Pain Procedures and anticoagulants

[SIIMS]

I revisited some prior threads but would appreciate some posts about what your current practice is regarding this....

What pain procedures do you 1. Do, 2. Not Do on Plavix/Warfarin/ASA

I believe the practice I'm in is extremely conservative so I would like some opinions before I attempt to bring about some type of change for patient safety (it seems like this applies to 1/4 in my practice)

Thanks

Also if you deviate from ASRA guidelines what would your defense be if you had a bad outcome as this seems to be the standard for "neuroaxial"

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[powermd]

I revisited some prior threads but would appreciate some posts about what your current practice is regarding this....

What pain procedures do you 1. Do, 2. Not Do on Plavix/Warfarin/ASA

I believe the practice I'm in is extremely conservative so I would like some opinions before I attempt to bring about some type of change for patient safety (it seems like this applies to 1/4 in my practice)

Thanks

Also if you deviate from ASRA guidelines what would your defense be if you had a bad outcome as this seems to be the standard for "neuroaxial"

On Plavix/Warfarin:
Anything non-neuraxial that can be accomplished with a 20g needle or smaller.
MBB/RF
Caudal (special technique possibly unique to our practice- 25 or 27g needle perpendicular to sacrum and through SC ligament, no driving needle all the way up the hiatus)

We hold Plavix 7 days, Warfarin 5 days (INR <1.3), Pradaxa 5 days for TL/TF epidurals, LSB/SHPB, SCS, kypho. In my last practice we would do neuraxial with a 5 day hold on Plavix, and my boss would frequently do epidurals without stopping Plavix. Glad I got out of there!

I saw a new one for me yesterday- I had a patient with factor V Leiden deficiency who takes Nattokinase, a soy based supplement for anticoagulation. No thrombotic events in her history, or since she started the stuff about a year ago. I did a quick search of pubmed and couldn't find any indication of how long the drug would need to be held before a neuraxial procedure. Anyone have knowledge of this?

 

[facets]

Caudal (special technique possibly unique to our practice- 25 or 27g needle perpendicular to sacrum and through SC ligament, no driving needle all the way up the hiatus)

No I do the same thing for people who cannot be taken off anticoagulants. I do a caudal with a tiny needle, no shoving it up the canal or mucking about. They do work. I will very carefully do a mbb in patients in whom I belive the risk of being taken off the anticoagulents is too high for 2 sets of MBB, i will take them off for the RF

 

[Ducttape]

now i am curious...

how many people would do MBB on plavix, pradaxa or coumadin? I have routinely stopped anticoagulation on those particular patients... and besides using smaller than a 20 gauge (which i do anyways), any changes in technique?

finally, i recently read a published paper on doing the "trial" MBB, using local, then proceeding with the RFA. Anyone try that, and/or have problems with ins. coverage?

 

[SSdoc33]

now i am curious...

how many people would do MBB on plavix, pradaxa or coumadin? I have routinely stopped anticoagulation on those particular patients... and besides using smaller than a 20 gauge (which i do anyways), any changes in technique?

finally, i recently read a published paper on doing the "trial" MBB, using local, then proceeding with the RFA. Anyone try that, and/or have problems with ins. coverage?

no MBBs for me on patients on plavix or coumadin, despite what my brain tells me....

 

[specepic]

I will do SIJ but nothing else in the spine on thinners. The only time I had an epidural bleed was a Lumbar FJI on pt taking excessive Aleve (which he later revealed). I don't know about you but I create a lot more bleeding with RFA than I ever do with ESIs.

 

[PMR 4 MSK]

now i am curious...

how many people would do MBB on plavix, pradaxa or coumadin? I have routinely stopped anticoagulation on those particular patients... and besides using smaller than a 20 gauge (which i do anyways), any changes in technique?

finally, i recently read a published paper on doing the "trial" MBB, using local, then proceeding with the RFA. Anyone try that, and/or have problems with ins. coverage?

