On the topic of anticoagulation...

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
EruditeDoc

EruditeDoc

Full Member
5+ Year Member
Joined
Mar 4, 2017
Messages
61
Reaction score
9
I have an elderly gentleman with a multitude of comorbidities encompassing almost all organ systems including AFIB on Eliquis. I am contemplating bilateral GTB injections in the office. Would you stop the anticoagulant or continue? If you continued it, what would you do about risk of bleeding as he lives alone and has a hard time obtaining transport?
Members don't see this ad.
 
EruditeDoc said:
I have an elderly gentleman with a multitude of comorbidities encompassing almost all organ systems including AFIB on Eliquis. I am contemplating bilateral GTB injections in the office. Would you stop the anticoagulant or continue? If you continued it, what would you do about risk of bleeding as he lives alone and has a hard time obtaining transport?
Click to expand...

I started holding for flu shots and for all diabetics to give their injections and check sugars at home. Same risk.
 
Members don't see this ad :)
EruditeDoc said:
I have an elderly gentleman with a multitude of comorbidities encompassing almost all organ systems including AFIB on Eliquis. I am contemplating bilateral GTB injections in the office. Would you stop the anticoagulant or continue? If you continued it, what would you do about risk of bleeding as he lives alone and has a hard time obtaining transport?
Click to expand...

god no. its good you are asking. its bad that you dont already know the answer
 
I am new out of fellowship and planning to continue anticoagulation in general for procedures that aren't high risk, and will stop for procedures that are high risk (interlaminar ESI, stellate, LSB, etc)

I am curious as to what you would do if patient is on multiple anticoagulants if it changes what you do?

For example I had someone on asa, warfarin, and plavix (PAD, CAD). It turns out vascular had him on plavix that should've been stopped previously so we d/ced, and I did his lumbar MBB/RF on asa+warfarin. Not sure I would've done it if he were to stay on his plavix.
 
Last edited by a moderator:
ragnathor said:
I am new out of fellowship and planning to continue in general for procedures that aren't high risk (interlaminar ESI, stellate, LSB, etc)

I am curious as to what you would do if patient is on multiple anticoagulants if it changes what you do?

For example I had someone on asa, warfarin, and plavix (PAD, CAD). It turns out vascular had him on plavix that should've been stopped previously so we d/ced, and I did his lumbar MBB/RF on asa+warfarin. Not sure I would've done it if he were to stay on his plavix.
Click to expand...
educate yourself
 
ragnathor said:
I am new out of fellowship and planning to continue in general for procedures that aren't high risk (interlaminar ESI, stellate, LSB, etc)

I am curious as to what you would do if patient is on multiple anticoagulants if it changes what you do?

For example I had someone on asa, warfarin, and plavix (PAD, CAD). It turns out vascular had him on plavix that should've been stopped previously so we d/ced, and I did his lumbar MBB/RF on asa+warfarin. Not sure I would've done it if he were to stay on his plavix.
Click to expand...

EruditeDoc said:
I have an elderly gentleman with a multitude of comorbidities encompassing almost all organ systems including AFIB on Eliquis. I am contemplating bilateral GTB injections in the office. Would you stop the anticoagulant or continue? If you continued it, what would you do about risk of bleeding as he lives alone and has a hard time obtaining transport?
Click to expand...

You both seem like you literally have no idea at all what you are even talking about

Please read the ASRA guidelines, before you seriously harm some patients
 
Timeoutofmind said:
You both seem like you literally have no idea at all what you are even talking about

Please read the ASRA guidelines, before you seriously harm some patients
Click to expand...

I have read them, thanks. I think they are overly conservative and believe the SIS guidelines make more sense. They don't makd specific recommendations on multiple anticoagulation, thus the reason for the question. Probably I wouldn't do the procedure at all on a patient with multiple anticoagulation, but was just asking for opinions.
 
ragnathor said:
I am new out of fellowship and planning to continue in general for procedures that aren't high risk (interlaminar ESI, stellate, LSB, etc)

I am curious as to what you would do if patient is on multiple anticoagulants if it changes what you do?

