Anticoagulation guidelines/ recs

[ED50]

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We have recently been getting some pushback for our local hospital on anticoagulation clearance for procedures. Our practice follows ASRA guidelines, but they are sending us back American college of cardiology guidelines which basically have all spine procedures as low risk and they recommend shorter holds then ASRA. Anyone else running into this issue and how are you handling it? I know the data shows how safe most these procedures are but I'd like to have some professional society back me up. What holding guidelines are you all following and any recs how to proceed?

 

[willabeast]

Figure out who you will want as a defense witness. Use their guidelines.

 

[clubdeac]

We have recently been getting some pushback for our local hospital on anticoagulation clearance for procedures. Our practice follows ASRA guidelines, but they are sending us back American college of cardiology guidelines which basically have all spine procedures as low risk and they recommend shorter holds then ASRA. Anyone else running into this issue and how are you handling it? I know the data shows how safe most these procedures are but I'd like to have some professional society back me up. What holding guidelines are you all following and any recs how to proceed?

Let me guess, cards wants 2 days for all DOACs and 5 days for all antiplatelet meds

 

[ED50]

Yeah they are. For example I know how safe LTFESIs are but ASRA guidelines still say 3 days for eliquis.

 

[clubdeac]

Yeah they are. For example I know how safe LTFESIs are but ASRA guidelines still say 3 days for eliquis.

I just send there clearance back saying we need 3 days and 7 respectively. They usually acquiesce

 

[CopaceticOne]

If they are being super rigid about the DOACs, you can counter with hold for 7 days and on hold day #2 patients will need to start therapeutic BID Lovenox until 24hr prior to procedure.

Note: this is not “bridging” a DOAC. This is switching a therapy class preoperatively.

 

[PMROralBoards]

Their view does not take into account that we are generally concerned about a spinal bleed

 

[Ducttape]

i find that asking the cardiologists about short course of lovenox and this commonly alters their opinion about the strict necessity of holding for short course.

of note, at this point in time i am not requesting hold for tfesi.

 

[ED50]

i find that asking the cardiologists about short course of lovenox and this commonly alters their opinion about the strict necessity of holding for short course.

of note, at this point in time i am not requesting hold for tfesi.

I think this is what I'm leaning towards doing. I'd really like to stop requesting holds for LTFESI's altogether. I'm just irritated at our society guidelines as I feel they are behind the times.

 

[jsaul]

I think this is what I'm leaning towards doing. I'd really like to stop requesting holds for LTFESI's altogether. I'm just irritated at our society guidelines as I feel they are behind the times.

I havenot held blood thinners for lumbar tf for almost10 years now

 

[lobelsteve]

Since 2009. LESI/TFESI/MBB/SIJ. So about n=20000

Only for CESI (not based on good science), SCS, and kypho (not based on good science since not in the canal).

 

[ED50]

Since 2009. LESI/TFESI/MBB/SIJ. So about n=20000

Only for CESI (not based on good science), SCS, and kypho (not based on good science since not in the canal).

That protocol makes sense to me but both SIS and ASRA don't back this up. They literally can't quantify the relative risk of holding v not holding anticoagulation since epidural hematomas are only seen in case studies for LTFESI. But still we are told 3 day hold for eliquis. Meanwhile complication rate of holding anticoagulation in these patients is .5% and can be catastrophic.

 

[Orin]

That protocol makes sense to me but both SIS and ASRA don't back this up. They literally can't quantify the relative risk of holding v not holding anticoagulation since epidural hematomas are only seen in case studies for LTFESI. But still we are told 3 day hold for eliquis. Meanwhile complication rate of holding anticoagulation in these patients is .5% and can be catastrophic.

We need an another paper talking about how SIS/ASRA guidelines are killing/hurting folks.

 

[mille125]

I think this is what I'm leaning towards doing. I'd really like to stop requesting holds for LTFESI's altogether. I'm just irritated at our society guidelines as I feel they are behind the times.

I am irritated too but I follow our society guidelines.

I have seen it used against docs in med mal and med board cases.

 

[au bon pain]

We need an another paper talking about how SIS/ASRA guidelines are killing/hurting folks.

Another paper? Has there already been a major one about this?

 

[Orin]

Only the Endres et al works that are routinely dismissed as being not science-y enough:
Endres, S. M., Shufelt, A., & Bogduk, N. (2017). Risks of Continuing or Discontinuing Anticoagulants for Patients Undergoing Common Interventional Pain Procedures. Pain Medicine, 18(3), 403–409

https://academic.oup.com/painmedicine/article-abstract/18/3/403/2924697

https://academic.oup.com/painmedicine/article-abstract/21/5/918/5714951

Example of a dismissal:

https://academic.oup.com/painmedicine/article-abstract/18/4/819/2646684

 

[drusso]

Since 2009. LESI/TFESI/MBB/SIJ. So about n=20000

Only for CESI (not based on good science), SCS, and kypho (not based on good science since not in the canal).

 

[au bon pain]

Only the Endres et al works that are routinely dismissed as being not science-y enough:
Endres, S. M., Shufelt, A., & Bogduk, N. (2017). Risks of Continuing or Discontinuing Anticoagulants for Patients Undergoing Common Interventional Pain Procedures. Pain Medicine, 18(3), 403–409

https://academic.oup.com/painmedicine/article-abstract/18/3/403/2924697

https://academic.oup.com/painmedicine/article-abstract/21/5/918/5714951

Example of a dismissal:

https://academic.oup.com/painmedicine/article-abstract/18/4/819/2646684

The authors in your last example should write a letter to the editor about this one too:

Parachute use to prevent death and major trauma when jumping from aircraft: randomized controlled trial - PMC

To determine if using a parachute prevents death or major traumatic injury when jumping from an aircraft. Randomized controlled trial. Private or commercial aircraft between September 2017 and August 2018. 92 aircraft passengers aged 18 and over ...

pmc.ncbi.nlm.nih.gov

 

[Orin]

The authors in your last example should write a letter to the editor about this one too:

Parachute use to prevent death and major trauma when jumping from aircraft: randomized controlled trial - PMC

To determine if using a parachute prevents death or major traumatic injury when jumping from an aircraft. Randomized controlled trial. Private or commercial aircraft between September 2017 and August 2018. 92 aircraft passengers aged 18 and over ...

pmc.ncbi.nlm.nih.gov

It's hard for smart people to understand sometimes they're doing or have done something wrong.

Ego is a barrier to growth for many.

 

[au bon pain]

It's hard for smart people to understand sometimes they're doing or have done something wrong.

Ego is a barrier to growth for

Definitely

 

[JFS]

I follow ASIPP guidelines. Much more relaxed than ASRA

 

[bubaghanush]

I follow ASIPP guidelines. Much more relaxed than ASRA

Same, not sure why ASRA guidelines are treated as the gold standard here.

Would like to see IPSIS come out with something as well.