Plavix and PNB

[CaliDreamin4Life]

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ASRA guidelines divide their recommendation based on "deep nerve block" and "superficial nerve block."

They recommend off plavix for 7 days if deep block and but plavix doesn't matter if superficial block. I have a patient who discontinued plavix 3 days ago, can I do an adductor canal or femoral block?

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[Gaseous Clay]

Yes and yes

 

[dchz]

It was my understanding that all lower extremity blocks are deep blocks

 

[nimbus]

Those terms are uselessly vague, thus the question. Just like light vs heavy meal, or GA vs deep vs moderate sedation. In a skinny patient, almost no blocks are deep. What is deep? Greater than 1cm? 2cm? below skin surface??

Just avoid the vessels.

 

[Shimmy8]

I figure if surgeon is willing to operate, we should be willing to do a block.

 

[dchz]

I figure if surgeon is willing to operate, we should be willing to do a block.

I'm just as aggressive as the next guy, but I think we have to stop and ask this: will the surgeon cut the pt's leg open to stop a bleed for anesthesia caused bleeding? cause they will certain achieve their own hemostasis if the made the booboo, but will your surgeons fix your mistake?

 

[anbuitachi]

Those terms are uselessly vague, thus the question. Just like light vs heavy meal, or GA vs deep vs moderate sedation. In a skinny patient, almost no blocks are deep. What is deep? Greater than 1cm? 2cm? below skin surface??

Just avoid the vessels.

I think it varies so much. I like to believe that Deep blocks are those you can't compress in the event of hematoma. Like paravertebrals. For lower extremities, they are all compressible, so I would like to think they are not deep blocks

 

[Arch Guillotti]

What is deep?

Lumbar plexus block.

 

[deleted126335]

Lumbar plexus block.

What else makes the deep list?

 

[Plead the Fifth]

ASRA guidelines divide their recommendation based on "deep nerve block" and "superficial nerve block."

They recommend off plavix for 7 days if deep block and but plavix doesn't matter if superficial block. I have a patient who discontinued plavix 3 days ago, can I do an adductor canal or femoral block?

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Anything encroaching on the epidural space (paravertebral, plexus blocks) would be off limits to me in a patient taking Plavix. I might could see an argument for a infra or supraclavicular block being questionable due to the clavicle impeding compression of an expanding hematoma. Everything else is fair game in my book.

 

[Psai]

What else makes the deep list?

If you need a surgeon's help to fix the bleeding.

 

[facted]

deep blocks are PVB, lumbar plexus and infraclavicular is 50/50.

The real question is if you hit the artery somewhere, are you able to compress the area enough to stop the bleeding? I think the answer is yes to any block except the 3 listed above.

 

[deleted171991]

Those terms are uselessly vague, thus the question. Just like light vs heavy meal, or GA vs deep vs moderate sedation. In a skinny patient, almost no blocks are deep. What is deep? Greater than 1cm? 2cm? below skin surface??

Just avoid the vessels.

To me, "superficial" = compressible (thus easily providing hemostasis in case of bleeding, after easy aspiration of hematoma if needed). "Deep" = not compressible (e.g. deep inside a muscle). It's like the difference between the IJ and subclavian approaches for central lines.

E.g. interscalene block is superficial in most patients. Adductor canal is superficial. Femoral is superficial. TAP is not. Sciatic in the thigh is probably not. Paravertebral is not. Intercostal is probably not. Most pain blocks for chronic pain are probably not.

 

[caligas]

To me, "superficial" = compressible (thus easily providing hemostasis in case of bleeding, after easy aspiration of hematoma if needed). "Deep" = not compressible (e.g. deep inside a muscle). It's like the difference between the IJ and subclavian approaches for central lines.

E.g. interscalene block is superficial in most patients. Adductor canal is superficial. Femoral is superficial. TAP is not. Sciatic in the thigh is probably not. Paravertebral is not. Intercostal is probably not. Most pain blocks for chronic pain are probably not.