For example I had someone on asa, warfarin, and plavix (PAD, CAD). It turns out vascular had him on plavix that should've been stopped previously so we d/ced, and I did his lumbar MBB/RF on asa+warfarin. Not sure I would've done it if he were to stay on his plavix.
Click to expand...

the issue isn't multiple anticoagulants. the issue is bleeding.

if your patient bleeds during a lumbar RFA, where are they bleeding, and will that cause a major complication that is worse than PE, stroke, MI, and possible death from holding the anticoagulant.
 
I am very familiar with the ASRA guidelines. I feel like they are not clear and leave quite a bit of room for interpretation based on the individual patient. In fact, I verbally spoke to 2 different pain docs in my office and both had differing opinions on the matter!

In the patient that I mentioned, I fully understand the implications of stopping anticoagulation. HOWEVER, there is a social factor to consider and if there are adverse events there may be difficulty addressing them ... I always put some consideration to what could occur with patients on either side of a scenario

Also everyone tends to have different ways of practicing and experiences on this forum which is why I posted to garner opinions of what others might do with a patient in this case vs. what others have done. Tips such as what size needle to use, utilizing image guidance, etc.are helpful

Negative statements with no specific commentary on the scenario are useless
 
EruditeDoc said:
I have an elderly gentleman with a multitude of comorbidities encompassing almost all organ systems including AFIB on Eliquis. I am contemplating bilateral GTB injections in the office. Would you stop the anticoagulant or continue? If you continued it, what would you do about risk of bleeding as he lives alone and has a hard time obtaining transport?
Click to expand...
He bleeds in area of GTB injection? Bfd. What’s the worst thing that happens? A bruise or superficial hematoma with no vital structures to compress.

You stop the AC and what’s the worst that happens....?
 
Members don't see this ad :)
DOctorJay said:
the issue isn't multiple anticoagulants. the issue is bleeding.

if your patient bleeds during a lumbar RFA, where are they bleeding, and will that cause a major complication that is worse than PE, stroke, MI, and possible death from holding the anticoagulant.
Click to expand...

Thanks for an actual response. Certainly I'd expect to an extraspinal hematoma to be nowhere near as catastrophic as the other complications. Where I trained and where I am now there were/are some holding single anticoagulation for all lumbar mbb/RFA which I disagree with. I hadn't encountered multiple anticoagulation so just wanted to see if people's opinions changed. If I were to do the procedure after discussing risks/benefits, I would likely continue both then.
 
ragnathor said:
I am new out of fellowship and planning to continue in general for procedures that aren't high risk (interlaminar ESI, stellate, LSB, etc)

I am curious as to what you would do if patient is on multiple anticoagulants if it changes what you do?

For example I had someone on asa, warfarin, and plavix (PAD, CAD). It turns out vascular had him on plavix that should've been stopped previously so we d/ced, and I did his lumbar MBB/RF on asa+warfarin. Not sure I would've done it if he were to stay on his plavix.
Click to expand...
Hopefully you are misquoting and plan to stop real anticoagulants IE eliquis for intralaminar procedures
 
Ronin1 said:
Hopefully you are misquoting and plan to stop real anticoagulants IE eliquis for intralaminar procedures
Click to expand...

Yes, I realize that first line as written makes me sound like an idiot, I've corrected it. What was in parentheses was what I consider high risk and plan to stop for anticoagulation for.
 
While we are on this topic, there is a new study which was presented at SIS of risk vs benefit of holding anticoagulants even for interlaminars.
 
bluehighlighter said:
Do you have a link to this?
Click to expand...

Not the exact one but here is something similar.

ain Med. 2018 Mar 1;19(3):438-448. doi: 10.1093/pm/pnx152.
Risks and Benefits of Ceasing or Continuing Anticoagulant Medication for Image-Guided Procedures for Spine Pain: A Systematic Review.
Smith CC1, Schneider B2, McCormick ZL3, Gill J4, Loomba V5, Engel AJ6, Duszynski B7, King W8; Standards Division of the Spine Intervention Society.
Author information

Abstract
OBJECTIVE:
To determine the risks of continuing or ceasing anticoagulant or antiplatelet medications prior to image-guided procedures for spine pain.

