Plavix

[spondy14]

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Sorry to beat a dead horse. I am having an increase in the number of cardiologists only allowing Plavix discontinuation for 5 days instead of 7. Never a problem before. Any recent study that people have heard about that might have brought this on?

 

[lobelsteve]

Sorry to beat a dead horse. I am having an increase in the number of cardiologists only allowing Plavix discontinuation for 5 days instead of 7. Never a problem before. Any recent study that people have heard about that might have brought this on?

Half life of platelets does not equal ASRA guidelines. ISIS speaks of upcoming changes to guidelines due to risk of stopping meds and several recent lawsuits. Nothing official yet, just banter at AAPMR.

 

[bedrock]

Half life of platelets does not equal ASRA guidelines. ISIS speaks of upcoming changes to guidelines due to risk of stopping meds and several recent lawsuits. Nothing official yet, just banter at AAPMR.

Doesn't ASRA recommend holding plavix for 7 days? This is the half-life of platelets.

ISIS couldn't agree on **** at the meeting. Was rather disgusted by the lack of science at this year's meeting. Not sure I'll be going back to ISIS meeting for a few years.

 

[bedrock]

We have all discussed in several recent threads. Algo's experience on this I must say has influenced my practice.

I never required patients to hold blood thinners for SIJ, but I now don't require them to hold thinners for facets or MBB.

Still hold thinners for ILESI, TFESI, disco, SCS, sympathetic blocks, and RF.

I'm working up to not making them hold thinners for lumbar RF, but I sometimes get 2-3ml of bleeding during RF on normal patients, and I've heard a couple horror stories of massive paraspinal hematomas in patients after RF done on thinners.

Hypervigilant about cervical ESI- I make them hold NSAIDs for 2 days, any level of aspirin for a week,and any herb I don't recognize for a week, before cervical ESI. Don't worry about those things for any other procedure as ASRA doesn't.

 

[nvrsumr]

I only hold for neuro axial. Would hold for stellate also need to think more about LSB. Anyone doing LSBs in anticoagulated patients?

 

[lobelsteve]

We have all discussed in several recent threads. Algo's experience on this I must say has influenced my practice.

I never required patients to hold blood thinners for SIJ, but I now don't require them to hold thinners for facets or MBB.

Still hold thinners for ILESI, TFESI, disco, SCS, sympathetic blocks, and RF.

I'm working up to not making them hold thinners for lumbar RF, but I sometimes get 2-3ml of bleeding during RF on normal patients, and I've heard a couple horror stories of massive paraspinal hematomas in patients after RF done on thinners.

Hypervigilant about cervical ESI- I make them hold NSAIDs for 2 days, any level of aspirin for a week,and any herb I don't recognize for a week, before cervical ESI. Don't worry about those things for any other procedure as ASRA doesn't.

If you stop asa and they have a mi you are at fault. Guidelines say don't stop ASA for any epidural procedure.

 

[bedrock]

If you stop asa and they have a mi you are at fault. Guidelines say don't stop ASA for any epidural procedure.

Who do they sue after SCI from cervical epidural hematoma? Oh, yeah.....me.

After MI, when they got cardiac clearance to hold their Asa/plavix? Not me.

Both are very rare events in the given timeframe. No one would be sued for either situation in any country other than America. However, given our ridiculous legal system, I will protect myself.

 

[PinchandBurn]

Who do they sue after SCI from cervical epidural hematoma? Oh, yeah.....me.

After MI, when they got cardiac clearance to hold their Asa/plavix? Not me.

precisely.


I too have heard patients tell me that their cards will now only hold Plavix for 5 days instead of 7. Coumadin around here is only held for 4 days...so I always check an INR now.

On a side note. I did a 2 level TFESI on someone not too long ago. He had told me he had stopped Coumadin for 7 days. I did the injection trusting him. He went down to the hospital an hour later to talk to his cards who had ran his INR. His INR was 2.1 ! Obviously he was neurochecked q 1 hour for 24 hours (trust me on this). No adverse event.

Saving grace....TFESI. I think the blood was allowed to leak out the foramen. I say this not to CONDONE this, but to say that things happen.

 

[Ducttape]

Who do they sue after SCI from cervical epidural hematoma? Oh, yeah.....me.

After MI, when they got cardiac clearance to hold their Asa/plavix? Not me.

Both are very rare events in the given timeframe. No one would be sued for either situation in any country other than America. However, given our ridiculous legal system, I will protect myself.

you are infinitely more likely to get sued for stopping ASA with resultant ischemic event - cardiac or neurologic - than you are to get sued for epidural hematoma related to aspirin use.

the incidence of hematoma due to aspirin use is low. the risk of acute coronary syndrome off ASA is much higher.

and btw, no cardiologist i know has ever recommended stopping aspirin. almost every patient i request anticoagulation hold has specifically come back with "okay to hold plavix/coumadin etc. but DO NOT STOP ASPIRIN".

