ampaphb

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What do you do when the cardiologist says they cant come off their Plavix or Aspirin since it has been less than a year since the stent was placed?
 

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What do you do when the cardiologist says they cant come off their Plavix or Aspirin since it has been less than a year since the stent was placed?
Not stick a needle anywhere that bleeding could be bad...
 

ampaphb

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I have done caudals in such cases using a 25g spinal needle. Risk-free? Nope, but I explain the risks in detail including the possible need for surgical decompression in the event of a significant bleed. Some don't want to risk it, which makes the decision easy. I'd do lumbar facets and joints without much concern.
 

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I'll do MBB's, SIJ's, and major joints.

I won't do ESI, disco, SCS, LSB.

One year for drug eluting stents, 3 months for bare metal.
Do not stop the Plavix. We had one patient die from restenosis and MI when a patient went in for hip surgery at 4 months post- DUS. Now the local heart guys are more adamant about the 1 year rule. I agree.

I just did a 3 day trial and then implant on a guy given permission to hold plavix after 4 months for non DUS. He had a DUS placed in a subclavian last April. He needed some additional work getting out a guidewire or canula (I'm unsure what the Radiologist was doing, but he get left hand CRPS). THe patient saw me four months later and we discussed stim. He stopped his Plavix in an effort to get me to trial him sooner. 3 days after self DC'ing his Plavix he had a large MI and has 3 non DUS stents placed. That was Nov and we got clearance to hold plavix at 3 months. Short trial and straight to implant so I would not have to hold his plavix for more than a week in total.
It was clinically definite CRPS and everything went well. I put the Eon Mini in his left posterior axilla- looking good at 1 week post-op. Feeling good in the hand. Some days are better than others (for me).
 

Jcm800

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So facets, but not ESIs?
i wont do facets either. nothing neuraxial. I will do SI and major joints...im a big chicken with bleeding. had some attending get into trouble as a resident with facets and plavix. dont remember much about it. but i avoid any fodder for litigiation, as best as i can, of course.
 

hyperalgesia

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So facets, but not ESIs?
On Plavix, I don't do anything in the neck except trigger points. Lower than that, I just won't do anything epidural. I will do lumbar facets on Plavix but not on coumadin. It's splitting hairs and kind of arbitrary...
 

lonelobo

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On Plavix, I don't do anything in the neck except trigger points. Lower than that, I just won't do anything epidural. I will do lumbar facets on Plavix but not on coumadin. It's splitting hairs and kind of arbitrary...
Will do Plavix but on not on Coumadin?

Every spine or ortho surgeon I talk to , all tell me Plavix causes many more issues with bleeding and oozing than Coumadin.
 

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On Plavix, I don't do anything in the neck except trigger points. Lower than that, I just won't do anything epidural. I will do lumbar facets on Plavix but not on coumadin. It's splitting hairs and kind of arbitrary...
Back it up with a logical sentence explaining why....
 

hyperalgesia

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Back it up with a logical sentence explaining why....
1) The risk of spinal hematoma is more well-defined/studied in coumadin than plavix, as per the most recent ASRA Guidelines Consensus Statement (http://www.asra.com/consensus-statements/2.html).
2) The cervical paraspinal region is more vascular than the lumbar paraspinal region so there is theoretically more risk of vascular complications.
3) It's still arbitrary.
 

lonelobo

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The actual risk of spinal hematoma with ticlopidine and clopidogrel and the GP IIb/IIIa antagonists is unknown. Consensus management is based on labeling precautions and the surgical, interventional cardiology/radiology experience.
Based on labeling and surgical reviews, the suggested time interval between discontinuation of thienopyridine therapy and neuraxial blockade is 14 days for ticlopidine and 7 days for clopidogrel.