DESIGN:
Systematic review of the literature with comprehensive analysis of the published data.

INTERVENTIONS:
Following a search of the literature for studies pertaining to spine pain interventions in patients on anticoagulant medication, seven reviewers appraised the studies identified and assessed the quality of evidence presented.

OUTCOME MEASURES:
Evidence was sought regarding risks associated with either continuing or ceasing anticoagulant and antiplatelet medication in patients having image-guided interventional spine procedures. The evidence was evaluated in accordance with the Grades of Recommendation, Assessment, Development, and Evaluation system.

RESULTS:
From a source of 120 potentially relevant articles, 14 provided applicable evidence. Procedures involving interlaminar access carry a nonzero risk of hemorrhagic complications, regardless of whether anticoagulants are ceased or continued. For other procedures, hemorrhagic complications have not been reported, and case series indicate that they are safe when performed in patients who continue anticoagulants. Three articles reported the adverse effects of ceasing anticoagulants, with serious consequences, including death.

CONCLUSIONS:
Other than for interlaminar procedures, the evidence does not support the view that anticoagulant and antiplatelet medication must be ceased before image-guided spine pain procedures. Meanwhile, the evidence shows that ceasing anticoagulants carries a risk of serious consequences, including death. Guidelines on the use of anticoagulants should reflect these opposing bodies of evidence.
 
I sometimes wonder if there are NPs or PAs doing IPM who post questions on here and all of us suckers help educate them and further advance their practices
 
conclusion:

The most recent edition of the anticoagulation guidelines of the American Society of Regional Anesthesia and Pain Medicine, together with other societies [10], reclassified lumbar medial branch blocks and lumbar radiofrequency neurotomy as low-risk procedures. The recommendation for these procedures is that anticoagulants not be discontinued. The results of the present study vindicate this recommendation for medial branch blocks, but they also strongly invite lumbar transforaminal injections to be added to the category of low-risk procedures.
Click to expand...
in other words, MBB and RFA - continue anticoag. for lumbar TF, consider continuing anticoag.


my question: are we seeing low risk of bleeding from TF because of the use of 25 gauge needle instead of lack of complication from continuing anticoagulation?
 
MD87 said:
Author says 25g for TFESI. Is this what you’re using? I hate using 25g for 5 inch needles. Though maybe I should use them to avoid holding AC?


Sent from my iPhone using SDN mobile
Click to expand...
You won’t have any problems with 22g 5-inch needles either. Stay a bit lateral of 6 o’clock if you are concerned and you’ll be fine.
 
Ducttape said:
conclusion:

in other words, MBB and RFA - continue anticoag. for lumbar TF, consider continuing anticoag.


my question: are we seeing low risk of bleeding from TF because of the use of 25 gauge needle instead of lack of complication from continuing anticoagulation?
Click to expand...
The way I read this, don't hold anticoagulation (i.e. continue blood thinneres) for LMBB, LRFA, and TFESI.
 
EruditeDoc said:
I have an elderly gentleman with a multitude of comorbidities encompassing almost all organ systems including AFIB on Eliquis. I am contemplating bilateral GTB injections in the office. Would you stop the anticoagulant or continue? If you continued it, what would you do about risk of bleeding as he lives alone and has a hard time obtaining transport?
Click to expand...

Continue- a little bleeding there is of no consequence. In fact, if you believe the PRP guys, the blood may be therapeutic. :heckyeah:
 
Courtroom - Here's a sentence that helps IMO - "Stopping AC has been shown to result in events that can't be treated, like a CVA...While a bleed can be drained in the OR."
 
lobelsteve said:
Bent tip. Belly technique, catch fascial plane and continue to foramen. Could not do with a down the barrel approach.
Click to expand...
Maybe I'm being dumb here, but can you explain this in more detail for me? Belly technique?

