Holding Prasugrel for Kyphoplasty

[oneforfighting]

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Sent request to cardiologist to hold prasugrel for 7 days for kyphoplasty. Form returned by cards PA stating patient may hold for 5 days. Would you push for 7? Hold for 5 days and do the procedure after discussing bleeding risks with patient? Decline the procedure?
From my research it looks like prasugrel is a very potent platelet inhibitor, significantly better than Plavix. ASRA recommends holding 7-10 days as does the medication manufacturers themselves.
Thoughts?

 

[BobBarker]

I think it will be ok. Lido with epi and the cement will take care of the vertbral body.

 

[oneforfighting]

I think it will be ok. Lido with epi and the cement will take care of the vertbral body.

My feeling is it would be too. Any personal experience with doing kyphos while continuing prasugrel or similar situation?

 

[BobBarker]

Not intentionally. But I’m sure over my career it has happened. I know for a fact I did several cesi’s on a patient on it in the past. Inadvertently.

 

[pmrmd]

Haven’t held AC of any kind for kypho in about a decade now. Lido/epi for the cannula trajectory. You’ll be fine.

 

[RoloTomassi]

I'd be comfortable with 5 days, but would make sure I discussed with the patient that it's not ideal for me but cards is trying to balance that with the risk of cardiac event.

Not to hijack the thread but I had a patient who wants to do Intracept without pre-op antibiotics due to hx of multiple bouts of c.diff after abx. What's everyone's comfort level of vertebral access without abx?

 

[PMROralBoards]

The time to hold is five days for normal non-spine procedures. Seven is generally the recommended duration for spine due to the potential consequences of a bleed into the spinal canal. I would ask for seven specifically and if they give pushback then just have and document a risk and benefit conversation. It is seven days in the asra guidelines and you would have to answer in court why you didn’t follow the guidelines.

 

[lobelsteve]

The time to hold is five days for normal non-spine procedures. Seven is generally the recommended duration for spine due to the potential consequences of a bleed into the spinal canal. I would ask for seven specifically and if they give pushback then just have and document a risk and benefit conversation. It is seven days in the asra guidelines and you would have to answer in court why you didn’t follow the guidelines.

How does a bleed occur into the spinal canal in a procedure that does not go in the spinal canal?

 

[PMROralBoards]

How does a bleed occur into the spinal canal in a procedure that does not go in the spinal canal?

By unintentionally violating the pedicle. Mistakes happen and this would most likely compound it and make it potentially much worse

 

[Orin]

The cardiologist took on the liability to give you freedom to do it at 5 days rather than 7. I would respect their expertise since you asked them, but at the end of the day, document your concerns in the pre-op notes/consent process so you can show you made a medical decision and didn't just forget to follow guidelines.

I would say I think it's safe.

 

[22yis]

Do people here regularly send messages to cardiologist/pcp to get approval to hold ac? Is it appropriate to ask the patient to obtain clearance from their prescriber and trust them when they say they held it the amount of days you told them is necessary?

 

[lobelsteve]

Do people here regularly send messages to cardiologist/pcp to get approval to hold ac? Is it appropriate to ask the patient to obtain clearance from their prescriber and trust them when they say they held it the amount of days you told them is necessary?

Nope. Get it in writing. Document or it did not happen.

 

[22yis]

Nope. Get it in writing. Document or it did not happen.

Thanks for sharing your note. 2 things. What are you referring to in regards to injection series? And if a patient states they’ve held the med several times before for similar procedures can you document and proceed or do you still require the signed note to CYA?

 

[Taus]

Thanks for sharing your note. 2 things. What are you referring to in regards to injection series? And if a patient states they’ve held the med several times before for similar procedures can you document and proceed or do you still require the signed note to CYA?

New signed form every time.

 

[lobelsteve]

Thanks for sharing your note. 2 things. What are you referring to in regards to injection series? And if a patient states they’ve held the med several times before for similar procedures can you document and proceed or do you still require the signed note to CYA?

Repeat ESI if needed.

 

[Ducttape]

fwiw, ASRA considers kyphoplasty to be a high risk procedure.

i tried to find out how they came to that assessment and did not find out the exact reason.

 

[lobelsteve]

fwiw, ASRA considers kyphoplasty to be a high risk procedure.

i tried to find out how they came to that assessment and did not find out the exact reason.

Like most of what they do: Expert consensus.
ASRA: still killing people after all of these years