New ASRA Guidelines

[crazywiththecheezwhiz]

I feel silly asking this. With the new guidelines, it looks like lumbar facet injections/RFA (or other low-risk procedures) can now be done while continuing Plavix.... BUT if the patient is also on another antiplatelet agent (such as ASPIRIN), then the guideline goes back to waiting for 7 days or having a shared risk assessment.

Most of my patients that are on Plavix are also on ASA... what do you guys do in this situation, given the new guidelines?

Also, by the guidelines, what constitutes "old age" when determining if a patient is at a higher risk of bleeding?

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[lonelobo]

Do not stop anticoagulants on any axial or peripheral (NON-Epidural) injection

 

[lobelsteve]

Do not stop anticoagulants on any axial or peripheral (NON-Epidural) injection

And kypho, SCS, LSB, or intradiskal (if anyone still doing this).

 

[emd123]

I feel silly asking this. With the new guidelines, it looks like lumbar facet injections/RFA (or other low-risk procedures) can now be done while continuing Plavix....

I haven't stopped anticoagulants for facet procedures, in years. I've never had a problem.

By the way, do you have a link to the new guidelines you're referring to?

 

[willabeast]

If this were eye surgery you would hold the aspirin and continue the plavix. Reason i know is a relative asked and i looked it up on "up to date".

 

[crazywiththecheezwhiz]

I can't post links for some reason.... can someone "like" my posts so that I have enough in my like to post ratio?

Here is the reference in the meantime: Regional Anesthesia and Pain Medicine: April 2018 - Volume 43 - Issue 3 - p 225–262

 

[crazywiththecheezwhiz]

And kypho, SCS, LSB, or intradiskal (if anyone still doing this).

Joking, right?

 

[lobelsteve]

Joking, right?

Those are reasons to hold blood thinners. As is interlaminar. I do not hold for tfesi.

 

[deleted472101]

Those are reasons to hold blood thinners. As is interlaminar. I do not hold for tfesi.

What about caudal?

I hold but I always wonder if it is necessary due to the needle location.

 

[Disciple]

Those are reasons to hold blood thinners. As is interlaminar. I do not hold for tfesi.

Do any of the available guidelines support this? I ask because I booked a patient today on Plavix for lumbar tfesi. Then called his cardiologist who said do not stop Plavix. Have not decided if I’ll proceed with the injection.

 

[Dr. Ice]

Do any of the available guidelines support this? I ask because I booked a patient today on Plavix for lumbar tfesi. Then called his cardiologist who said do not stop Plavix. Have not decided if I’ll proceed with the injection.

Have not stopped plavix for lumbar tfesi in quite some time now. Also not stopped for mbb, rf or joints.

 

[lobelsteve]

Sis supports.

 

[bedrock]

What about caudal?
I’d say it depends on your technique. If you just barely pop 1mm through the ligament like some docs, and stop right there, I’d argue that patients can stay on thinners for those casuals.

I hold but I always wonder if it is necessary due to the needle location.

Depends on technique. If you just pop 1mm through ligament like some docs, I’d argue those cases don’t need to hold thinners, again particularly for the docs that use that technique and 25G needles.

Personally, I think you very often achieve inconsistent superior epidural flow that way, so I typically advance to s3-s4 junction with a 22G Quincke. This can involve some mild bone scraping and since this is an enclosed spinal canal, i hold thinners.

Have not stopped plavix for lumbar tfesi in quite some time now. Also not stopped for mbb, rf or joints.

SIS makes some good arguments for not holding thinners routinely for TFESI and should offer some legal protection for TFESI cases on thinners.
I’m going to allow patients to stay on thinners for all lumbar TFESI superior to S1.

However, S1, S2 differ in that your needle isn’t 95% outside the canal like in most TFESI, and you get venous flow and bleeding very frequently at those two levels, so I will continue to hold blood thinners thinners for S1 or S2 TFESI.