cervical esi and VWF disease

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smarterchild

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hi all,

I have a patient with a history of an anterior cervical fusion present with a 2 month history of cervical radic that hasn't responded to NSAID, PT, oral steroids, or even percocet. She wants to have an epidural done but has this history of VWF disease. I don't have any records about and she isn't entirely clear about this diagnosis. She just told me "they told me I bled a lot after a prior surgery and diagnosed me with VWF disease". She did tell me she received DDAVP prior to her cervical fusion.

I really haven't seen this before and kind of unsure how to proceed with regards to prepping her for a cervical ESI (If thats even a good idea). any ideas?

Thanks
 
I think you have two options.

1. Don't do it. This would probably be where I would go with it. Your best outcome is 50% reduction of the subjective experience of pain lasting 2-3 months and your worst outcome is quadriplegia or death.
2. Send her to a hematologist for a more formal evaluation and documentation. If she comes back clean then consider it.

Just imagine what your possible defenses would be if she had a catastrophic outcome and you had to defend yourself in court. What reasonable arguments for your decision could you make?

Does she have recent imaging suggesting a cause for her radiculopathy?
 
you need to determine the type of VWDx before proceeding with injection, if at all.

type 1 - mildest. type 3 - most severe.
type 1 and i think one of the type 2s respond to DDAVP.

otherwise, need factor VIII replacement.

hematology referral would answer it all for you, and let you know if it is safe, or what premedication is required.

I had a patient with Type 2A. got DDAVP before procedure. ill tell you that my sphincter tone, usually high for CESI, was particularly high that day.
 
Heme c/s

Had a pt with this in fellowship we did a scs trial on. Had specific recs from heme who monitored her before/after.
 
have been recommend in the past for amicar po tabs, get heme consult let them sort it out depends on VWD type, lean towards conservative care
 
Frequently the hematologist will simply prescribe nasal DDAVP prior to the procedure. Much easier now with intranasal prophylaxis. Used to need IV infusions in the past. I like the VWF above 150.

what’s your cut of for thrombocytopenia? 100k?
INR? My rogue attendings used 1.5 for Intraop epidurals..... scary. that’s academia for you.
 
Similarly have a patient next week - what about a lovenox bridge from Coumadin? Doing injection 24hrs after last lovenox dose, when can they restart next lovenox?
 
painfree23 said:
Similarly have a patient next week - what about a lovenox bridge from Coumadin? Doing injection 24hrs after last lovenox dose, when can they restart next lovenox?
Click to expand...

Assuming this is for cESI.

If you go by ASRA recommendations(they get a lot of flack on here), you would hold for 24 hours then resume 12-24 hours after. For me, it would depend on the indication for the coumadin. Afib stroke prophylaxis I would probably err more towards 24h. Active DVT/PE treatment I would probably lean more towards 12.
 
24 hrs before and after for therapeutic dose lovenox. 12 hrs for prophylactic dose. INR < 1.3 and I like plts above 100k but know guys that do epidurals on 50k
 
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