General consensus on coumadin/plavix and emg testing?

[Karying14]

Hi there,
Wanted to know in general, how many days coumadin is stopped before emg testing? I have heard varied answers. Some don't stop coumadin, while others stop 3-5 days. For cervical paraspinals or lumbar paraspinals I am thinking maybe hold for a few days, but for the other muscles that are not as deep, do we have to hold coumadin? Thanks

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[SSdoc33]

Hi there,
Wanted to know in general, how many days coumadin is stopped before emg testing? I have heard varied answers. Some don't stop coumadin, while others stop 3-5 days. For cervical paraspinals or lumbar paraspinals I am thinking maybe hold for a few days, but for the other muscles that are not as deep, do we have to hold coumadin? Thanks

i dont know what answers you've heard, but you dont need to stop it. you'll get in to a lot more trouble stopping it that keeping it in place. risk of bleeding is minimal

 

[DOctorJay]

Risk of hematoma following needle electromyography of the paraspinal muscles.

Jon T Gertken, Christopher H Hunt, Nataly I Montes Chinea, Jonathan M Morris, Eric J Sorenson and Andrea J Boon Muscle Nerve 44(3):439-40 (2011) PMID 21996804
The purpose of this study was to establish the incidence of MRI-detectable hematomas following paraspinal EMG. We provide a retrospective review of patients who underwent paraspinal EMG and subsequent concordant level spine MRI. A total of 370 charts (431 MRIs) met the inclusion criteria. No paraspinal hematomas were observed. These results should further the development of evidence-based guidelines for patients who have greater-than-normal bleeding risk and support the notion that paraspinal EMG is a relatively safe procedure. Muscle Nerve 44: 439-440, 2011. Copyright © 2011 Wiley Periodicals, Inc.


Hematoma risk after needle EMG
Andrea J. Boon MD1,2,*, Jon T. Gertken MD1, James C. Watson MD2, Ruple S. Laughlin MD2, Jeffrey A. Strommen MD1, Michelle L. Mauermann MD2, Eric J. Sorenson MD2
Abstract
Introduction:
Although needle electromyography (EMG) appears to be a relatively safe procedure based primarily on clinical experience, no evidence-based guidelines exist for EMG procedures in patients taking anticoagulant or antiplatelet medications.

Objectives:
To determine if there is an increased risk of hematoma formation after EMG of potentially high risk muscles in patients taking anticoagulant or antiplatelet agents.

Methods:
After undergoing routine EMG, if any of 7 predetermined high risk muscles were tested, study subjects then underwent ultrasound to evaluate for hematoma formation.

Results:
Patients were divided into 3 groups based on medication (warfarin; aspirin/clopidogrel; no blood-thinning medication), with at least 100 muscles examined per group. Two small, subclinical hematomas were seen on ultrasound; there was no difference in hematoma risk between groups (p=0.43)

Conclusions:
This study suggests that hematoma formation from standard needle EMG is rare even in high risk muscles, which have been avoided historically in anticoagulated patients.

 

[Karying14]

thanks for the input...

 

[PMR 4 MSK]

Your risk of causing problems by holding the coumadin is likely far higher than the risk of causing problems from a 26-27 g EMG needle while the pt is anticoagulated.

 

[DrFreshair]

THank DoctorJay for sharing!

 

[PMR2008]

Our EMG lab does not perform EMGs on patients with supra therapeutics INRs. We follow the guidelines per the following articles.

----Lynch SL, Boon AJ, Smith J, Harper CM Jr, Tanaka EM. Complications of needle electromyography: hematoma risk and correlation with anticoagulation and antiplatelet therapy. Muscle Nerve. 2008 Oct;38(4):1225-30.
( http://www.ncbi.nlm.nih.gov/pubmed/18785189)


----Gruis KL, Little AA, Zebarah VA, Albers JW. Survey of electrodiagnostic laboratories regarding hemorrhagic complications from needle electromyography. Muscle Nerve. 2006 Sep;34(3):356-8.
(http://www.ncbi.nlm.nih.gov/pubmed/16810693)

----Al-Shekhlee A. Shapiro BE. Preston DC. Iatrogenic complications and risks of nerve conduction studies and needle electromyography. Muscle & Nerve. 27(5):517-26, 2003 May.
(http://www.ncbi.nlm.nih.gov/pubmed/12707972)

 

[SSdoc33]

Our EMG lab does not perform EMGs on patients with supra therapeutics INRs. QUOTE]


this would imply that you CHECK an INR prior to performing and EMG on everyone on coumadin. overkill, IMHO

 

[PMR2008]

We just use the most recent INR as most patients have there INR checked atleast once a week. Would you do a paraspinal needle emg on someone with an INR of >7?

