Inr cutoff for shoulder blocks
Started by dabears505
interscalene? wouldn't even look at the INR
If the site is compressible, who cares? Cutting open their shoulder with an INR 1.6 is another story.
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If the surgeon is willing to operate and it’s deemed safe/acceptable…I’m very likely doing the block.
This.
Probably the only patients with significant vascularity in that area tend to be the dialysis patients. Need to be careful with them, but no contraindications based on INR
ASRA guidelines say peripheral nerve blocks (in compressible areas logically though don’t recall it being stated exactly) are low risk and up to clinical discretion and risk stratification.
Only neuraxial is less than 1.5
Liability is another thing since there is discretion and up to some other doc who thinks you should have never done it. I’d rather it be normal for an elective case. If it’s something that can’t wait, then I’d go ahead
I used to replace supraclavicular catheters on people only 12hrs out from their 1mg/kg lovenox shot. Then again, it was the Army, so very different med-mal environment.
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deleted1112838
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There was a time when ASRA ****ed us all with guidelines that treated peripheral blocks at compressibile sites the same as neuraxial with regard to anticoagulation. This was before ultrasound was ubiquitous and everyone was doing landmark/stim and some were even still doing transarterial stuff.
They meant well but the guideline was dumb and we all knew it. Most of us ignored them, but it was unpleasant to have guidelines like that out there. Many (most?) people for many years wouldn't do any PNBs in anticoagulated people for medicolegal reasons.
There ain't nothing wrong with someone asking for opinions about this subject. Even now there's some fuzziness between what constitutes a deep block or not. Lumbar plexus? Sure. Adductor canal? No. Interscalene? Well ... how shallow and compressible is a fat neck? There's a lot of vasculature around that site. I think ultrasound makes it safe. Others may reasonably differ.
Don't be a dick.
i thought you went to wall street
He came back
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deleted1183938
What happened? Not enough money? Too many jerks to work with?
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deleted1112838
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This may be the first thing you’ve said that most of us will agree with. We would in fact be shocked to learn that.
Anyone that publicly states this is almost certainly universally disliked in the hospital
I have no doubt you genuinely believe this.
I bet there's a positive correlation between "trolling people on the internet" and "being annoying at work" ...
It's within the realm of mathematical possibility that you're the guy keeping that number below 1. 🙂
Yeah you're pretty dislikeable honestly online. Some people are like that however online but can be quite reasonable in person. They either need to vent online and get it all out there or else they just don't know how to communicate in writing well...
So it's possible
im more interested in the wall street story. too much money? retired and pursuing a medical hobby?
I have personally performed many blocks with an INR above 1.5. But, what about an INR of 2.0? 2.5? Platelet count of 45,000? Yes, u/s makes an ISB very safe but zero risk? I have found that orthopedic surgeons are sometimes like little children in that they need pushback and guidance.
Do you really want to be performing surgery with an INR above 2.0? 2.5? So, it’s worth reviewing the INR and the labs prior to surgery and a block.
I’m generally fine with some procedures if the INR is less than 2.0.
How often is it really even an issue where the INR is 2 or the platelets are 45, but ortho wants to be doing elective shoulder surgery anyway?
They whine about bleeding to the point of routinely asking for unsafe reductions in blood pressure. They inappropriately stop DAT in people who are under a year out from stents or strokes.
They're not going to want to do the case at all in an anticoagulated patient.
If they do, you could just tell them that functioning platelets or clotting factors move Ancef molecules around or something and they'll happily cancel.
They whine about bleeding to the point of routinely asking for unsafe reductions in blood pressure. They inappropriately stop DAT in people who are under a year out from stents or strokes.
They're not going to want to do the case at all in an anticoagulated patient.
If they do, you could just tell them that functioning platelets or clotting factors move Ancef molecules around or something and they'll happily cancel.
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deleted1183938
I don’t get how this is not well known. To many people this is their “safe space”. Where they can anonymously venti all their frustrations and go completely frontal lobe here.
But in person they know how to be decent to others.
We all have frustrations in life. Some people keep it all in, others take it all out in real life and others separate their real life and online life.
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deleted1183938
Why did you leave medicine for wallstreet? Money?
Because I can’t imagine the personalities there would be easy to get along with. I mean medicine is cutthroat but Wallstreet is in a different league.
This
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deleted1112838
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Exactly what "frustrations" do you think he was understandably "venting" when he gave the OP some sarcastic **** about his qualifications because he asked a question?
It's not that it isn't "well known" that some people go online to be asshats and vent their frustration.
It's that most of us are adult enough to not do that. Just because this is an open semi-anonymous forum doesn't mean it isn't dumb and annoying to others to dump random abuse on people. Don't try to normalize being a dick to strangers to make yourself feel better.
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deleted1183938
How interesting that you go after me for stating what people tend to do online in regards to venting and Call me a dick but you seem to not call others dickheads when they are normalizing abusing medical students and residents at work in real life? That’s real mature and adult isn’t it?
Maybe you are the OG of this place or something but if you are going to call people out, be a fair old papa. Or do you only pick and choose the newbies to school?
