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.
Plavix before epidural
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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.
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I just access the hiatus. I don’t drive it up. Many of the elderly people, the hiatus is nearly closed.
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No typo
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.
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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.
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I do think it’s worth it.
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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.
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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?
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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?
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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.
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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
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Yeah man, send that patient to the ER next time. Plts of <10 gets admitted unequivocally.
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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.
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This is the first I have heard of this occurring. Sorry that happened to you.
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This was done at the hospital
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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.
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So what’s the story? Patient on comfort care with a disc herniation? There must be some very compelling reason because no one in their right mind would hand a patient with undetectable platelets a tissue to blow their nose, let alone stick a needle in their back, without some serious extenuating circumstances.
I think, as most have said, issues are very rare but they do happen. Even with an informed consent, I would want to have the vast majority of the literature and expert opinions supporting my actions. You have to remember that the experts on the medical boards and in malpractice plaintiff litigation are very conservative. Many are not practicing and are just reading recs. Keep that in mind.
Not trying the scare anyone, but it is impt to know that things do happen all the time. I just feel that you want the body of evidence to support you and in doing epidurals on plavix for caudals and TFESIs (and intralaminars), I dont think that the majority of the evidence supports this. Also remember all of this is elective.
This is my 2 cents as one who does med mal and medical board defense (defense only). In the end we are all big men and women and we are going to do what we thing we should.
Not trying the scare anyone, but it is impt to know that things do happen all the time. I just feel that you want the body of evidence to support you and in doing epidurals on plavix for caudals and TFESIs (and intralaminars), I dont think that the majority of the evidence supports this. Also remember all of this is elective.
This is my 2 cents as one who does med mal and medical board defense (defense only). In the end we are all big men and women and we are going to do what we thing we should.
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Greater risk holding the meds, and that risk includes death as opposed to a hematoma which can be identified quickly and treated. Frequency of adverse events is also greater holding the meds.
The debate is one of ethics not guidelines.
Agree on the elective nature of what we do.
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Sure, obviously I believe we all do that until it fails and then we do what we can to salvage their quality of life, but IMO this entire discussion comes down to whether or not you’re stopping my mother’s Eliquis to do a TFESI with a 25g needle, to do that knowing the risk profile is ethics, not guidelines.
Yes, strokes and embolic events can happen and may exceed bleeding risks. The best evidence that we have caused us to continue blood thinners for low risk procedures like facets, RFAs, SI Joints, etc. but not for epidurals, SCS, etc. I agree with you that I think that a TFESI with a 25G needle is low risk for events on plavix. I would also caution against anything that is not in line with what our societies and guidelines are saying. Things change daily and if there is some body of knowledge now that the majority of the societies say that TFESI with 25G needle should be added to the low risk category, please quote it because I would love to use it for my medical legal and medical board work. The last that I checked, this did not exist and with the said those who ignore it roll the dice.
I dont know if you have ever been involved in a med mal or medical board investigation but let me tell you it sucks and it takes years from your life.
Well the courts and medical boards have said differently at least in the cases that I have been involved in. No offense but their opinion is more important than yours when it concerns my license.
No need to call names especially with an issue that is definitely not straight forward and is not unanimous
If you can forward whatever you are quoting, that is appreciated. If not, that is fine too.
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he's quoting Lobel et. al
CleanUp
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No this is wrong.
As previously stated as long as the patient is aware of the r/b/a and it is properly documented then it is ok.
Bonus points for documenting really well and also following up after.
An informed consent while definitely needed does not defend your from negligence which can be implied if you practice outside of the standard of care. If they can show that you practiced in a way that is outside of what your societies are saying, you will have a very steep uphill battle. You have to remember that most experts doing board work or most hired experts for the plaintiffs are extremely conservative. Many are not practicing. Some never practiced pain and are anesthesiologists. Unfortunately, the reasonable voices on this forum are not going to help you in these setting. People like me can try really hard to defend and rely on our own practice but sometimes it is not enough.
It is stressful. It is time consuming. And it needs to be avoided at all costs.
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And there are good folks that will come to your aid.
Complication either way leads to lawsuit.
That is the worst part of it. Insurance takes over from there.
Would you rather live with hematoma and need for surgery or a dead patient?