 

[Taus]

The emg guru at my program frequently quotes the AANEM cutoff of 2.5 INR. He also advises against sticking muscles within tight fascial planes ( ie anterior calf) to avoid a potential compartment syndrome from hematoma. l ask him for the exact reference when I can

 

[PMR 4 MSK]

We just use the most recent INR as most patients have there INR checked atleast once a week. Would you do a paraspinal needle emg on someone with an INR of >7?

INR of >7 should be admitted and encased in bubble-wrap.

 

[SSdoc33]

We just use the most recent INR as most patients have there INR checked atleast once a week. Would you do a paraspinal needle emg on someone with an INR of >7?

that is an idiotic hypothetical.

 

[SSdoc33]

We just use the most recent INR as most patients have there INR checked atleast once a week. Would you do a paraspinal needle emg on someone with an INR of >7?

most patients have "their" INR checked about once every 2 weeks, not once a week.

 

[Jitter Bug]

Someone showing up for an EMG with INR over 7 is not an idiot hypothetical if you work in a VA AND they will have a NA of 121 and a BAC of .17

I don't check INR before EMG's and I don't stop anticoagulation.

If they are on coumadin I skip the paraspinals if I can. Most other sites ar pretty easy to hold pressure on for a minute after needling. (I don't do larygeal or diaphragm EMG's ).

 

[PMR2008]

We have found patients INR to be more than 5-6 atleast twice in the last month without any evidence of bleeding. They were not hospitalized. Just told to stop the coumadin and followup with their cardiologist/PCP. Most patients do get their INR checked 1/week and testing interval increases to once every 2 weeks so I agree with you.
My attendings will not do a needle EMG on a patient with INR above 3. I will probably follow the same guideline when I start practicing next year.

 

[Louisville04]

Someone showing up for an EMG with INR over 7 is not an idiot hypothetical if you work in a VA AND they will have a NA of 121 and a BAC of .17
).

I have to respectively disagree with you. At the VA I work at pharmacists run an anticoagulation clinic and monitor PT/INR's. Their notes are very thorough. An INR over 7 is more likely in the private sector where a PCP cannot devote as much time to monitoring (especially if he is handling it over the phone and not billing for it)

 

[RUOkie]

We have found patients INR to be more than 5-6 atleast twice in the last month without any evidence of bleeding. They were not hospitalized. Just told to stop the coumadin and followup with their cardiologist/PCP. Most patients do get their INR checked 1/week and testing interval increases to once every 2 weeks so I agree with you.
My attendings will not do a needle EMG on a patient with INR above 3. I will probably follow the same guideline when I start practicing next year.

so are you going to check them? Have them show up with an INR within a day or two? (I do that for many injections, but not EMG)

I will not stick Post Tib in an anticoagulated patient with unknown INR. Otherwise, I proceed. With the little needles, it really is not an issue. Just hold some pressure.

 

[Jitter Bug]

I wsn't knocking the VA, I was knocking the higher risk of non-compliance with medical recommendations by VA patrons. You can ask them to get their blood drawn weekly, doesn't mean they'll do it. Even if a nurse calls them up to check on them.

 

[topwise]

How about INR prior to joint injections? What guidelines do you use?

 

[lobelsteve]

How about INR prior to joint injections? What guidelines do you use?

Anything under 4 is reasonable. Really, it is. No dark orchid.

Withholding blood thinners (coumadin for valves/afib, plavix for stents) can prove fatal to the patient.

Know what drug they are on and why they are taking it before deciding to ask them to hold it. Work with their Cardiologist/Vascular/Neurologist in regards to these things.

Using the same paperwork and asking non-medical staff to just hold all thinners will certainly kill off some patients at some point. And guess who will pay the price (besides the patient and their family)?

 

[Gauss]

there are bigger boogeymen out there than coumadin: plavix, asa, aggrenox, pradaxa, ticlodipine....
I have never stopped any of these meds for EMG or peripheral joint injections. And I have done neuraxial procedures with them on board as well.

 

[Jitter Bug]

Update, check out the new article in Muscle and Nerve this month, 3 patient groups average 100 muscles stuck each group. Group 1: coumadin, Group 2: Plavix Group 3: no blood thinner. Results no statistically significant difference in hematoma rate, only 2 hematomas total, 78 y/o lady on Plavix, posterior tib hematoma, 84 y/o male on coumadin (INR 2.3) hematoma in FPL.

More evidence that EMG much less risk than risks of stopping anticoagulation.

Sorry I don't have the link, maybe someone can post. Boon et al, Hematoma Risk After Needle Electromyography.

 

[PMR2008]

Thank you for the update. Do you recall how they diagnosed the patients with hematoma. For example the posterior tib hematoma. Was it by U/S or MRI?

 

[fozzy40]

Ultrasound