Caution should be used when performing neuraxial techniques in patients recently discontinued from chronic warfarin therapy. The anticoagulant therapy must be stopped, ideally 4-5 days prior to the planned procedureand the PT/INR measured prior to initiation of neuraxial block. Early after discontinuation of warfarin therapy, the PT/INR reflect predominantly factor VII levels, and in spite of acceptable factor VII levels, factors II and X levels may not be adequate for normal hemostasis. Adequate levels of II, VII, IX, and X may not be present until the PT/INT is within normal limits


What I am missing here?
These ARSA reccs from 2002
Plavix came out late 1997 so probably little data by time these put out, think the risks are more than unknown now-Plavix+Neuraxial=bad

My local Neurosurgeons say their literature states to Hold Plavix 14 days for NS spinal procedures
 
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what about aggrenox?
 

lobelsteve

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what about aggrenox?
The low dose aspirin component is not a problem. The persantine has some antiplatelet activity that may increase bleeding risk. I am unaware of any pooled data that would make me hold this medication for a neuraxial procedure.

There are always new and different drugs we need to be aware of: Effient, Jantoven (Coumadin), Trental, Pletal.

Effient would be same as Plavix or Ticlid, but I'm unsure how many days we would need to hold it- at least 7. Trental and Pletal- to hold or not to hold- these would be the only controversial drugs in my book- I'd hold 3-5 days.
 

Jcm800

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The low dose aspirin component is not a problem. The persantine has some antiplatelet activity that may increase bleeding risk. I am unaware of any pooled data that would make me hold this medication for a neuraxial procedure.

There are always new and different drugs we need to be aware of: Effient, Jantoven (Coumadin), Trental, Pletal.

Effient would be same as Plavix or Ticlid, but I'm unsure how many days we would need to hold it- at least 7. Trental and Pletal- to hold or not to hold- these would be the only controversial drugs in my book- I'd hold 3-5 days.
all of these get held for 7 days, the life of the platelet. Aggrenox should be treated the same as plavix, IMHO. If they alter the platelet at all, then I wait 7 days, except for ASA, where the ASRA guidelines specifically state there is no increased risk of neuraxial bleeding with ASA (325 or less).
 

Tenesma

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no intra-spinal or peri-spinal procedures....

only do those areas where pressure can be applied until bleeding stops.... or where bleeding is not going to cause permanent nerve damage...
 

ampaphb

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no intra-spinal or peri-spinal procedures....
are intra-articular facet blocks "peri-spinal"? How about medial branch blocks?
 

Tenesma

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yes, and yes....

now clearly in our mind a well placed facet inj or MBB should not be anywhere near the spinal canal.... however, i have heard/read (chart reviews) a few horror stories with facet inj and MBB gone bad by pain docs that I respect (good training, good skills, bad luck) to know that I am not good enough to be 100% perfect in an anti-coagulated patient....
 

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Our local cardiologists recently recommending Plavix after stents "forever" and since all our procedure are elective and relatively short lived and I elect not to take anyone off the Plavix or Coumadin. Just as Steve said SI joints and MBB are only options that are reasonably safe.
 

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we've gotten some push-back from our local cardiologists who agree to let their patients(post-stent greater than one year) come off Plavix for 5 days but not 7 which puts me into no-mans land as there isn't evidence that it's safe at 5 days off, yet it's safer than if they're still taking plavix that morning. (procedure in mind is an interlaminar epidural, guess I could consider a caudal with 25 gauge that was recommended earlier)

I'd appreciate suggestions as I'm debating what to do about this.
 
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Tenesma

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i have one cardiologist who refuses to discontinue anti-coagulation on ANY of her patients including those with only paroxysmal a.fib... she must have been burnt by some bad outcome and now pretty much as soon as her name appears in the chart, i realize this will all be med management and PT...
 

hyperalgesia

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I would stick to your reference-based guidelines, whatever they are. I wouldn't do anything epidural unless the pt meets criteria exactly. Even though it seems like splitting hairs, that's where the hairs are split, at least in my guidelines. And in court, you will have to explain why you did what you did. You will be the greedy doctor, trying to get that 79 dollars at the patient's expense :scared:
 

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I would stick to your reference-based guidelines, whatever they are. I wouldn't do anything epidural unless the pt meets criteria exactly. Even though it seems like splitting hairs, that's where the hairs are split, at least in my guidelines. And in court, you will have to explain why you did what you did. You will be the greedy doctor, trying to get that 79 dollars at the patient's expense :scared:
Could not have said it better.