I do not stop anticoagulants for MBB. My theory is the risk of taking them off the meds is far higher than any damage you could cause with your needle.

Watch someone lose their ability to speak right in front of you before you do a procedure and you'll quickly rethink your approach as well. Lucky for that pt it was a TIA.

 

[stim4u]

i agree with you.
would be nice if somebody publishes something regarding anticouagulants and MBB block safety.

 

[Mister Mxyzptlk]

I keep the thinners going for extra-spinal procedures like facets (except C1/2), MBB, SI. Anything that goes into the canal, I hold them.

 

[jsaul]

I will do SIJ but nothing else in the spine on thinners. The only time I had an epidural bleed was a Lumbar FJI on pt taking excessive Aleve (which he later revealed). I don't know about you but I create a lot more bleeding with RFA than I ever do with ESIs.

did your needle go through the joint all the way?

 

[Jcm800]

no MBBs for me on patients on plavix or coumadin, despite what my brain tells me....

me neither.

i will do SI, hip, knees, shoulders, etc...

 

[101N]

I would advise against hips, knees, and shoulders while on anticoagulation. Risk of hemarthrosis is too high.

 

[Aether2000]

Will do MBB, medial branch RF, sacroiliac and z-joint injections, ganglion of impar, peripheral joint and nerve injections, bursa injections all routinely on warfarin, plavix, or any other anticoagulant.
Will do caudal ESI, vertebroplasty, sphenopalatine ganglion injection/RF with the anticoags on board only if they cannot be taken off the anticoagulant.
Will not do TFESI, IL ESI, lateral recess blocks, catheter passage in the canal, spinal injections, discography, celiac plexus blocks, grey ramus communicans blocks/RF, stellate ganglion, splanchnic nerve blocks, glossopharyngeal nerve blocks unless anticoags have been stopped for the appropriate amount of time.

 

[jj337]

If patient only needs one MBB prior to going to RF, I generally hold the anti-coagulant and do MBB and plan on RF within 1 to 2 days if positive so I only need to come off anti-coagulation once.

 

[lobelsteve]

I would advise against hips, knees, and shoulders while on anticoagulation. Risk of hemarthrosis is too high.

Hope you are joking- cause your talking out your ass and could kill someone by unnecessarily holding their anticoags.

 

[101N]

Hope you are joking- cause your talking out your ass and could kill someone by unnecessarily holding their anticoags.

I've caused a knee hemarthrosis on a patient who was on warfarin who I performed and arthrocentesis/cortisone injection on. It wasn't pretty and he had to be admitted almost requred debridement/drainage. I'm not joking. If it REALLY needs to be done bridge them with LMWH, hold the dose the day of, and then restart LMWH and warfarin.

 

[bedrock]

Hope you are joking- cause your talking out your ass and could kill someone by unnecessarily holding their anticoags.

I'm with steve on this.
(And keeping patients on blood thinners for peripheral joint injections is the standard of care by the way)

Hemarthrosis isn't fun, but a stroke is WAY less fun.....!

 

[101N]

I'm with steve on this.
(And keeping patients on blood thinners for peripheral joint injections is the standard of care by the way)

Hemarthrosis isn't fun, but a stroke is WAY less fun.....!

Standard of care. Show me the literature.

If you cause a hemarthrosis without having offered the patient bridging YOU are liable.

 

[bedrock]

Standard of care. Show me the literature.

Show me the literature showing that holding blood thinners for peripheral joint injections is the standard of care-

I can't think of a single orthopedic surgeon who ever stopped blood thinners for a shoulder/knee/hip injection. Not one, and I've worked with hundreds, including orthopedists at Mayo and Harvard.

 

[lobelsteve]

I apologize for my inflammatory remarks. I cannot discuss further at this time. Risk of hemarthrosis is less than stroke/stent thrombosis under 1 year/MI. Morbidity/mortality much higher with latter than former.