ASRA does not recommend holding aspirin for any procedure.

On a side note: Epidural Hematoma Related with Low-Dose Aspirin : Complete Recovery without Surgical Treatment states that there are 6 reported cases of spontaneous epidural hematoma due to aspirin use.

 

[Jcm800]

Something my program director told me a long time ago. "You are going to have many problems in your career if you make a decision based on what a patient tells you whether they have held their Coumadin or not. Because you can check, you need to,"


If someone has held Coumadin for 2 weeks, and is not going back on it (done with PE treatment or something) then maybe. Otherwise, check. I don't care if its 10 days, check. Patents forget to NOT take a med just as easy as they can forget TO take something.

precisely.


I too have heard patients tell me that their cards will now only hold Plavix for 5 days instead of 7. Coumadin around here is only held for 4 days...so I always check an INR now.

On a side note. I did a 2 level TFESI on someone not too long ago. He had told me he had stopped Coumadin for 7 days. I did the injection trusting him. He went down to the hospital an hour later to talk to his cards who had ran his INR. His INR was 2.1 ! Obviously he was neurochecked q 1 hour for 24 hours (trust me on this). No adverse event.

Saving grace....TFESI. I think the blood was allowed to leak out the foramen. I say this not to CONDONE this, but to say that things happen.

 

[PinchandBurn]

you are infinitely more likely to get sued for stopping ASA with resultant ischemic event - cardiac or neurologic - than you are to get sued for epidural hematoma related to aspirin use.

the incidence of hematoma due to aspirin use is low. the risk of acute coronary syndrome off ASA is much higher.

and btw, no cardiologist i know has ever recommended stopping aspirin. almost every patient i request anticoagulation hold has specifically come back with "okay to hold plavix/coumadin etc. but DO NOT STOP ASPIRIN".

ASRA does not recommend holding aspirin for any procedure.

On a side note: Epidural Hematoma Related with Low-Dose Aspirin : Complete Recovery without Surgical Treatment states that there are 6 reported cases of spontaneous epidural hematoma due to aspirin use.

clear as mud😉

 

[bedrock]

you are infinitely more likely to get sued for stopping ASA with resultant ischemic event - cardiac or neurologic - than you are to get sued for epidural hematoma related to aspirin use.

the incidence of hematoma due to aspirin use is low. the risk of acute coronary syndrome off ASA is much higher.

and btw, no cardiologist i know has ever recommended stopping aspirin. almost every patient i request anticoagulation hold has specifically come back with "okay to hold plavix/coumadin etc. but DO NOT STOP ASPIRIN".

I know where ASRA stands on this, but I have had noticeably more bleeding doing facets/MBB on patients on aspirin, than off of it. Worried if I get bleeding using a 25 gauge quincke for MBB, what might happen after 18 gauge Touhy for the CESI. This is in patients with normal PT/INR, platelets.

The compromise I've used for the past several years has been that my clearance note requests plavix, coumadin, etc be stopped, and ASA decreased to 81mg. All the cardiologist have been fine with this. They feel better with some aspirin on board, and I feel better if it's 81mg instead of 325/650

 

[pastafan]

I know where ASRA stands on this, but I have had noticeably more bleeding doing facets/MBB on patients on aspirin, than off of it. Worried if I get bleeding using a 25 gauge quincke for MBB, what might happen after 18 gauge Touhy for the CESI. This is in patients with normal PT/INR, platelets.

The compromise I've used for the past several years has been that my clearance note requests plavix, coumadin, etc be stopped, and ASA decreased to 81mg. All the cardiologist have been fine with this. They feel better with some aspirin on board, and I feel better if it's 81mg instead of 325/650

This "compromise" makes a lot more sense than the earlier statement about no ASA. The last CME lecture that I attended on CAD prevention strategies stated that the standard is 81mg ASA as higher doses were found to have no added protective benefits but a much higher rate of GI bleeds. Patients should be on 81mg and it does not need to be held.

The coumadin issue is another matter. Since INR can be measured it has always been my practice to confirm that the anticoagulant effects have resolved prior to procedure. I routinely check and I have been unpleasantly surprised a number of times when the INR was still elevated and the procedure had to be rescheduled for a day or two. There was one elderly lady that took about two weeks for her INR to normalize due to her poor diet. That could have been a disaster.

 

[Pain Applicant1]

I haven't been holding anything for MBBs, both C (25 gauge) and L (22 gauge), LRFs, SIJs. No problems so far.

I hold pretty much everything for LESI and CESI. I allow NSAIDs low dose ASA for TFESI and caudal.

On another note, while we're on the topic of MBBs, I recently stopped using local and I'm finding it much better. Now, not only do I not sedate, but I don't even use local with my 22 gauge. I went from 1% to 0.5% to now nothing. Better tolerated and much faster. I'll post this in the other thread.