ISIS Anticoagulant Guidelines

[lobelsteve]

http://spinalinjection.site-ym.com/?page=ANTICFF

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[Pain Applicant1]

I'm glad to see this. I've recently pretty much stopped requiring anticoagulation cessation for anything outside of the epidural space. Epidural space I'll still hold and large joints may be a concern (but still not holding) but I don't see the big deal if they bleed from MBB/RF. The blood won't really go anywhere.

 

[emd123]

Beautiful. Lumbar and cervical Rf they say, "Continue anticoagulation."

I'm also assuming that would apply to diagnostic MBB since the needle placement is identical.

(Don't know if MBB could be considered "extra spinal" though, since your needle does theoretically contact the spine, though it never goes neuraxial.)

Do we all take this to mean "continue anticoagulation for all cervical/thoracic/lumbar MBBs and RFs"?

I think yes.

 

[lobelsteve]

Beautiful. Lumbar and cervical Rf they say, "Continue anticoagulation."

I'm also assuming that would apply to diagnostic MBB since the needle placement is identical.

(Don't know if MBB could be considered "extra spinal" though, since your needle does theoretically contact the spine, though it never goes neuraxial.)

Do we all take this to mean "continue anticoagulation for all cervical/thoracic/lumbar MBBs and RFs"?

I think yes.

For the last 8 years, no problems.

 

[geauxg8rs]

For those who do not hold anticoagulants for RFA,

Do you use a smaller needle or use the same size (18 or 20G)? What about cervical? any changes there?
this helps.

I went to the CCF pain symposium a month ago and Benzon was saying that they were working on new guidelines for ASRA to be consensus international guidelines and to include pain procedures (rather than just spinal/epidural for anesthesia). He seemed to hint that they would be conservative. I like the sound of these ISIS ones better.

 

[bedrock]

Don't hold for MBB/LBB, SIJ, but I hold for RF.

Ideal ISIS RF placement involves at some mild-moderate scraping along bone to ensure the cannula is next to the nerve you're burning. This produces mild oozing in some patients, but I'd worry about doing this with someone on plavix.

I may start allowing patients to continue blood thinners for lumbar/SIJ RF, but I don't see myself doing that for cervical RF.

 

[Aether2000]

Since 2002 have not held any anticoagulants, antiplatelet, or NSAIDS for MBB, IA facet injections, RF of lumbar and cervical MB, sacroiliac joint, troch bursa, IA hip, IA knee injections, peripheral nerve injections. For caudal ESI have held them only if there would not be any significant risk to the patient, and if so, then continued these with a short needle high volume caudal ESI. Have always held them for TFESI and discograms (any level). There is a significant risk to the radicularis magna with any thoracic or lumbar TFESI or discogram. There is a risk to the vertebral and carotid arteries for cervical TFESI or discography.

 

[ampaphb]

Algos, when you do ESIs and discograms, do you do hold Celebrex? Mobic? Non-COX specific NSAIDs?

 

[drrinoo]

for the record--they selectively omit publications
its amazing that a specialty society doesn't even make an effort to cite literature (that is freely available)-frankly it is irresponsible

take a look a tables 7-10 in the 2004 paper- which to my knowledge was the first attempt to stratify risk based on patient factors (anticoagulant) and procedure factors


Display Settings:AbstractThe following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version.Destroy user interface controlSend to:
Pain Physician. 2004 Jan;7(1):3-51.
Bleeding risk in interventional pain practice: assessment, management, and review of the literature.
Raj PP, Shah RV, Kaye AD, Denaro S, Hoover JM.
Source
World Institute of Pain, Section of Pain Practice, 4748 Matterhorn Way, Antioch, CA 94521, USA. [email protected]
Abstract
The rarity of published bleeding complications with respect to the practice of interventional pain medicine suggests two possibilities: techniques are being performed in a manner to minimize bleeding or the process of hemostasis is very forgiving. Hence, bleeding complications may increase if techniques are not performed with due skill or if the process of hemostasis is impaired. Interventional pain physicians may be well acquainted with the technical aspects of procedures, but the degree of their expertise in the field of coagulation is unclear. This monograph will review coagulation physiology, coagulation pathophysiology, common anticoagulants, and minor and major bleeding complications associated with interventional pain and regional anesthetic procedures. This manuscript will present a tool to help stratify the risk of bleeding with specific techniques and specific hemostatic abnormalities. The Overall Risk of Significant Bleeding score may help interventional pain practitioners in their individualized assessment of bleeding risk. If used collectively, this tool may help improve patient safety and data collection, with respect to bleeding complications.
Comment in
The following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version.Destroy user interface controlClopidogrel use after spinal cord stimulator implantation. [Pain Physician. 2004]
PMID: 16868610 [PubMed] Free full text

Current Opinion in Anaesthesiology:
August 2008 - Volume 21 - Issue 4 - p 433-438
doi: 10.1097/ACO.0b013e328306eb75
Drugs in anesthesia: Edited by Alan D. Kaye
Bleeding risk and interventional pain management
Shah, Rinoo Va; Kaye, Alan Db

Abstract
Purpose of review: Interventional pain management is an emerging specialty that uses procedures to diagnose and treat chronic pain. Most of these procedures are performed percutaneously and carry a risk of bleeding. Patients undergoing these treatments may be receiving exogenous anticoagulants. The pain practitioner faces a dilemma in performing an elective procedure on a patient with a bleeding risk.