 

[101N]

I apologize for my inflammatory remarks. I cannot discuss further at this time. Risk of hemarthrosis is less than stroke/stent thrombosis under 1 year/MI. Morbidity/mortality much higher with latter than former.

Apology excepted Don't know the right answer, 'once burned twice shy".

 

[SSdoc33]

out of curiosity, do you know the INR when the patient had the hemarthrosis?

you can get a spontaneous hemarthrosis even without an injection if you are on coumadin.

ive done hundreds of hips and shoudlers on coumadin without a problem -- yet. i suppose if i had a big bleed i might think twice, though

 

[101N]

out of curiosity, do you know the INR when the patient had the hemarthrosis?

you can get a spontaneous hemarthrosis even without an injection if you are on coumadin.

ive done hundreds of hips and shoudlers on coumadin without a problem -- yet. i suppose if i had a big bleed i might think twice, though

Good question. INR was 2.6. It wasn't spontaneous, I caused it.

Because of this case I will now bridge all hips and knees that need an injection.

 

[SIIMS]

Thanks for the posts,

Looks like their is a mixed bag going on out there

In residency (PM&R) we did not hold for shoulders/hips, done under US

In fellowship we would not hold for SI's peripheral joints and TPI's but for all others it was held per ASRA guidelines

For those of you who are bridging people with LMWH, are you writing the orders or having the patients primary organizing it?

 

[101N]

I will call the primary or cardiologist responsible for the anticoagulation, explain the rationale for the proposed procedure, and ask them if the patient is safe to be bridged or off anticoagulation. If they
are safe I will offer to do the bridge but more often than not the cardiologist or primary does it.

I do this for all hips and knees. I've never had a shoulder arthrogram on a patient on long-term anticoagulation. I will perform subacromial injections on patients who are on anticoag.

 

[clubdeac]

I would advise against hips, knees, and shoulders while on anticoagulation. Risk of hemarthrosis is too high.

That's what happens when you use a 14G to inject

 

[specepic]

I've caused a knee hemarthrosis on a patient who was on warfarin who I performed and arthrocentesis/cortisone injection on. It wasn't pretty and he had to be admitted almost requred debridement/drainage. I'm not joking. If it REALLY needs to be done bridge them with LMWH, hold the dose the day of, and then restart LMWH and warfarin.

Holding anti-coag for joint injection is not the standard of care, it appears to be your opinion/choice. I have also never seen anyone hold anticoag for joint inj, I think you are the outlier. I do appreciate your story though. I hold anticoag for MBBs/facets which some people also think is overkill.

I bleed in the knee is a TOTALLY different scenario than the spine. I would argue that the risk/benefit ratio of holding/messing with anticoag for a joint injection is not favorable for your paradigm. Do you do this out of medical legal fear or b/c you actually feel it is appropriate? Do you use U/S?

I have never seen an issue with this but have seen strokes with pts waiting for ESI off coumadin. Odds ratio is undoubtably not in your favor imho. You will not be convinced however as you are a stubborn bastard like the rest of us.

 

[101N]

Holding anti-coag for joint injection is not the standard of care, it appears to be your opinion/choice. I have also never seen anyone hold anticoag for joint inj, I think you are the outlier. I do appreciate your story though. I hold anticoag for MBBs/facets which some people also think is overkill.

I bleed in the knee is a TOTALLY different scenario than the spine. I would argue that the risk/benefit ratio of holding/messing with anticoag for a joint injection is not favorable for your paradigm. Do you do this out of medical legal fear or b/c you actually feel it is appropriate? Do you use U/S?

I have never seen an issue with this but have seen strokes with pts waiting for ESI off coumadin. Odds ratio is undoubtably not in your favor imho. You will not be convinced however as you are a stubborn bastard like the rest of us.

Your argument only holds water if there is a substantially increased risk of an embolic or thrombotic event due to bridging. Note that I was never merely suggesting holding the patients anticoagulation.