I think he's talking about this
The Risks of Continuing or Discontinuing Anticoagulants for Patients Undergoing Common Interventional Pain Procedures - PubMed
Lumbar transforaminal injections, lumbar medial branch blocks, trigger point injections, and sacroiliac joint blocks appear to be safe in patients who continue anticoagulants. In patients who discontinue anticoagulants, although low (0.2%) the risk of serious complications is not zero, and must...
pubmed.ncbi.nlm.nih.gov
www.ipsismed.org/resource/resmgr/factfinder/2020/sis_factfinder_20_02_anticoa.pdf
I also like to discuss the Oncology/LP or the IR literature sometimes when pushing the trainees to think before they pull up the ASRA app
Lumbar Puncture in Thrombocytopenia: The Floor Is Not Firm - PMC
Objective Lumbar puncture (LP) is a diagnostic procedure that accesses the spinal subarachnoid space to measure the opening pressure of the cerebrospinal fluid (CSF) and obtain samples of CSF for analysis. Although commonly performed, LPs are ...
pmc.ncbi.nlm.nih.gov
Society of Interventional Radiology Consensus Guidelines for the Periprocedural Management of Thrombotic and Bleeding Risk in Patients Undergoing Percutaneous Image-Guided Interventions—Part II: Recommendations
"Bleeding anywhere within the central nervous system has the potential for devastating neurologic consequences; therefore, multiple societies have chosen to classify pain procedures such as vertebral augmentation and procedures with risk of epidural bleeding as being associated with high bleeding risk (32), and the AABB has chosen to recommend a “fairly liberal” platelet count of 50 × 109/L as the threshold for lumbar puncture (69). This is supported by the C17 guidelines committee (84), which recommends transfusion at a platelet count threshold of 50 × 109/L for diagnostic lumbar puncture for newly diagnosed pediatric patients with leukemia and a threshold for transfusion of 20 × 109/L for pediatric patients in stable condition requiring lumbar puncture. Similar studies and recommendations are not available to establish an INR threshold"
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"Shared decision making" won't hold up in a malpractice claim if there's a hint of a guideline/society recommendation you may have violated. The argument is how could a patient really know the r/b/a, you're the doctor. This sort of discussion and documentation with the patient is best where society recs and guidelines are 100% equivocal or don't exist. As stated there are major societies recommending holding plavix for TFESI.
Source: emergency medicine residency, 8+ years attending experience. This sort of risk assessment and SDM is done several times each shift. I have heard too many colleague stories and read enough malpractice lawsuits that I never bank on shared decision making to save me from litigation.
Edit: I am not endorsing holding plavix but simply saying the quoted piece is absolutely not protecting you.
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Terrible luck. Nothing more. No other cases of caudal injections done in this manner on blood thinners have ever been reported. We have 5 or 6 year data on this published in 2021 and at that time had 670+ shots with no complications (Caudal Epidural Steroid Injections in the Setting of Remaining on Antithrombotics: A Retrospective Study - PubMed). 4 years later and still no cases in my practice. I work in a large group - all the hematomas (a handful) that I know of in the last decade in my practice have been in ILESI patients who weren’t even on blood thinners and pics looked great. Knock on wood, never happened to me. I can’t say I blame you being spooked and never doing it again, but your complication is incredibly rare.
I find it surprising that many in this group in the past have really hammered down on appropriate and inappropriate evidence and now suggest that an observational study is sufficient evidence for a position. Needless to say observational studies with analyzing patient data from a private practice group by definition establishes no causation (which is the most impt aspect here), have comfounding variables, have data inconsistency, and of course bias with no controls.I think he's talking about this
The Risks of Continuing or Discontinuing Anticoagulants for Patients Undergoing Common Interventional Pain Procedures - PubMed
Lumbar transforaminal injections, lumbar medial branch blocks, trigger point injections, and sacroiliac joint blocks appear to be safe in patients who continue anticoagulants. In patients who discontinue anticoagulants, although low (0.2%) the risk of serious complications is not zero, and must...
As I said before, I share the opinion that TFESIs may be safer on thinners than off in certain patients but until the societies positions and guidelines change we are left in a rather untenable position. I can tell you whether we agree with it or not professional societal guidelines trump observational studies and anecdotes in the courtroom and medical board room and that is just fact. In light of this each person needs to do what they see fit. We should all realize that if one of us makes a decision on this contrary to someone else's opinion, it is not unethical but more likely well thought out.
