
Arixtra 36hrs from last dose, but 12h hold after procedure

I see a lot of fresh stents and folks that need to stay anticoagulated.
Document R&B and use Lovenox weight based dosing pre and post procedure.

 

[DistantMets]

Ligament, might want to list Fiorinal on you aspirin containing list. I was at a neurosurgery M&M a couple weeks ago a young guy needed a cranial mass resected and forgot to tell the surgeon he was taking Fiorinal frequenly for his HAs. The surgeon went through a whole list of potential blood thinners with him too. No big complications, but he oozed alot, needed a transfusion in the OR and the case took a couple extra hours. The surgeon had a couple sleepless nights worrying about him.

 

[Tenesma]

stents: there is some data suggesting waiting 1-2 years (depending on the stent) before stopping/holding Plavix --- which is worse than the previous 6 month rule...

i agree w/ previous poster re: epidural hematoma vs stroke risk... and i'd be curious what the incidence of epidural hematomas is in TFESI vs ILESI?? i don't know of any literature that has looked at that... and what is the likelihood of an epidural hematoma with a 25 gauge TFESI...

i guess it is all risk/benefit - except i don't think we have a great handle on the risks...

then why not just run some FFP for patients on coumadin just prior to procedure??? cost?

 

[lobelsteve]

stents: there is some data suggesting waiting 1-2 years (depending on the stent) before stopping/holding Plavix --- which is worse than the previous 6 month rule...

i agree w/ previous poster re: epidural hematoma vs stroke risk... and i'd be curious what the incidence of epidural hematomas is in TFESI vs ILESI?? i don't know of any literature that has looked at that... and what is the likelihood of an epidural hematoma with a 25 gauge TFESI...

i guess it is all risk/benefit - except i don't think we have a great handle on the risks...

then why not just run some FFP for patients on coumadin just prior to procedure??? cost?

Mostly these are topics for ISIS and ASRA to sort out. We cannot do any RCT's for this data.

 

[PMR 4 MSK]

I've had one epidural hematoma identified - a few weeks after a LESI, pt had Lami for stenosis. The surgeon discovered a small epidural hematoma and removed it - I presume he got paid extra for it, since it was listed as a seperate procedure. It was asymptomatic. Makes me wonder how many we cause like this.

I have had a pt get a TIA from being off coumadin - believe I've posted it before. I can't do any spinal procedures on him now. He's pretty much stuck on opiates.

 

[Jcm800]

my limit is 325mg of ASA per day - and they don't have to stop it for any of my procedures.


my limit as well. less than 325 is fine for me...

 

[Ligament]

You guys still allowing Aspirin for epidural injections? Still 325mg or less or what? thanks.

 

[lobelsteve]

You guys still allowing Aspirin for epidural injections? Still 325mg or less or what? thanks.

ASA is not restricted per ASRA.

 

[Gauss]

Horlocker's article:
http://www.anesthesia-analgesia.org/content/95/6/1691.abstract

 

[Jcm800]

You guys still allowing Aspirin for epidural injections? Still 325mg or less or what? thanks.

yes. 325 or less

 

[PinchandBurn]

I do not stop any meds for MBB's or RF or joints.

Only epidural, discal, sympathetic blocks get the Plavix/Coumadin stoppage.

You dont stop coumadin/plavix for MBB/RFA?? A bit unconventional wouldnt you say??

 

[clubdeac]

I don't stop anything for lumbar medial branch blocks or facets or SIJs or other peripheral joints. I do for cervical stuff, ESIs, RFAs (bc of the gauge) disco's, LSBs etc

 

[mille125]

You guys still allowing Aspirin for epidural injections? Still 325mg or less or what? thanks.

I dont hold ASA or ibuprofen.

Steve, I know that you have excellent technique and this would never happen to you, but some docs have been known to get epidural spread during facet blocks. Just food for thought.....

 

[lobelsteve]

I dont hold ASA or ibuprofen.

Steve, I know that you have excellent technique and this would never happen to you, but some docs have been known to get epidural spread during facet blocks. Just food for thought.....

I do not go IA on facets, only MBB. If 0.3cc makes it from Dreyfuss position 2 into the canal, then we better dig up Frank Netter and rewrite that text.

I do know lots of folks hold lots of medications for no reason other than that is the way they trained. NSAIDS and ASA just do not equate to increased risk of spinal hematoma. If someone can point to an adverse outcome from a MBB/RF in properly trained hands and with pictures to match, I'll happily hold the Coumadin/Plavix.

I believe the risk is far greater that they have a vascular event in the week of stopping the medication than a bleeding event from a retro-spinal injection.

We have one Ortho who stopped Plavix on a DUS for elective hip surgery (4 months after stent placed). MI on table, patient dies.

 

[mid|ine]

I allow up to 325mg of ASA per day. I don't hold ASA for any procedures.

I do get worried about people on asa, fish oil, garlic,... I usually have them stop all of the herbals for 1 week prior.

 

[mdvol]

any reccomendations for this?

 

[lobelsteve]

Even though the latest guidelines don't restrict ASA, I'm still leery of epidural/neuraxial procedures while they're on it. I think a 3 day window is reasonable, simply from the perspective that it'll take 5 days for the platelets to completely turn over, so at 3 days, slightly more than 50% of the platelets should be functional.

As for the Plavix, the problem there is the ACC/AHA guidelines are pretty clear about not stopping Plavix in the first 6 months after stenting for elective procedures.

I recently had a referral for a patient to have an ESI who just had a stent placed last month and is on Plavix. Appropriately, her normal pain doc said "no" to the procedure because he wouldn't stop the Plavix to do an elective procedure that has only provided her ~25-30% relief anyway.

Of course, she gets p!ssed, goes to her PCP, who then sends her onto me as if I'm gonna do it. I politely decline, stating that I agree with her normal doc that in light of the recent stent and the need to stay on Plavix she's not currently a candidate for the procedure. She can be considered for having it done in 5 months, if her cardiologist agrees that she can come off the Plavix for a week.

The Plavix thing is insurmountable and indefensible. Just say No!!! Good job on that. Having a nearby patient die from coming off Plavix and knowing it was likely preventable just makes it not an option. The ASA thing is not as big a deal. Whether they take it or not- 3 days risk is little issue.

But what if a patient comes in to you and forgot to stop the ASA? Do you cancel? I don't have this problem.

 

[Jeff05]

ASA irreversibly inhibits platelets for their lifespan - about 10 days. where is the 3 day recommendation coming from?


where is the 325mg/day cutoff coming from?

also ASRA specifically states that there is no contraindication to asa or nsaids - at any dose.

 

[Gauss]

where is the 325mg/day cutoff coming from?

also ASRA specifically states that there is no contraindication to asa or nsaids - at any dose.

see horlockers article I posted. That is also where asra guidelines link to

 

[mille125]

I do not go IA on facets, only MBB. If 0.3cc makes it from Dreyfuss position 2 into the canal, then we better dig up Frank Netter and rewrite that text.

I do know lots of folks hold lots of medications for no reason other than that is the way they trained. NSAIDS and ASA just do not equate to increased risk of spinal hematoma. If someone can point to an adverse outcome from a MBB/RF in properly trained hands and with pictures to match, I'll happily hold the Coumadin/Plavix.

I believe the risk is far greater that they have a vascular event in the week of stopping the medication than a bleeding event from a retro-spinal injection.

We have one Ortho who stopped Plavix on a DUS for elective hip surgery (4 months after stent placed). MI on table, patient dies.

definitely less intrathecal spread risk with MBB vs IA facets...i agree.