Personally I didn’t read his responses and I don’t care what he wrote. I was just saying in general as I have spent my fair share online in some other pages and see how people can behave.
I don’t need hypocrites schooling me. Nor some wanna be OG Papa telling me what I am doing to make myself feel better. You don’t know me Pops.
So until you call out your other OG papas equally for normalizing abuse I suggest you ignore people like me.
I didn't
Read again, for comprehension this time.
I asked m2w not to be a dick to people and I asked you not to normalize or excuse trolling in the name of "venting".
I'm a moderator for the forum, which means I try to steer people back toward being civil to each other.
Then why are you here?
OK, choco.
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deleted1183938
I responded to someone else. So no I didn’t read his responses and like I said I don’t care.
I am here because I came to spread some Take Medicine Back news and got roped in to all the drama.
And you are correct I misread, you didn’t call me a dick but you sure came after me for trying to normalize venting. And I don’t read every single response. Some things I just scroll bye and ignore.
And like I said Pops, as a moderator if you are going to go after me for “normalizing abuse” then go after everyone else as this other person I was going back and forth with was literally normalizing abusing students and not a peep from you.
Clearly you are a biased moderator. and a hypocrite.
Yeah, I warn, posthold, and ban sooooo many people. I'm such a moderating-happy moderator, drunk on power, that you didn't even know I was a moderator until I told you.
🙂
Lighten up, eh? This is supposed to be a fun place.
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deleted1183938
Fun place? Who came after who? You are so much fun.
You like to dish but can’t take it in return. I just made a general statment.
I never said anything about you drunk on power or banning people or whatever. I don’t know what you do or how you moderate. I just said you are hypocritical if you think me talking about people venting online is excusing abuse when someone who literally advocates for abuse you say absolutely nothing to.
Again, hypocrite.
Again -
I asked m2w not to be unpleasant to people asking clinical questions.
I asked you to not defend trolling. This isn't a place to vent at the expense of others.
I did tease you a bit at the end there by referring to you as choco. She was a famously histrionic former member who also openly admitted trolling the forum because it was a fun way for her to vent. You remind me of her and I'm still not 100% convinced you aren't her, posting under a new account.
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deleted1183938
What exactly is considered trolling?
And what’s wrong with online venting? I am not even speaking of specific people here. I go on Facebook in my groups and air frustrations. Lots of people do. So many rude people online and I bet many just use online media as an outlet.
I was not defending anyone specifically. Just said people do it.
I see a hell of a lot of it on here. The things people say here many would never, ever say in real life to the people they talk about.
Is that trolling? Is it Venting? What is the proper definition and whose rules say one is this verses the other?
From the nysora website.
In conclusion, anticoagulated patients receiving perineuraxial, deep plexus, or deep peripheral nerve blocks should be managed as if they are undergoing neuraxial anesthesia. Clinical discretion should be used for decision-making regarding the safety of other regional anesthesia techniques, such as superficial plexus blocks and nerve blocks. As an example, the vascularity and compressibility of the anatomical site where the blocks are being performed and the potential consequences of bleeding at those sites should be kept in mind. The risks of discontinuing anticoagulation therapy in these patients should be weighed versus the benefits of neuraxial and nerve block anesthesia and analgesia.
I actually am board certified. I've noticed that sometimes people who actually fail to get board certified are people like you who think they know it all. To completely dismiss the idea that INR may be relevant in a law suit or bad outcome is just ignorant of you.
Also I find it hard to believe you are not a douche in real life as you are on this forum. Sometimes people lack insight into what people actually think of them. I've worked with a surgeon who used to think the staff loved him and would constantly be making sexually suggestive jokes. Behind his back they all disposed him and eventually got fired because a nurse complained to admin about sexual harassment.
Stay humble.
Yup. Puts you in the hot seat. For outpatient elective cases, why do it with an abnormal INR when a lawyer will point it out? ASRA guidelines don’t necessarily stop lawsuits. American medicine is so great.
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deleted1183938
Are you slow? Is being a hypocrite the same as being mod happy?
WTF is even mod happy? What are you smoking? What dictionary are you using for this weird ass definition?
This post is choc full of unnecessary insults without making a morsel of sense. Huh, where have I seen this before?
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deleted1183938
I don’t know. In your dreams maybe?
To the person I posted it to and who responded, they made sense of it.
The point is made and been understood and responded to.
Arch Guillotti
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Lighten up Frances.
Choco*
You’ve been a “resident” for quite some time now. Curious.
Ha. Well not looking at an INR at all before a nerve block doesn’t answer should the surgery happen with “x” INR. I don’t trust most surgeons prediction on blood loss. I don’t want to be the first to transfuse PRBCs for a routine joint case. Hopefully you have better cohorts out there that you can trust
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deleted1112838
They keep extending it for some reason.
LOL
Every time I did something dumb I had an attending who'd say "well that's why it's a 5 year program" ...
If you are still a resident in 2027, the year aliens apparently show up, I will give some mad props for your trolling skills.
