coags

[painfree23]

Coagulation guidelines

Have a patient with cirrhosis, checked Coags, PT barely above normal (by 1.0), INR 1.1, PTT normal, platelet normal. Reports nose bleeds once every few months ("when the air gets dry")..nothing new. Denies easy bruising...

Has a disc at L4

Would u do an LESI?

What's ur cut off? Is there a number published somewhere we can use as a cut off?

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[willabeast]

Coagulation guidelines

Have a patient with cirrhosis, checked Coags, PT barely above normal (by 1.0), INR 1.1, PTT normal, platelet normal. Reports nose bleeds once every few months ("when the air gets dry")..nothing new. Denies easy bruising...

Has a disc at L4

Would u do an LESI?

What's ur cut off? Is there a number published somewhere we can use as a cut off?

you could run the numbers by a hematologist AND document what is said but IMHO it sounds like from a clotting standpoint you are OK BUT i would advise that because of cirrhosis there is increased risk of infection and get an ESR pre procedure so less confusion later.

 

[painfree23]

you could run the numbers by a hematologist AND document what is said but IMHO it sounds like from a clotting standpoint you are OK BUT i would advise that because of cirrhosis there is increased risk of infection and get an ESR pre procedure so less confusion later.

Yea, thats true. Increased risk of infection definitely is serious -- what about lumbar mbnb? would u follow the same thing?

 

[drusso]

Coagulation guidelines

Have a patient with cirrhosis, checked Coags, PT barely above normal (by 1.0), INR 1.1, PTT normal, platelet normal. Reports nose bleeds once every few months ("when the air gets dry")..nothing new. Denies easy bruising...

Has a disc at L4

Would u do an LESI?

What's ur cut off? Is there a number published somewhere we can use as a cut off?

I would inject.

 

[clubdeac]

you're fine

 

[willabeast]

Yea, thats true. Increased risk of infection definitely is serious -- what about lumbar mbnb? would u follow the same thing?

yes. don't stick yourself. sometimes cirrhosis is viral.

 

[painfree23]

What's ur take on joint injections on eliquis or Coumadin? Let's say that can't come off it (even after cards clearance). What about for occipital nerve block?

I'm a little weary of the occipital on eliquis, probably ok with knees and shoulders.. just curious about all of your thoughts

 

[pastafan]

Can't remember reference off hand but INR 1.3 is what we use as cutoff for neuraxial.

 

[Ducttape]

might want to check a bleeding time.

best test (not readily available) might be thromboelastography (TEG).

 

[clubdeac]

I keep them on all anti-coagulants and anti platelet agents for all joint injections and occipitals.

 

[painfree23]

I keep them on all anti-coagulants and anti platelet agents for all joint injections and occipitals.

never had issues?? what about dual antiplatelet? thats awesome

 

[Tapspatellas]

never had issues?? what about dual antiplatelet? thats awesome

Had an Asa 81, plavix, warfarin. Made get clearance for the plavix to do cervical MBB. It had been well over a year since the stent and that was just more than I was willing to deal with. DAPT or anticoag (without supratherapeutic INR) bring it on for anything not within the canal.

Edit: I will say that for a stupid indication of antiplt or anticoag (eg primary prevention without a reason) I do prefer to get clearance to hold for spinal, but wouldn't sweat any peripheral.

 

[NOSfan]

Can't remember reference off hand but INR 1.3 is what we use as cutoff for neuraxial.

See attached for article regarding suggested INR guidelines.

Cheers