Recent findings: A literature review about coagulation physiology and pathophysiology, anticoagulants, and bleeding complications in interventional pain would be useful to a busy pain physician. This review aims to meet this knowledge goal.

Summary: Knowledge about normal and impaired hemostasis, coupled with a bleeding risk tool, enables practitioners to make informed decisions when offering interventional pain care to their patients.



Results: 4
Select item 23159981
1.
Assessment of practice patterns of perioperative management of antiplatelet and anticoagulant therapy in interventional pain management.
Manchikanti L, Benyamin RM, Swicegood JR, Falco FJ, Datta S, Pampati V, Fellows B, Hirsch JA.
Pain Physician. 2012 Nov-Dec;15(6):E955-68.
PMID: 23159981 [PubMed - in process] Free Article
Related citations
Select item 22430660
2.
Complications of fluoroscopically directed facet joint nerve blocks: a prospective evaluation of 7,500 episodes with 43,000 nerve blocks.
Manchikanti L, Malla Y, Wargo BW, Cash KA, Pampati V, Fellows B.
Pain Physician. 2012 Mar-Apr;15(2):E143-50.
PMID: 22430660 [PubMed - indexed for MEDLINE] Free Article
Related citations
Select item 22430650
3.
A prospective evaluation of complications of 10,000 fluoroscopically directed epidural injections.
Manchikanti L, Malla Y, Wargo BW, Cash KA, Pampati V, Fellows B.
Pain Physician. 2012 Mar-Apr;15(2):131-40.
PMID: 22430650 [PubMed - indexed for MEDLINE] Free Article
Related citations
Select item 21785475
4.
A prospective evaluation of bleeding risk of interventional techniques in chronic pain.
Manchikanti L, Malla Y, Wargo BW, Cash KA, McManus CD, Damron KS, Jackson SD, Pampati V, Fellows B.
Pain Physician. 2011 Jul-Aug;14(4):317-29.
PMID: 21785475 [PubMed - indexed for MEDLINE] Free Article
Related citations

 

[Aether2000]

The incidence of bleeding complications is so low that it makes even large prospective studies and retrospective reviews difficult to interpret. Many have no statistical validity and those that do may have no clinical validity. I applaud ISIS for at least making an attempt at a consensus statement even if it would not withstand statistical rigorous analysis. ASIPP previously has made significant contributions in answering these questions, but came at it from a different angle. We need both approaches when there are no clear cut answers.

 

[lobelsteve]

http://www.painphysicianjournal.com/2004/january/2004;7;3-51.pdf

RInoo's 2004 article link.

 

[Aether2000]

Impressive work....47 page reference article!

 

[oreosandsake]

http://spinalinjection.site-ym.com/?page=ANTICFF

Hey Steve - wondering if there is a pubmed document with the formal guidelines. I do not own the new edition

Although I am almost certain what it will say, I am looking for a statement regarding NSAIDs.

 

[ihaveaquestion]

Hey Steve - wondering if there is a pubmed document with the formal guidelines. I do not own the new edition

Although I am almost certain what it will say, I am looking for a statement regarding NSAIDs.

Look up the ASRA guideline article.

 

[oreosandsake]

Look up the ASRA guideline article.

thank you.

I have seen those. I have also seen the recent ASIPP review. What I need to find is a document (if it exists) from ISIS. the chart from the website only describes levels of risk with anticoagulation. I do not own the new isis book.

Wondering if they ever published a formal guideline re AC/antiplatelet meds. I could not find one on pubmed.

 

[Aether2000]

thank you.

I have seen those. I have also seen the recent ASIPP review. What I need to find is a document (if it exists) from ISIS. the chart from the website only describes levels of risk with anticoagulation. I do not own the new isis book.

Wondering if they ever published a formal guideline re AC/antiplatelet meds. I could not find one on pubmed.

 

[Aether2000]

ISIS has never published a formal guideline since that requires comprehensive literature review and evaluation. This project would be huge. I am unsure if ASRA guidelines are in the National Guideline Clearinghouse, the organization tasked with placing some standards on guideline makers.

 

[emd123]

ISIS has never published a formal guideline since that requires comprehensive literature review and evaluation. This project would be huge. I am unsure if ASRA guidelines are in the National Guideline Clearinghouse, the organization tasked with placing some standards on guideline makers.

In the new ISIS guideline book, they list procedure by procedure, whether anticoagulation is absolute, relative or not- contraindicated, and have an entire section on it.

 

[Aether2000]

It is a best practice book that is not a formal guideline. Formal guidelines are published in the clearinghouse