Show me the literature...

 

[lobelsteve]

Your argument only holds water if there is a substantially increased risk of an embolic or thrombotic event due to bridging. Note that I was never merely suggesting holding the patients anticoagulation.

Show me the literature...

It's not the literature. It's when the suit is filed: would you rather defend hemarthrosis or death ?

 

[Jcm800]

It's not the literature. It's when the suit is filed: would you rather defend hemarthrosis or death ?

He won't have to defend death, he is bridging them. I think it's looney to bridge someone for joint injections, but arguably he won't get a hemarthrois OR a stroke...

Excessive IMO, but legally and medically safe

 

[PinchandBurn]

He won't have to defend death, he is bridging them. I think it's looney to bridge someone for joint injections, but arguably he won't get a hemarthrois OR a stroke...

Excessive IMO, but legally and medically safe

exactly...wht's wrong with bridging. I think it's safer. Some of my older patinets hate it. They're like "doc I hate doing those shots in the stomach". But then they wink at me and tell me they'd rather be safe and that they understand.....

Just remember , most of these are 'elective' procedures. I'd hate to have a patient come in for a joint injection and then next day be in the hospital s/p I and D of a hematoma in the knee/hip......

Just bridge them.....or have their pcp/cardiologist bridge them....

What do you guys do for trigger point injections? I go off of the patient's clinical signs. If they have bruising all over, i tell them to get off the coumadin/plavix and bridge before even a TPI. If they do not have bruising everywhere, then maybe a TPI on anticoagulation, but that's just me. Nothing else on anticoagulation.

 

[Jcm800]

What do you guys do for trigger point injections? I go off of the patient's clinical signs. If they have bruising all over, i tell them to get off the coumadin/plavix and bridge before even a TPI. If they do not have bruising everywhere, then maybe a TPI on anticoagulation, but that's just me. Nothing else on anticoagulation.

now this is becoming plain silly...

 

[PinchandBurn]

now this is becoming plain silly...

JCM-

Here's the issue though. I get it, we use only a 27G needle for the TPIs. But I had a little old lady that was on some coumadin, who in my opinion had a trigger point. The problem is that her hands, arms, even sides were all bruised looking. She had hte thinnest skin possible.

Clearly she's very sensitive to the anticoag she's on. If I do a TPI, and do some mechanical disruption of the trigger point, what's not to say that that will cause some bruising/bleeding into the muscles. Sure that's not going to paralyze her, but the intramuscular bleeding could end up being more painful than what the originally trigger point was!!

Again, if someone's on anticoag and doesnt have bruising everywhere, I would likely just do the TPI. I just think each patient is different.

 

[clubdeac]

JCM-

Here's the issue though. I get it, we use only a 27G needle for the TPIs. But I had a little old lady that was on some coumadin, who in my opinion had a trigger point. The problem is that her hands, arms, even sides were all bruised looking. She had hte thinnest skin possible.

Clearly she's very sensitive to the anticoag she's on. If I do a TPI, and do some mechanical disruption of the trigger point, what's not to say that that will cause some bruising/bleeding into the muscles. Sure that's not going to paralyze her, but the intramuscular bleeding could end up being more painful than what the originally trigger point was!!

Again, if someone's on anticoag and doesnt have bruising everywhere, I would likely just do the TPI. I just think each patient is different.

Do you tell your patients to come off and bridge before massage or PT?

 

[PinchandBurn]

Do you tell your patients to come off and bridge before massage or PT?

only deep tissue massage


i know that i'm overly cautious. But as one of my attendings told me, all the procedures we do for the post part are elective. Coming in for a simple knee injection and walking out and being admited for an I and D d/t a knee hemarthrosis d/t an injection shouldnt happen (of course it beats being paralyzed). Sometimes we do the best we can, and bad things happen.

