• Practice your interview with the new SDN AI Interview Coach. Choose a school, answer by voice or typing, and receive a personalized feedback report. Available now to all SDN members. Try the AI Interview Coach.

Anticoagulation guidelines/ recs

Started by ED50
This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
E

ED50

Full Member
Verified Member
10+ Year Member
Physician
Advertisement - Members don't see this ad
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?
 
ED50 said:
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?
Click to expand...
Let me guess, cards wants 2 days for all DOACs and 5 days for all antiplatelet meds
 
Advertisement - Members don't see this ad
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.
 
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.
 
Ducttape said:
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.
Click to expand...

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.
 
lobelsteve said:
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).
Click to expand...

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.
 
ED50 said:
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.
Click to expand...
We need an another paper talking about how SIS/ASRA guidelines are killing/hurting folks.
 
ED50 said:
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.
Click to expand...
I am irritated too but I follow our society guidelines.

I have seen it used against docs in med mal and med board cases.
 
Advertisement - Members don't see this ad
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



Example of a dismissal:
 
lobelsteve said:
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).
Click to expand...
Meme Reaction GIF by Robert E Blackmon
 
Orin said:
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



Example of a dismissal:
Click to expand...

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 pmc.ncbi.nlm.nih.gov
 
au bon pain said:
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 pmc.ncbi.nlm.nih.gov
Click to expand...
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.
 
Hey I forget, what’s the consensus nowadays for holding thinners for cervical medial branch blocks? Are most of you guys still holding them for these or continuing? I’m on the fence.
 
ED50 said:
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?
Click to expand...
You have a decent argument for using any larger named guideline you prefer. If something goes wrong be prepared for a more stringent guideline to be cited against you in any legal action.
 
clubdeac said:
Hey I forget, what’s the consensus nowadays for holding thinners for cervical medial branch blocks? Are most of you guys still holding them for these or continuing? I’m on the fence.
Click to expand...

I am pretty conservative when it comes to following the ASRA guidelines but that is one case where I will continue the blood thinners. I do discuss it with the patient and document that we discussed the r/b/a and the patient elected to continue the blood thinners and accept the risk.
 
We still largely follow ASRA. They're "consensus" guidelines. ASIPP is better, but unfortunately only one society. SIS softballs everything and won't give guidelines.

Unfortunately, medicolegally, we get clearance for virtually everything.
 
This has been an interesting thread. I couldn't imagine what I would do if I was told my patient had a stroke or MI while their blood thinners were being held for a TFESI. I don't think I would sleep very well at night. Saying "well the guidelines said hold the blood thinner, even though the best evidence says not too" wouldn't be enough for me. To each their own I guess. I haven't held for a number of years, and just always have the discussion with the patient about the state of the guidelines and the current evidence.
 
Advertisement - Members don't see this ad
kstarm said:
This has been an interesting thread. I couldn't imagine what I would do if I was told my patient had a stroke or MI while their blood thinners were being held for a TFESI. I don't think I would sleep very well at night. Saying "well the guidelines said hold the blood thinner, even though the best evidence says not too" wouldn't be enough for me. To each their own I guess. I haven't held for a number of years, and just always have the discussion with the patient about the state of the guidelines and the current evidence.
Click to expand...
I hear you, but I would rather be told my patient had a stroke or MI after holding blood thinners when the guidelines say I should and the cardiologist said it was fine than have my patient become paralyzed from a bleed and trying to explain to a jury that it's actually safe to do so when the published guidelines say it's not and the cardiologist wasn't aware I'm doing spine injections on them on anticoagulation.

It's the world we live in.
 
Ferrismonk said:
I hear you, but I would rather be told my patient had a stroke or MI after holding blood thinners when the guidelines say I should and the cardiologist said it was fine than have my patient become paralyzed from a bleed and trying to explain to a jury that it's actually safe to do so when the published guidelines say it's not and the cardiologist wasn't aware I'm doing spine injections on them on anticoagulation.

It's the world we live in.
Click to expand...
One is more likely than the other.
 
Ferrismonk said:
I hear you, but I would rather be told my patient had a stroke or MI after holding blood thinners when the guidelines say I should and the cardiologist said it was fine than have my patient become paralyzed from a bleed and trying to explain to a jury that it's actually safe to do so when the published guidelines say it's not and the cardiologist wasn't aware I'm doing spine injections on them on anticoagulation.

It's the world we live in.
Click to expand...
So you want to get sued for killing a patient over potentially paralyzing a patient?
 
clubdeac said:
But you have society guidelines on your side as well as cardiology’s blessing. In the other scenario you don’t have any defense other than maybe random pain doc Steve Lobel
Click to expand...
Either way when complication occurs, you may get sued. Death is final. Paralysis can be prevented or reversed with emergent decompression.
 
Ferrismonk said:
I hear you, but I would rather be told my patient had a stroke or MI after holding blood thinners when the guidelines say I should and the cardiologist said it was fine than have my patient become paralyzed from a bleed and trying to explain to a jury that it's actually safe to do so when the published guidelines say it's not and the cardiologist wasn't aware I'm doing spine injections on them on anticoagulation.

It's the world we live in.
Click to expand...
???

id rather have an epidural hematoma than a stroke or MI. bleeds are also rare. strokes and MIs are not
 
Ferrismonk said:
I hear you, but I would rather be told my patient had a stroke or MI after holding blood thinners when the guidelines say I should and the cardiologist said it was fine than have my patient become paralyzed from a bleed and trying to explain to a jury that it's actually safe to do so when the published guidelines say it's not and the cardiologist wasn't aware I'm doing spine injections on them on anticoagulation.

It's the world we live in.
Click to expand...

I agree that there is no easy answer right now for this. Perhaps we can do the YOU test: if you were on blood thinners and needed a transforaminal epidural would you stop your blood thinners for the injection?
 
All of the case reports I’ve found that have had catastrophic outcomes are ILESI,, anyone know of reports or anecdotal bad outcomes from tfesi and blood thinners?
 
You must log in or register to reply here.

Similar threads

S
SCS cadaver course recs
Replies
3
Views
922
Orin
O
Green Grass
ASPN DETER Infection Guidelines
Replies
0
Views
962
Green Grass
Green Grass
D
Recs for pain doc in Las Vegas
Replies
9
Views
2K
Ducttape
D
O
Thoracic TFESI and anticoagulation
Replies
37
Views
3K
oneforfighting
O
N
  • Question Question
Are the IPSIS practice guidelines worth buying?
Replies
10
Views
3K
bedrock
bedrock