Plavix before epidural

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interjectionreflection

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I usually hold plavix for 7 days before epidural. I have an elderly patient that does well with ESI but recently had a stent and cardio says to hold for 72 hours. I disagreed, suggested we wait until it's safer to hold plavix (after the dual therapy period). Cardiologist didn't seem happy with that wants a note from me again recommending 7 days. Looked online there's some things online that says maybe 5 days is ok but only in those with low bleed risk. before I write back, wanted to check in not missing anything does anyone do ESI by holding plavix less than 7 days?

Edit: the five says I found was for surgery not for elective outpatient epidural for pain
 
Never stop blood thinners for a transforaminal epidural or caudal, and you can most likely do lumbar ILESI with a 25g needle on thinners as well.

So, do a TFESI and certainly do not stop the Plavix unless you want to potentially kill your patient, which is generally frowned upon.
 
MitchLevi said:
Never stop blood thinners for a transforaminal epidural or caudal, and you can most likely do lumbar ILESI with a 25g needle on thinners as well.

So, do a TFESI and certainly do not stop the Plavix unless you want to potentially kill your patient, which is generally frowned upon.
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It's a lumbar ILESI. I was thinking to wait until it's safe to hold for 7 days so prolly delay procedure
 
I always hold for 7. Even if the cardiologist says 5 days. I’m looking for confirmation they are healthy enough to hold plavix at all, and I will take the liability of the extra 2 days. If they are not cleared to do an injection I send them to PT first. No one died from radicular pain. Yes TFESI is less risky but the guidelines for neuraxial injections and blood thinners are the gold standard. Anecdotally, my colleague had an epidural hematoma form in the c-spine on a patient who wasn’t even on blood thinners.
 
Just do a bilateral TF and stay on Plavix. Do it for the next one or two shots until you can hold the Plavix. Caudal is okay too, but they’re just not as effective if you ask me.
 
Have any of the major societies come out with guidelines protecting us if we do decide to do a TFESI while on thinners?
 
clubdeac said:
Have any of the major societies come out with guidelines protecting us if we do decide to do a TFESI while on thinners?
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Ipsis is the only one I'm aware of which says that the pros and cons need to be considered and staying on thinners might be ok. Asra still says to hold them.
 
IPSIS article


I think at the very least if you routinely choose not to stop anticoagulants for patients, you need to inform them that some guidelines recommend it and some don’t. And that you think it’s riskier if they stop it. If they’ve been told their options and agree not to hold their plavix then it’s “shared decision making”
 
I generally document that it's worth the risk/benefit, referencing the patient's specific circumstances. In this case, you've got an elderly patient with a recent stent, so there's an increased risk of bleeding due to age and Plavix, and then an increased risk of stent related thromboembolism. You may understand the risk of the epidural well, but the cardiologist understands the risk of that stent event. A quick look at the numbers would suggest a <1:1000 vs >1:100 risk for epidural bleeding vs thromboembolism. If you think the patient needs the interlaminar epidural, I would do it on the Plavix. If you think the patient needs an epidural but don't like the Plavix, do the caudal.

Although ASRA's app often suggest it's very black and white, their actual guidelines allow for flexibility and have reasonable discussion on the why. They do seem to fail to consider the thromboembolic risk of holding anticoagulation.

"Deviation from suggestions or recommendations contained in this document may be acceptable based on the judgment of the responsible anesthesiologist. The recommendations are designed to encourage safe and quality patient care but cannot guarantee a specific outcome."
 
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.
 
clubdeac said:
Have any of the major societies come out with guidelines protecting us if we do decide to do a TFESI while on thinners?
Click to expand...
I can't look it up right now but pretty sure ASIPP does, although they do something like low lumbar TFESI is low risk so continue thinners, and high lumbar is medium risk so shared decision making.
 
i cannot find any organization that suggests continuing plavix with caudal.

does anyone have data or a society recommendation to state that?

(i stop plavix for caudals for 2 reasons - lack of data/society support as mentioned above and the resultant confusion amongst nursing staff when continuing plavix for caudal epidural steroid injection, which is what they would focus on)
 
This has been posted in more than a handful of threads already.
Over the past 20 years on this website.
ASRA is wrong.
IPSIS is coming along in supporting not killing patients by stopping blood thinners.
Data is from Endres.
Recommendations are from expert consensus.
Data>expert opinion.
 
Why would anyone stop Plavix for a caudal? Good Lord...Do they need to stop fish oil too?
 
lobelsteve said:
This has been posted in more than a handful of threads already.
Over the past 20 years on this website.
ASRA is wrong.
IPSIS is coming along in supporting not killing patients by stopping blood thinners.
Data is from Endres.
Recommendations are from expert consensus.
Data>expert opinion.
Click to expand...
understood, from a medico-legal standpoint if plavix isn't stopped and they have a poor outcome (bleeding, etc), wont this be indefensible in court?
 
buddababa said:
understood, from a medico-legal standpoint if plavix isn't stopped and they have a poor outcome (bleeding, etc), wont this be indefensible in court?
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See other threads.
If you stop Plavix and the epidural goes fine (no hematoma) but they die of an MI or CVA: won't this be indefensible in court?
 
lobelsteve said:
See other threads.
If you stop Plavix and the epidural goes fine (no hematoma) but they die of an MI or CVA: won't this be indefensible in court?
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100% agree, just dealing with lawyers for expert witness cases, they will always go back to "society guidelines", which generally recommends holding plavix...not disagreeing with you, trying to safely change my practices
 
buddababa said:
100% agree, just dealing with lawyers for expert witness cases, they will always go back to "society guidelines", which generally recommends holding plavix...not disagreeing with you, trying to safely change my practices
Click to expand...