Also, attorneys will always find a MD on the other side that will testify that you should have held the anti-coag. In front of a jury of lay people with an 8th grade education, he'll make it sound like one was negligent. Yes, it's defensive medicine, but it's also the 21st century medicine....

 

[emd123]

would be nice if somebody publishes something regarding anticouagulants and MBB block safety.

:bump:

Any update on this?

Facet/MBB/Rf and anticoagulants.

I don't like the idea of injecting that close to neuraxial (though technically not), but I don't like the idea of someone having a stroke or MI due to an elective facet procedure either.

We need some consensus.

 

[hyperalgesia]

I want to do a stim trial in a postlami pt who is on coumadin for PE. PCP wants bridging with Lovenox. I am thinking about doing a 24h trial, then restarting Love/Coumadin. Would anyone restart Lovenox with the lead in and hold again to remove lead? TIA

 

[lobelsteve]

I want to do a stim trial in a postlami pt who is on coumadin for PE. PCP wants bridging with Lovenox. I am thinking about doing a 24h trial, then restarting Love/Coumadin. Would anyone restart Lovenox with the lead in and hold again to remove lead? TIA

On the tablet trial and implant same time if they like it.

Implant is easier than the trial and risk may be too significant to do it twice.

 

[Aether2000]

Interesting.....I am curious about the responses also.

 

[101N]

Interesting.....I am curious about the responses also.

Not enough experience here to give a ligit answer. Would run this past Giancarlo were it my patient.

 

[Ducttape]

Is this patient going to be on anticoagulation indefinitely? Most patients are taken off after a some months unless there is recurrence or some underlying hypercoagulable state. Might be good to ask - and wait until off Coumadin...

 

[SSdoc33]

Is this patient going to be on anticoagulation indefinitely? Most patients are taken off after a some months unless there is recurrence or some underlying hypercoagulable state. Might be good to ask - and wait until off Coumadin...

thats a good point. might make sense to wait until coumadin is done. a better hypothetical is what happens if needs to be maintained indefinitely. i can envision some logistical/billing problems with a trial +/- implant on the same day

 

[SeniorWrangler]

This is an interesting question. If you look at the ASRA guidelines for regional anesthesia in anticoagulated patients, they are pretty conservative. I don't think they are necessarily the best guide for pain practice, but I can't think of a better source of data.

 

[ctts]

Interesting thread...

Seems like bridging may be the safest way to go, but I can also understand the feeling that it may be overkill.

For those who do injections while patient is on Coumadin, do you have them check their INR to make sure it is not supratherapeutic? If so, how recent does the INR need to be? Within same day as injection? Within 24 hours?

 

[bedrock]

Interesting thread...

Seems like bridging may be the safest way to go, but I can also understand the feeling that it may be overkill.

For those who do injections while patient is on Coumadin, do you have them check their INR to make sure it is not supratherapeutic? If so, how recent does the INR need to be? Within same day as injection? Within 24 hours?

check within 24 hours. Had several patients over 4. They were rescheduled

 

[hyperalgesia]

Appreciate all the suggestions...

For my pt, I was only able to get PCP buy-in with bridging. Unable to DC coumadin. I ended up bridging to Lovenox, off Lovenox for a day - placed lead, then on Lovenox for one day with lead in, then off for a day - lead out, then back on Lovenox/coumadin.

This was a post lami pt. He was "desperate" but was incredibly sensitive on the table. Practically crying during the subq lidocaine with a 27g hypodermic (he did have similar response during other injections - I should've known). He takes less than Percocet 5mg TID - prescribed by PCP. Completely uninterested in more narcs.

He only got about 40% relief with the trial even though the stim was completely covering his painful areas. Not an implant candidate.

No complications. Anyway, I don't think there's a right answer for this kind of anticoagulation issue. Only less-wrong answers. I get more selective/skeptical with every SCS I do...

 

[clubdeac]

I know someone posted this awhile back but I couldn't find it. Can someone post the letter you send referring physicians if a patient needs to come off their anticoagulation/antiplatelet therapy

 

[lobelsteve]

Dear Dr.

