holding plavix before LESI

[AndyDufrane]

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so I did an inpatient general physiatry consult recently, older patient who had been on plavix for CAD s/p stents, 2 weeks ago, his plavix was held for 4th injection ( LESI) by a local pain med anesthesiologist, and patient suffered a L MCA now w/ expressive/receptive aphasia, so , in order for me to avoid this situation, I have heard some interventional providers will have the patient follow up with their cardiologist to say hold the plavix which is what our practice does, but I have also heard that some patients are put on heparin for the 2 weeks while their plavix is held, but is it even really up to me to bring this up to the cardiologist, or will I appear to be stepping on toes if I discuss this with the cardiologist, I am assuming if I place the patient on Heparin when all the cardiologist recommends is holding the plavix, then I run the risk of being outside the scope of my field, input? thank you in advance

 

[Gauss]

fresh stents, <1year, do not get plavix held. heparin or lovenox at discretion of cards. ALWAYS get cards permission. If you hold plavix or coumadin there is an extraordinarily high likelihood of catastrophic MI or stroke so you have to ask is the ESI truly worth it? If cards says no, discussion over

 

[AndyDufrane]

thank you for insight

 

[RUOkie]

exactly what Gauss said. An ESI is never worth it in that situation.

 

[Doctodd]

How long ago was the stent placed? 2 weeks ago? And it was his 4th injection? Need a bit more info.

I usually only hold ASA or Plavix for cervical procedures. I have done what was discussed above but am very conservative in injecting patients with significant CAD/CVA risk. Check INR day of procedure if on Coumadin. If patient really needs anti coagulation place them on Lovenox for a couple of days during the procedure. You don't need cardiology blessing for that.

 

[SSdoc33]

How long ago was the stent placed? 2 weeks ago? And it was his 4th injection? Need a bit more info.

I usually only hold ASA or Plavix for cervical procedures. I have done what was discussed above but am very conservative in injecting patients with significant CAD/CVA risk. Check INR day of procedure if on Coumadin. If patient really needs anti coagulation place them on Lovenox for a couple of days during the procedure. You don't need cardiology blessing for that.

first of all, never hold aspirin.

second of all, the patient should have lovenox within 24 hours of an epidural.

third off, of course plavix needs to be help for lumbar procedures.

ASRA puts out pretty good guidelines on this stuff.



also, i may be wrong but heparin and/or lovenox doesnt really work the same as plavix, so i dont think you can just switch them. i dont think that they offer the same type of prevention for stent occlusion. thats why we have cardiologists. to sort out this nonsense. let them assume the risk. what happens if the patient has a bleed when you put them on the heparin or lovenox? not a headache that id like to deal with.

 

[Gauss]

as far as I know plavix binds platelets, heparin binds antithrombin.
I would advise that you don't guess and don't assume ASRA is on top of this area and just ask Cards.
There are now new anti-platelets on the market: brilinta, effient. We don't know much about these in the interventional spine world and it's not worth guessing.