Plavix before epidural

[Snowmen96]

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I thought caudal was same as interlaminar in risk given you’re injecting into an enclosed space so I will have patient hold for both. FWIW I’ve been doing TFESI’s on thinners for the past few years because of what I had read here and Endres.

Technically speaking, a caudal has the highest risk of bleeding of any procedure, but there is no significant arterial blood supply in this area so any bleeding would be venous and therefore very low risk especially considering that if doing the procedure correctly, you wont be inserting the needle further than the space where there no longer is a thecal sac.

 

[BoardingDoc]

I’ve done caudal on pts with PLT 0. I never hold thinners for caudals.

I assume this is a typo? You absolutely should not be doing any procedure on a patient with that degree of thrombocytopenia.

Perhaps more importantly, if the patient has plts of 0 (or any number less than 10 for that matter) they need to be in the ER where they will ultimately be admitted for monitoring and steroids and/or IVIG.

 

[BobBarker]

I just access the hiatus. I don’t drive it up. Many of the elderly people, the hiatus is nearly closed.

 

[MitchLevi]

I assume this is a typo? You absolutely should not be doing any procedure on a patient with that degree of thrombocytopenia.

Perhaps more importantly, if the patient has plts of 0 (or any number less than 10 for that matter) they need to be in the ER where they will ultimately be admitted for monitoring and steroids and/or IVIG.

No typo

 

[mille125]

What matters is which move subjects the patient to more risk, stopping the Plavix or not stopping the Plavix.

Very clearly, the most risk to the patient is stopping the Plavix. It is obvious, not debatable in the least.

Given that is a fact, do next what you would want done to your mother.

Quit living your life by the leave of your local ambulance chasing attorney.

I agree with you that the risk is low. However, with respect, you are giving rather poor advice. You obviously want to do what is best for the patient but to totally ignore your society and standard medical practices is a very quick way to sit in front of the medical boards and courthouses. Take it from someone who does medical board defense frequently for my colleagues. The info that I have is not anecdotal but is rooted in actual unfortunate cases, some that I have been able to help mitigate and others that I could not.

 

[MitchLevi]

However, with respect, you are giving rather poor advice.

Disagree.

 

[mille125]

Disagree.

That is fine to disagree.

Had a case. Doc operated as you mentioned concerning TFESI. Didn't help pain but no complication happened...

Patient had to be discharged for opioid related aberrancy. Patient made board complaint and also complained that injections were done to make money and not to help him. Board reviewed with their expert (who are usually quite conservative). Said doing TFESIs on plavix is not standard of care. Doc ended up with a fine and CME. That is the world we live in. I don't think its worth it but since you disagree maybe you do.

 

[MitchLevi]

That is fine to disagree.

Had a case. Doc operated as you mentioned concerning TFESI. Didn't help pain but no complication happened...

Patient had to be discharged for opioid related aberrancy. Patient made board complaint and also complained that injections were done to make money and not to help him. Board reviewed with their expert (who are usually quite conservative). Said doing TFESIs on plavix is not standard of care. Doc ended up with a fine and CME. That is the world we live in. I don't think it’s worth it but since you disagree maybe you do.

I do think it’s worth it.

 

[No_Pain_No_Gain]

LESI?
Just do a caudal on plavix. I have done them for years on plavix/eliquis/anything.

In 2018, during my first year out of fellowship, I performed a caudal ESI using a 25-gauge, 1.5-inch needle on an 89-year-old woman on Plavix. At the time, my much more experienced physician employer had been doing caudals with this size needle on elderly patients while continuing anticoagulation for years and convinced me to as well. The patient developed an L2-3 epidural hematoma. My thoughts on the mechanism of action was that the patient likely had a friable venous plexus in the epidural space and the pressure from the 10 cc of medication I injected caused a small tear in one of these bridging veins at that level. The Plavix did the rest. Just sharing as a cautionary tale. I have not performed an ESI on a patient on anticoagulation since that experience. I obtain clearance from the patient's cardiologist and hold per the multisociety guidelines.

 

[PMROralBoards]

In 2018, during my first year out of fellowship, I performed a caudal ESI using a 25-gauge, 1.5-inch needle on an 89-year-old woman on Plavix. At the time, my much more experienced physician employer had been doing it for years and convinced me to as well. The patient developed an L2-3 epidural hematoma. My thoughts on the mechanism of action was that the patient likely had a friable venous plexus in the epidural space and the pressure from the 10 cc of medication I injected caused a small tear in one of these veins at that level. The Plavix did the rest. Just sharing as a cautionary tale. I have not performed an ESI on a patient on anticoagulation since that experience.