We are considering performing a neuraxial Injection (ie: Epidural Injection, Nerve Root block, etc.) on your patient for the management of their pain; however, they are currently on the following anti-coagulation medication (listed below):

The American Society of Regional Anesthesia Guidelines on neuraxial procedures and anti-coagulation indicates that medication should be held as follows:

Coumadin (Warfarin) 5 days prior PT/INR can be checked in office
Clopidogrel (Plavix) 7 days prior We cannot stop if stented in last 12 months
Ticlodipine (Ticlid) 10 days prior
Effient (Prasugrel) 7 days prior
Pradaxa (Dabigatran) 2 – 4 days prior (Depends on CrCl)
Aggrenox 3 days prior, but should take baby aspirin those 3 days
Brilinta (Ticagrelor) 5 day-
Rivaroxaban (Xarelto) 24 hours prior

For Coumadin: While the non-spine related surgical literature suggests a goal INR of 1.5, the neuraxial data shows that epidural hematomas can still occur at that level of anti-coagulation. Therefore, my goal is INR <1.3 prior to any neuraxial procedure.

The patient may remain on Aspirin 81-325mg.

We would like to know if this medication can he held for this procedure? o YES o NO
Could this patient come off medication 2 to 4 times per year as needed? Please note, we do not do a series of injections and would repeat the procedure if effective every 3-6 months. o YES o NO

COMMENTS:

Patient:_______________________________ DOB:____________


Signed by: ____________________________ Date:____________


After completing this form, please fax it back to Medical Associates of North Georgia.

 

[clubdeac]

Awesome! Thanks Steve!

 

[ampaphb]

Efficacy/Safety of Performing Fluoroscopically Guided Spinal Interventions in Conjunction with Anticoagulation Therapy

S. Endres, MD, DABPM, N. Bogduk, PhD, DSC; M. Schlimgen, MD;
A. Shufelt, RA; B. Endres, RA.

Pain Medicine 2011 Volume 12, Issue 9, p. 1442

Background: Spinal injections are contraindicated in anticoagulated patients. Present standards for performing interventional spinal procedure in the presence of anticoagulation and anti-platelet therapies are extrapolated from reviews from surgical and anesthesia literature. These standards were based on complications from regional anesthetic injection procedures done using anatomical landmarks with needles and catheters placed without fluoroscopic guidance.

Objective: Assess the efficacy/safety of fluoroscopic guided lumbosacral spinal interventions on patients with therapeutic anticoagulation and anti-platelet therapy.

Criteria: Transforaminal ESI, facet, MBB, SI joint injections and non-spinal musculoskeletal
procedures were performed by experienced interventionists using ISIS endorsed techniques Follow up ranged from 1 to 4 weeks either in clinic or via phone call.

Methodology. Chart review from 1/1/2005 to present was performed. Data included: demographics, diagnosis of the condition requiring a procedure, reason for anticoagulation or antiplatelet therapy, medication dose, (INR) if applicable, whether the medicine was stopped or not stopped, how long was it stopped, number procedures performed, type and gauge of needle used, the fluoroscopy time, the pre/post VAS, procedural complications
and anticoagulant complications.

Results: 473 charts were reviewed. 1,936 procedures were performed. 255 TF injections, 521 facet injections, 73 SI joint injections and 105 non spinal musculoskeletal injections were performed on patients with therapeutic anticoagulation and anti-platelet therapy. 311 TF injections, 143 interlaminar injections, 275 facet injections, 19 SI joint injections, and 18 non spinal musculoskeletal injections were performed on patients whose anticoagulation therapy
and anti-platelet therapy was stopped and INR was normalized. No post procedure complications were noted.

Conclusion: This review demonstrates that anticoagulants or anti-platelet therapies need not be discontinued for selected fl uoroscopic guided spinal interventions.