7 days off plavix. No less.

There are always alternatives.
 

Tenesma

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i had one cardiologist tell me 3 days off plavix should be fine.... i was like "do you have any understanding of how plavix works??"
 

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Lumbar RF 3 levels after MBB x2 at 80C for 90 secs? Heat coagulation via RF? Thoughts.
 

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Lumbar RF 3 levels after MBB x2 at 80C for 90 secs? Heat coagulation via RF? Thoughts.
I see no problem with this. You are not neuroaxial, you are paraspinal. The hematoma would be in the multifidus and erectors, not the compressible epidural space.
 

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Any thought from the group about doing transforaminals / SNRBs on Plavix? Technically, the needle tip is outside the neuraxis, although I guess a large psoas compartment bleed could be compressive to the lumbar plexus. Any thoughts about using the Smith & Nephew TruCath for additional safety by keeping the needle tip even more posterior?

FWIW, the only epidural hematoma I know of personally happened to a friend of mine after an easy lumbar SCS trial with a patient on ASA 81mg. No Plavix or Coumadin. ASRA guidelines or no guidelines, sometimes **** happens.
 

Jcm800

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i had one cardiologist tell me 3 days off plavix should be fine.... i was like "do you have any understanding of how plavix works??"
when someone tells me 5 days "is good enough" i just ask them to do the procedure...since they must be so good that it wont bleed with 5 days of plavix being held...
 

Ligament

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Any thought from the group about doing transforaminals / SNRBs on Plavix? Technically, the needle tip is outside the neuraxis, although I guess a large psoas compartment bleed could be compressive to the lumbar plexus. Any thoughts about using the Smith & Nephew TruCath for additional safety by keeping the needle tip even more posterior?

FWIW, the only epidural hematoma I know of personally happened to a friend of mine after an easy lumbar SCS trial with a patient on ASA 81mg. No Plavix or Coumadin. ASRA guidelines or no guidelines, sometimes **** happens.
Hey Paravert,

I've used the S&N TruCath for lumbar TFESIs, and although the needle tip is still a little more out of the foramen, you still gotta get it through the intertransverse ligament, and if any bleeding occurs ventral to the intertransverse ligament the blood is going to go at least partially in the neuroforamen and epidural space. Also, the needle itself is 22 or 20 ga, I cant remember. therefore more vascular damage than a 25ga or 27ga.

I get patients off ASA for epidural injections..the ASRA guidelines are not written for pain procedures, they are written for anesthesia.
 

Tenesma

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1) i don't get patients off ASA OR NSAIDS - i follow ASRA to the tee

2) technically if you are careful you should not cause a neur-axial bleed.... that being said, a colleague (that i respect) did an RF and it bled like stink from one of the RF sites... he literally held pressure for 40 minutes before it calmed down... 2 hours later the patient develops a radiculopathy (severe pain, weakness and numbness into the foot).... stat MRI shows a HUGE hematoma where the nerve root used to be... patient was on NO anti-coagulation (not even an ASA).... pt admitted, neurosurgery saw and opted to do nothing just some medrol... a few hours later the patient was going completely uncontrollable from the pain and the weakness was very dense... neurosurgery goes in and cleans things up - an artery had been lacerated by RF cannula tip (according to NS)... patient had prompt recovery....

that is why i don't do RFs on anti-coagulated patients....
 

Jcm800

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1) i don't get patients off ASA OR NSAIDS - i follow ASRA to the tee

I agree. I dont hold ASA (325 or less) or NSAIDs, i do what ASRA says.


ASRA guidelines have the breath and scope of much greater experience then the pain world. Also the needles are bigger, and the patients are sicker...

so if it is good enough for anesthesia, then i am comfortable, since i generally dont use 17 gauge needles, and i dont go intra-thecal that often, as they (i used to ) do every day.
 

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1) i don't get patients off ASA OR NSAIDS - i follow ASRA to the tee

I agree. I dont hold ASA (325 or less) or NSAIDs, i do what ASRA says.