I've already switched all by LESI/CESI to your 25G CLO technique and love it. Would love to learn the tricks to hang up my 22 for good.
 
lobelsteve said:
I've been in the court room for this. Wrongful death/malpractice for stopping anticoag for a hip injection.
Click to expand...

dont play coy. hip inj does not = LESI

any one of us could have been the expert witness in that case. there was no gray area. lots of gray with ESI and anti-coags.
 
SSdoc33 said:
dont play coy. hip inj does not = LESI

any one of us could have been the expert witness in that case. there was no gray area. lots of gray with ESI and anti-coags.
Click to expand...
Then you completely misinterpreted what I was saying. There’s no risk in the spine that equals death except for cervical tfesi. You’re also unable to determine the risk as far as the likelihood of one thing happening versus the other.
The calculations have been performed and I think I have them saved somewhere. There is a risk for epidural injections regarding epidural hematoma both on and off anticoagulant. Epidural hematoma requiring surgery is a known complication and it something that is a fairly easy to get Morley adequate informed consent for. Telling someone to stop the medication and they might die is a different beast all together.
 
Epidural injections to not cured cancer and did not see it live. The marginally effective in a cute radiculopathy and possibly effective for spinal stenosis. Both of these are not as common as all other reasons for the injections to be performed.

if you’re going to make the wrong decision on anticoagulation you’ll find that out after the fact. Think of it like war game. If you can’t decide the right way the best answer is to not play that game I do not offer that shot.
 
in general, i am in agreement with you. strokes and heart attacks are way worse than anything we deal with.

a better precedent you could give us is if you are aware of a legal case where anticoagulation was stopped and there was an ischemic event. of if it was continued and there was a bleed. your hip case is, frankly, irrelevant.

at least half of us still stop anticoagulation for ESIs. the endres data is compelling, but evidently not compelling enough to have SIS take a firm stance on this. why? because they dont want the liability either. im coming closer, but still not there
 
SSdoc33 said:
in general, i am in agreement with you. strokes and heart attacks are way worse than anything we deal with.

a better precedent you could give us is if you are aware of a legal case where anticoagulation was stopped and there was an ischemic event. of if it was continued and there was a bleed. your hip case is, frankly, irrelevant.

at least half of us still stop anticoagulation for ESIs. the endres data is compelling, but evidently not compelling enough to have SIS take a firm stance on this. why? because they dont want the liability either. im coming closer, but still not there
Click to expand...

The hip case: On Plavix x5 years. Stopped for 7days IA hip injection. Died of MI the night of hip injection.
 
lobelsteve said:
The hip case: On Plavix x5 years. Stopped for 7days IA hip injection. Died of MI the night of hip injection.
Click to expand...

SMH. i remember that 101n argued way back in the day for stopping blood thinners before hip injections b/c he had a hemarthrosis once. i would love to be able to say to patients that blood thinners never need to be stopped. it would be SO much easier and less confusion. i still see patients who come to see my in clinic b/c they think they are getting a shot and have already held their plavix 7 days. WTF?
 
we want to do what’s best for patients but telling the story about the guy who had an MI the night of a hip injection bc plavix was held isn’t going to help in the court room if ur patient is paralyzed from an epidural hematoma from an ESI and u didn’t hold anticoagulantion bc of this study
 
painfree23 said:
we want to do what’s best for patients but telling the story about the guy who had an MI the night of a hip injection bc plavix was held isn’t going to help in the court room if ur patient is paralyzed from an epidural hematoma from an ESI and u didn’t hold anticoagulantion bc of this study
Click to expand...
But when you hold it and he dies from MI you are in court and add extra zeroes.

which is worse?
Which is more likely?
 
You must log in or register to reply here.

Similar threads

O
Thoracic TFESI and anticoagulation
Replies
37
Views
2K
oneforfighting
O
GlowInTheDark
Topic ideas for annual department conference?
Replies
4
Views
453
kstarm
K
drusso
Congratulations Kristen Klein Pain APP of the Year
Replies
12
Views
1K
clubdeac
clubdeac
B
Anticoagulation for RFA
Replies
25
Views
2K
geauxg8rs
G
ErrantWhatever
"When your practice owns 100% of the ASC" question...
2
Replies
56
Views
4K
nvrsumr
N
Top