Usually easy to see vessels but if you did make a big hematoma doing an interscalene, that could be problematic.

 

[lobelsteve]

Meh, ASRA is overly protective of a bleed at the expense of the MI or CVA.

The Risks of Continuing or Discontinuing Anticoagulants for Patients Undergoing Common Interventional Pain Procedures. - PubMed - NCBI

 

[nimbus]

We frequently put big lines in these patients but wring our hands over a single shot injection with an ultrasound guided 22g needle.

 

[deleted171991]

Usually easy to see vessels but if you did make a big hematoma doing an interscalene, that could be problematic.

Worst case scenario, one just strangles the patient.

 

[narcusprince]

What else makes the deep list?

Me.... I dont date women on plavix. I would not do the block as if a hematoma happens a jury of your peers may agree you went against guidelines.

 

[deleted697127]

Me.... I dont date women on plavix. I would not do the block as if a hematoma happens a jury of your peers may agree you went against guidelines.

Plus it’s rarely just plavix..usually aspirin and a little dose of heparin for good measure

Also, it’s not like surgeons go around draining hematomas even if there is a large stable one. As was stated above we don’t typically freak out about Anticoagulation with line placement or removal. People barely flinch at removing femoral MAC lines in the unit and act like a superficial purse string does anything to stop a bleeding vessel 5cm deep.

 

[The Physician Philosopher]

I can only tell you how we practice at my place, which is a big academic medical center in the south where we do a boatload of blocks.

To us, deep typically means neuraxial or close to it. So epidural, spinal, paravertebral, lumbar plexus block. These are out when on plavix. Yes, we do lumbar plexus blocks. If someone really needs chest coverage for multiple days we have been placing erector spinae catheters under ultrasound guidance if anticoagulation is present.

We would prefer someone to be off plavix, but will perform most peripheral blocks where the vessel involved is compressible. So this excludes things around the clavicle, particularly an infra clavicular block.

I'd personally feel comfortable performing most other blocks on plavix, particularly if the patient was not a great candidate for general anesthesia.

TPP

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[BLADEMDA]

I do blocks frequenty outside the ASRA guidelines. Paravertebral blocks may be controversial but at Pitt they have proven safety even when anticoagulated following the block. These days I do Erector Spinae Blocks instead of paravertebrals and Plavix, Eliquis, Xarelto, etc may not be a contraindication IMHO. The typical consensus is a Paravertebral block is a "deep block."

The blocks I won't typically perform on these patients are the following:

1. Neuraxial
2. Lumbar Plexus
3. Infraclavicular
4. Paravertebral
5. +/_ Supraclavicular (depends on patient size, weight, U/S scan, etc)

The rest of them I typically do on a routine basis.

 

[BLADEMDA]

It is probably too restrictive to adapt the ASRA guidelines on neuraxial blocks to patients undergoing peripheral nerve blocks. The European Society of Anaesthesiology has noted that the guidelines for neuraxial block do not routinely apply to peripheral nerve blocks. The Austrian Society for Anesthesiol- ogy, Resuscitation and Intensive Care, on the other hand, has suggested that superficial nerve blocks can be safely performed in the presence of anticoagulants.161 Because of the possibility of retroperitoneal hematoma, lumbar plexus and paravertebral blocks merit the same recommendations as for neuraxial injec- tions. The same guidelines should also apply to visceral sympa- thetic blocks. The ASRA guidelines may therefore be applicable to blocks in vascular and noncompressible areas, such as celiac plexus blocks, superior hypogastric plexus blocks, and lumbar plexus blocks. Clinicians should individualize their decision and discuss the risks and benefits of the block with the patient and the surgeon. Most importantly, the clinician should follow the patient closely after the block placement.


https://www.nysora.com/neuraxial-anesthesia-peripheral-nerve-blocks-patients-anticoagulants