ASRA guidelines have the breath and scope of much greater experience then the pain world. Also the needles are bigger, and the patients are sicker...

so if it is good enough for anesthesia, then i am comfortable, since i generally dont use 17 gauge needles, and i dont go intra-thecal that often, as they (i used to ) do every day.
In the event of a malpractice suit, they are going to look at what is the "standard of care." That is ill-defined and further defined case-by-case in the court, based on who's lawyer and witnesses are better.

Most every conference and course I've been to, as well as most written recommendations for handling anticoagulation in neuraxial injections are based on ASRA. Those are what I will take in to court with me, should the need arise.
 

Tenesma

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the problem with standard of care is that it is not community or regional but national standards that they look at and will have no compunction about calling to the witness stand the author of the ASRA guidelines--- and then you look like a fool for not following them.
 

hyperalgesia

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And the thing is, even if you think you're being extra conservative by discontinuing ASA for SIJ injections, when the person strokes or has an MI, you are just as f'd as if they had a direct injection complication. It's just not worth deviating from established guidelines...
 

Tenesma

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i do draw a line though --- no more than 325mg of ASA per 24 hours.... i did a procedure on a patient and they bled like STINK for HOURS from a tiny little puncture wound (it was an SI joint).... turns out (from the wife) that the patient was taking 2-3 aspirin every 4 hours for their pain but didn't admit that to us... now our forms clarify 325mg max per day and they sign it.
 

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1) i don't get patients off ASA OR NSAIDS - i follow ASRA to the tee

2) technically if you are careful you should not cause a neur-axial bleed.... that being said, a colleague (that i respect) did an RF and it bled like stink from one of the RF sites... he literally held pressure for 40 minutes before it calmed down... 2 hours later the patient develops a radiculopathy (severe pain, weakness and numbness into the foot).... stat MRI shows a HUGE hematoma where the nerve root used to be... patient was on NO anti-coagulation (not even an ASA).... pt admitted, neurosurgery saw and opted to do nothing just some medrol... a few hours later the patient was going completely uncontrollable from the pain and the weakness was very dense... neurosurgery goes in and cleans things up - an artery had been lacerated by RF cannula tip (according to NS)... patient had prompt recovery....

that is why i don't do RFs on anti-coagulated patients....
Wow, that's horrible but a great example of why not to do RF with 20 or 18G sharp RF needles when anticoagulated. I've sometimes debated this as I will do lumbar mbb's while anticoagulated. This confirms it, never gonna attempt an RF while anticoagulated. Thanks for the story.....
 

lobelsteve

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Wow, that's horrible but a great example of why not to do RF with 20 or 18G sharp RF needles when anticoagulated. I've sometimes debated this as I will do lumbar mbb's while anticoagulated. This confirms it, never gonna attempt an RF while anticoagulated. Thanks for the story.....
I'm never gr going to lacerate an artery (inominate) that was in an area that I perform thousands of procedures in. Sht happens, the real issue is this:

1. Do not do procedure and patient can suffer (reasonable)
2. Do procedure and patient may get relief (reasonable)
3. Do procedure and patient may get relief and have hematoma (reasonable)
4. Hold Plavix, Do procedure and patient may get relief (reasonable)
5. Hold Plavix, Do procedure and patient may get relief and have hematoma (less likely)
6. Hold Plavix, Do procedure and patient may get relief and have CVA or MI (less likely)

It's risks and benefits. My question is this: how likely is a CVA or MI from holding Plavix compared to a hematoma from not holding Plavix. We've got a few patients in GA pass away from stent thrombosis due to holding Plavix for elective Orthopedic surgery before 12 months was up. Tenesma's description is the first report I have heard of extraspinal needle placement causing evacuation surgery. Food for thought.
 

Tenesma

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the interesting thing is that the bleeding wasn't intra-spinal....
 

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Keep in mind holding the anticoag may not be in the patient's best interest. I've posted before about a pt who had a RIND right in front of me just a few minutes before a planned CESI. Glad he had it before I stuck a needle in him. Pt had an artifical valve and was on coumadin.