You'd rather one of your colleagues stop your mother's Plavix in this case?
 
buddababa said:
im not disagreeing, im talking about the legal issues if you dont stop the plavix and have a hematoma or poor outcoming (ignoring the premise that if you stop the plavix and get a CVA, etc)
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Either way, if complication occurs you may get sued.
Would you rather face a jury saying patient had hematoma requiring surgery or died?
 
lobelsteve said:
Either way, if complication occurs you may get sued.
Would you rather face a jury saying patient had hematoma requiring surgery or died?
Click to expand...
i dont take them off the blood thinners. the cardiologist or hematologist do. THEY are the ones who will be sued (probably).

the endres data is compelling, but it is 1 study, that i believe is retrospective. if the data is that good, why havent any societies stepped up to the plate to protect us? b/c they are are shunning responsibility b/c THEY dont want to be held accountable either.
 
MitchLevi said:
I wish I had starting keep track of these so I could publish them. I bet I have done a thousand or so TFESI on thinners. Probably more than that TBH.
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If your EHR lets you data mine the codes and meds....
I have performed 50-100k procedures in practice.
My patient pop is elderly. But only 1-5% would be on blood thinners and most procedures I perform are MBB/RF.
So I have probably performed 500-1000 ESI on antiplatelet or anticoagulated patients.
But have been to court 2x for held meds and bad outcomes (not my patients).
 
lobelsteve said:
If your EHR lets you data mine the codes and meds....
I have performed 50-100k procedures in practice.
My patient pop is elderly. But only 1-5% would be on blood thinners and most procedures I perform are MBB/RF.
So I have probably performed 500-1000 ESI on antiplatelet or anticoagulated patients.
But have been to court 2x for held meds and bad outcomes (not my patients).
Click to expand...
were the held meds for ESIs, or some BS like SIJ or facets?
 
lobelsteve said:
CESI=CVA
IA Hip= MI and death (ugh)
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did the CVA occur before the ESI?

rough outcome from a hip injection.... some guy on here years ago had a hemarthrosis after a hip injection, then held blood thinners for everything after that (?101n?)
 
SSdoc33 said:
did the CVA occur before the ESI?

rough outcome from a hip injection.... some guy on here years ago had a hemarthrosis after a hip injection, then held blood thinners for everything after that (?101n?)
Click to expand...
CVA day(s) before. I believe it was coumadin.
The hip case was plavix. Stents placed 5 years earlier.
 
but where is the data that suggests that it is okay to continue plavix on interlaminar epidural injections? (i continue anticoagulants for transforaminals.)

the 2020 IPSIS report specifically states to consider discontinue anticoagulants for "all interlaminar epidural injections".

Lumbar Interlaminar ESI
• There is a risk of epidural hematoma with all interlaminar epidural injections, even when stopping AC medication [6,20]
• It is likely, but not founded in published data, that this risk of hematoma is greater if therapeutic AC is continued for this procedure; therefore, alternative treatments to lumbar interlaminar ESI should be considered in patients with high thrombotic risk for whom discontinuation of therapeutic AC may be illadvised.
Click to expand...

 
Ducttape said:
but where is the data that suggests that it is okay to continue plavix on interlaminar epidural injections? (i continue anticoagulants for transforaminals.)

the 2020 IPSIS report specifically states to consider discontinue anticoagulants for "all interlaminar epidural injections".



Click to expand...
Sure, so just do a transforaminal. There's no reason not to do a TFESI, especially in the case of someone on anticoagulants who cannot stop them. Really, the dangerous drug is Coumadin if you're going to hold something, Plavix probably the second most given you're recommended hold is so long (7d).
 
I agree with Mitch, if they're on thinners just don't do an interlaminar when you can do a TFESI or a caudal. If they're not on thinners, do an interlaminar or TFESI based on your clinical judgement.
 
SSdoc33 said:
i dont take them off the blood thinners. the cardiologist or hematologist do. THEY are the ones who will be sued (probably).

the endres data is compelling, but it is 1 study, that i believe is retrospective. if the data is that good, why havent any societies stepped up to the plate to protect us? b/c they are are shunning responsibility b/c THEY dont want to be held accountable either.
Click to expand...
I guess it is fine to think you will not be sued--but that is not true. They will sue everyone involved.
 
I had a really nice old guy scheduled for an SGB for PHN. He arrived and had forgotten to hold his Plavix so we rescheduled the case. A few days later, while he was still on plavix, having never stopped it, had a massive CVA. I dodged a bullet in terms of liability.

Overall, every specialty is lopsided in guidelines to protect its own members from liability and it does a disservice to patients.

I really think it can't be overstated how individualized the decision should be and must include the most important person in the room - the patient.
 
hyperalgesia said:
I had a really nice old guy scheduled for an SGB for PHN. He arrived and had forgotten to hold his Plavix so we rescheduled the case. A few days later, while he was still on plavix, having never stopped it, had a massive CVA. I dodged a bullet in terms of liability.

Overall, every specialty is lopsided in guidelines to protect its own members from liability and it does a disservice to patients.

I really think it can't be overstated how individualized the decision should be and must include the most important person in the room - the patient.
Click to expand...
Great post
 
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