I hear you Steve but at least in my cases I have defended 3 docs against hematomas and have no cases of strokes, thrombotic events, etc from stopping thinners.
To be clear none of the hematomas were a result of a TFESI on thinners. Two were SCS and one was a CESI. One of the SCS was on baby ASA while the others had no thinners.
In my area many more people hold thinners for TFESIs vs proceeding on them so I would think that my board and malpractice cases would be skewed more towards thombosis, stroke, or death as Lobel mentions. However,, there have been none, not one. Both are rare events and we are likely only discussing academic issues meaning that in reality there is likely very very little difference between both groups. I do agree with Steve that complications either way can lead to lawsuits or board referrals. I am just saying that if that happens you are better off if your professional societal guidelines fit your actions.
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Yes...you are correct
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Any issues with S1 TFESI on thinners? I definitely get more bleeding there than any other lumbar TFESI level.
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Nothing personal, but that’s much less effective than driving it up to S3-S4. Our fellowship specifically had fellows just access the hiatus with contrast documented pre and post epidural spread on multiple views…..and then do a caudal with the needle driven to S3-S4. Superior epidural spread to L4-L5 was significantly better in the second group of patients. with more improvement of VAS scores.
In some patients it really didn’t matter, but for others that extra 90 seconds spent helping them often provided a much better clinical outcome.
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Never.
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I worked to the left of the judge.
Held plavix: died.
Held coumadin-CVA-left MCA-right hemi.
Always love a Chicago courtroom.
River Roast- If Michael Keaton Were Here.
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I'm assuming this cited of the guidelines on these ones Steve. Would you be willing to share what came with these cases and if there's any critical arguments that we should be aware about?
Also I don't do any of this type of work but for people that do, are the majority of these cases around anticoagulation holding / continuing?
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Please allow me to further flesh out my thoughts.
1. EM care isn’t elective. In pain medicine patients have the luxury of talking it over, getting a second opinion, thinking about it. This weighs heavily in the “a” of r/b/a.
2. I’ve been an expert on both sides for these cases and been an expert for other “hot topics” in Pain Medicine. You turn and look at the jury “Look, there’s a risk in everything. Heck, you could have gotten into a car accident today. But, you still came in. Every time we use a needle there’s a risk. If that was your mother and they couldn’t (list ADLs) then isn’t the upside worth it? Who here has seen their mother not get out of bed? Did those pills work for her?” You get the point.
3. We all know you can get sued for anything. Using chlorprep can get you sued.
4. If the patient has signed and clearly understood “I can bleed and die from this injection” then there isn’t ambiguity. This isn’t EM where there tend to be more in depth analysis. Heck put that in all capital letters, in bold, and underline it. Looks great in the court.
5. Your care has to be strong. Again, this is the “a” in r/b/a. If they’ve failed PT, multiple NSAIDs, a MDP, gp, tramadol etc then the jury will ultimately say “geez what else is there?” If you say “another option is surgery - do you want to speak with a surgeon?” or “could you just live with this” and they say no both then you’ve thoroughly exhausted all alternatives.
6. I agree like you said you cannot simply write in your note that you discussed rba. You cannot merely click off a box. This is not informed consent.
7. Fun fact - I have been part of one case where actually doing legitimate informed consent can cause harm to the patient and thus is *not* the recommended course because like you said the patient lacks the training and ability comprehend everything.
8. Speaking of “you could be sued for anything” here’s something to chew on - the government has spent a lot of money training us. We all make terrific money. Now imagine with that skill set you won’t provide a service to someone because YOUR license is at risk (due to your perception) and not due to their pain and suffering. I get it, it is your license. And I agree we hold agency. No one should force us to do anything. However, the public *may* not look favorably upon someone trained to do something who failed to do it. Imagine if fire fighters didn’t run into a burning house or if a cop didn’t stop a robbery. The optics are terrible. Public opinion and optics influence courts not just repeating conflicting guidelines. We have to view it as the jury would view it not with our physician lens.
9. Guidelines do just that - guide. Physicians are licensed to practice the art and science of medicine. We all know contraindications can be relative or absolute.