On a side note, on the same pt, because we ran out of options to treat him, I agreed to prescribe Norco 10/325 TID for him since then. He was always on time, never ran out early, UDS consistent with teatment, no calls for lost/stolen meds. 2-3 weeks ago, we found out through his insurance he had been getting hydrocodone through at least 4 other docs over the past few months. I did not contact him but waited for his next appt with me. That was 2 days ago - he called before we opened and left a message to cancel his appt, no reason given.

Even when you prescribe minimal opioids to few people and are very careful and diligent, you still get burned.
 

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i had a patient w/ a massive infarct off her coumadin... hx of afib... she stopped coumadin for endoscopy....

so again - not without risk.
 

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So I was at a Bost Sci dinner the other night, round table discussion. There was one ortho spine surgeon in the group who of course took over the conversation. Anyway, he said now the standard of care is to hold plavix 14 days! He said all of his cardiology colleagues recommend this now. WTF? Anyone else hearing this??
 

lobelsteve

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So I was at a Bost Sci dinner the other night, round table discussion. There was one ortho spine surgeon in the group who of course took over the conversation. Anyway, he said now the standard of care is to hold plavix 14 days! He said all of his cardiology colleagues recommend this now. WTF? Anyone else hearing this??
He's wrong. Belgian, German, Asra 2010, and ACCP all have 7 d on Plavix.
 

Jcm800

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So I was at a Bost Sci dinner the other night, round table discussion. There was one ortho spine surgeon in the group who of course took over the conversation. Anyway, he said now the standard of care is to hold plavix 14 days! He said all of his cardiology colleagues recommend this now. WTF? Anyone else hearing this??
in the immortal words of Fred Sanford, that ortho spine surgeon is " big dummie"

7 days...there was talk in the new ASRA consensus of going to 10 days, but it never happened.

hold it for 14 days, get an infarct...medically legal its all a mess...
 

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Their patients can wait 2 weeks for a routine, elective procedure. Pain patients have a much harder time.

It is all based on opinion, not science.
 

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i had one cardiologist tell me 3 days off plavix should be fine.... i was like "do you have any understanding of how plavix works??"

Actually, it should be good enough, if the platelet count is 2x what your minimal platelet count would be for a procedure. After 3 days ~1/2 of the platelets have turned over. If platelet count is >150-200 and you are willing to do a procedure at 75-100 then you have 75-100 normal platelets...

Not saying I would do it. But in theory it should be fine (as long as you check platelet levels).
 

lobelsteve

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Actually, it should be good enough, if the platelet count is 2x what your minimal platelet count would be for a procedure. After 3 days ~1/2 of the platelets have turned over. If platelet count is >150-200 and you are willing to do a procedure at 75-100 then you have 75-100 normal platelets...

Not saying I would do it. But in theory it should be fine (as long as you check platelet levels).
In theory and on the stand going against all published guidelines are two very different things. The science behind he guidelines is there and the ASRA guys are not just making things up.
 

mid|ine

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In theory and on the stand going against all published guidelines are two very different things. The science behind he guidelines is there and the ASRA guys are not just making things up.
Thats why I said I wouldn't do it. No point in arguing against ASRA guidlines on a stand.
 

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Thought I'd share this story. Did a two lead stim trial on a patient. Took the needles out and prepared to steristrip the leads down. The guy wouldn't stop bleeding. I literally applied firm pressure for 45 min. Asked the guy about all the possible risk factors and he tells me, "I eat lots of garlic with every meal". I was like great, well let me know if you can't walk or lose bowel or bladder control in the next 24 hrs. Fortunately nothing happened. I now ask most all my patients about garlic, ginseng and gingko.....
 

lobelsteve

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Thought I'd share this story. Did a two lead stim trial on a patient. Took the needles out and prepared to steristrip the leads down. The guy wouldn't stop bleeding. I literally applied firm pressure for 45 min. Asked the guy about all the possible risk factors and he tells me, "I eat lots of garlic with every meal". I was like great, well let me know if you can't walk or lose bowel or bladder control in the next 24 hrs. Fortunately nothing happened. I now ask most all my patients about garlic, ginseng and gingko.....
He doesn't take Plavix. Just clopidogrel.