I just did a genicular rfa in an elderly patient with an old tka on xarelto and he ended up getting hemarthosis and a large hematoma in his quad. He was admitted to the hospital for pain control and discharged a few days after. Has anyone else heard of this happening?

 

[interjectionreflection]

In 2018, during my first year out of fellowship, I performed a caudal ESI using a 25-gauge, 1.5-inch needle on an 89-year-old woman on Plavix. At the time, my much more experienced physician employer had been doing caudals with this size needle on elderly patients while continuing anticoagulation for years and convinced me to as well. The patient developed an L2-3 epidural hematoma. My thoughts on the mechanism of action was that the patient likely had a friable venous plexus in the epidural space and the pressure from the 10 cc of medication I injected caused a small tear in one of these veins at that level. The Plavix did the rest. Just sharing as a cautionary tale. I have not performed an ESI on a patient on anticoagulation since that experience.

Wow, I'm sorry that happened. If you don't mind me asking. What came with that case? Did the patient say anything to you and how did you explain it to them?

 

[No_Pain_No_Gain]

Wow, I'm sorry that happened. If you don't mind me asking. What came with that case? Did the patient say anything to you and how did you explain it to them?

The patient did not have neurologic deficits on exam and was thus monitored in the hospital for 5 days without the need for surgical decompression. I visited the patient in the hospital multiple times during her stay and discussed what happened. I was honest and empathetic during those visits. I explained that I would change my practice moving forward based on this complication as well. Fortunately, I had good rapport with this patient before and during this ordeal and neither she nor her family were litigious. Other than the significant pain, short-term disability, and the inconvenience of the hospital stay, there were no further negative consequences for the patient nor myself. I was lucky and dodged a bullet.

 

[interjectionreflection]

The patient did not have neurologic deficits on exam and was thus monitored in the hospital for 5 days without the need for surgical decompression. I visited the patient in the hospital multiple times during her stay and discussed what happened. I was honest and empathetic during those visits. I explained that I would change my practice moving forward based on this complication as well. Fortunately, I had good repertoire with this patient before and during this ordeal and neither she nor her family were litigious. Other than the significant pain, short-term disability, and the inconvenience of the hospital stay, there were no further negative consequences for the patient nor myself. I was lucky and dodged a bullet.

How did you discover that hematoma? Was it just imaging for increased pain? Also before you did this after deal did you discuss the blood thinner risk with the patient? I'm only asking because sometimes there are patients that really are impatient and want their injection despite the risks always nice to see how other people have the discussion

 

[BoardingDoc]

No typo

Yeah man, send that patient to the ER next time. Plts of <10 gets admitted unequivocally.

 

[No_Pain_No_Gain]

How did you discover that hematoma? Was it just imaging for increased pain? Also before you did this after deal did you discuss the blood thinner risk with the patient? I'm only asking because sometimes there are patients that really are impatient and want their injection despite the risks always nice to see how other people have the discussion

Over a 12-18 hour period after the injection, the patient developed severe pain with subjective weakness in her legs. She was unable to walk while she had the ability to walk prior to the injection. When her family called me to report this, I asked them to call 911 to have her taken via ambulance to the ER. I called the ER and gave them a heads up with my concerns and asked them to obtain a stat MRI when patient arrived. They consulted neurosurgery and gave me the courtesy to call me to report the results.

Prior to the injection, I discussed the risks of the injection with the patient as I do with all patients. I emphasized the risk of epidural hematoma with patients on anticoagulation. I discussed with this patient that the risk was low due to the location of the injection and needle size and that was why the practice did not require her to hold the anticoagulation. I also discussed that there was likely a higher risk of a life threatening condition (such as blood clot/CVA etc.) from holding the anticoagulation compared to the risk of serious complication from bleeding in the epidural space.

 

[No_Pain_No_Gain]

I just did a genicular rfa in an elderly patient with an old tka on xarelto and he ended up getting hemarthosis and a large hematoma in his quad. He was admitted to the hospital for pain control and discharged a few days after. Has anyone else heard of this happening?

This is the first I have heard of this occurring. Sorry that happened to you.

 

[MitchLevi]

Yeah man, send that patient to the ER next time. Plts of <10 gets admitted unequivocally.

This was done at the hospital

 

[BoardingDoc]

This was done at the hospital

On an inpatient? Who was actively being treated for this? If so, that's shocking. If not, then that doesn't change anything and they need to go to the ER. That's like saying it's ok doing a LESI on a guy with active chest pain and EKG changes because it's a HOPD.

To be clear for everyone reading this, this isn't a style points thing or a pain medicine thing in general. Plts below 10 = significantly increased risk of spontaneous intracranial bleeding and death. Go to the ER. Do not pass go. Do not get a caudal on your way there.