POC Glucose for diabetics in outpatient setting

[NJPAIN]

Currently practice in ASC where, by policy, all diabetics get a FS glucose check and generally canceled if FS >250.
Moving to outpatient hospital procedure suite.

How many of you are routinely checking FS glucose in diabetics?
Are you only checking in the setting of steroid injection?
What's your cutoff number to cancel the case?

Literature indicates that rise in BG is about 100 and lasts 2-3 days.

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[gaspasser127]

Currently practice in ASC where, by policy, all diabetics get a FS glucose check and generally canceled if FS >250.
Moving to outpatient hospital procedure suite.

How many of you are routinely checking FS glucose in diabetics?
Are you only checking in the setting of steroid injection?
What's your cutoff number to cancel the case?

Literature indicates that rise in BG is about 100 and lasts 2-3 days.

Only if insulin dependent diabetics. Cancel for >250 generally. Only check if steroid injection

 

[MitchLevi]

Never check

 

[callmeanesthesia]

Ask patient to check BG at home prior to coming for injection. Most do. If they’re uncontrolled I’m generally not ordering a steroid injection to begin with.

 

[thecentral09]

Do you all use hemoglobin A1c cut offs?

 

[RoloTomassi]

Do you all use hemoglobin A1c cut offs?

No

 

[MitchLevi]

Do you all use hemoglobin A1c cut offs?

On stimulators I do.

Certainly not on injections.

 

[Ferrismonk]

I work in a HOPD part of the time. Hospital does blood glucose on diabetics and checks INR if they're on coumadin even if they've stopped for 5 days. I can't seem to stop this.

That being said, I will postpone the case if glucose is greater than 300. 250 gets a conversation and "shared decision making"

 

[Dr. Ice]

Been checking blood sugar on diabetics forever. Probably not gonna stop. Have had many people walking around with bs in 300s. Doesn’t make sense to me to do an elective procedure on someone in which the medicine used can cause an iatrogenic elevation of sugar in an already uncontrolled diabetic

 

[deleted875186]

I work in a HOPD part of the time. Hospital does blood glucose on diabetics and checks INR if they're on coumadin even if they've stopped for 5 days. I can't seem to stop this.

That being said, I will postpone the case if glucose is greater than 300. 250 gets a conversation and "shared decision making"

Correct me if I am wrong, but checking INR is still necessary even after stopping warfarin for a full days.

 

[bedrock]

Correct me if I am wrong, but checking INR is still necessary even after stopping warfarin for a full days.

Agree. I’ve caught several unsafe INR that way.

 

[MitchLevi]

I do not check INR.

 

[lobelsteve]

I check INR. I don’t check FBS. But if elevated and they mention over 300, would reschedule.

 

[bedrock]

I do not check INR.

just had a 1.7 INR last month on an elderly patient coming in for a CESI who was adament she had held coumadin for 5 days.
I was glad to be able to dodge that bullet.

Might want to reconsider your position.

 

[MitchLevi]

just had a 1.7 INR last month on an elderly patient coming in for a CESI. Glad to dodge that bullet.

Might want to reconsider your position.

But...But I don't want to...

 

[Dr. Ice]

Could make the argument that ilesi (especially cervical) is a totally different animal from tfesi/mbb/rfa/sij

 

[Tboned]

just had a 1.7 INR last month on an elderly patient coming in for a CESI who was adament she had held coumadin for 5 days.
I was glad to be able to dodge that bullet.

Might want to reconsider your position.

Completely agree with bedrock, I’m 8 months into practice and I have had 3 cases where patient stopped warfarin for 5 days and still INR elevated. One of the cases was 2.3! Too much variability with warfarin.

 

[SSdoc33]

Dont just blood sugar. Dont really even ask if they are diabetics. I guess i see their medications, but.......

Overly cautious IMHO

 

[Dr. Ice]

Dont just blood sugar. Dont really even ask if they are diabetics. I guess i see their medications, but.......

Overly cautious IMHO

Agree to disagree here. Docs get sued in my state for looking at someone the wrong way. If I don’t take every precaution of due diligence, I’m setting myself up for something. I’ve checked supposedly “controlled” diabetics on the morning of their procedure and they were at 350. I could just see it now…”well doctor, you patient went into a diabetic coma after your procedure and you did not explain the risks adequately enough, nor did you check their sugar while fully knowing the medication you injected could have caused this…”

No thank you. Pack your bags and go to another state..and when you get there, ask the docs if they are looking to hire and please call me…

 

[lobelsteve]

just had a 1.7 INR last month on an elderly patient coming in for a CESI who was adament she had held coumadin for 5 days.
I was glad to be able to dodge that bullet.

Might want to reconsider your position.

Still would not have bled. Endres.

 

[MD87]

Still would not have bled. Endres.

Can you provide name of article? My understanding was his articles were for lumbar? Thx.

 

[MitchLevi]

Still would not have bled. Endres.

Endres article made very clear the fact DC'ing Coumadin specifically carries the highest risk of events. That drug was the only one that resulted in adverse events.

ILESI was not done on AC in that study. It was TFESI, SIJ and MBB.

 

[lobelsteve]

Endres article made very clear the fact DC'ing Coumadin specifically carries the highest risk of events. That drug was the only one that resulted in adverse events.

ILESI was not done on AC in that study. It was TFESI, SIJ and MBB.

Sorry. I posted wrong name. Endres did cervical epidural on his own father while on coumadin. This study followed:

Antiplatelet and Anticoagulant Risk for Select Spine Interventions: A Retrospective Cohort

AbstractObjectives. To identify significant bleeding complications following spinal interventions in patients taking medications with antiplatelet or anticoagul

academic.oup.com

 

[deleted875186]

Sorry. I posted wrong name. Endres did cervical epidural on his own father while on coumadin. This study followed:

Antiplatelet and Anticoagulant Risk for Select Spine Interventions: A Retrospective Cohort

AbstractObjectives. To identify significant bleeding complications following spinal interventions in patients taking medications with antiplatelet or anticoagul

academic.oup.com

Out of 275 patient encounters, 21 patients continued Plavix and 4 continued warfarin …. Not sure this paper proves any point other than journals will publish crappy retrospective studies.

 

[lobelsteve]

Out of 275 patient encounters, 21 patients continued Plavix and 4 continued warfarin …. Not sure this paper proves any point other than journals will publish crappy retrospective studies.

They comment on the numbers required to show a difference. At SIS conference it was talked about need for a registry. It takes several thousand injections for a difference in outcome to be significant and not by chance.

 

[Ducttape]

BGs always checked on ASC patients. its part of their compliance, ive been told.

trying to get them to check them on office patients.

>350, cancel unless nonsteroidal injection.

HgA1C>8, no steroid injection. patient has much bigger issues. average BG is 183.

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the study is retrospective, and seems low powered.

it is especially low powered for ILESI - there were only 10 and in each case anticoagulants were stopped.

in addition:

The most common procedure type and AC medication combination was LTFESI performed while the patient was continued on apixaban (N = 3)

hard to draw conclusions based on so little data.

 

[MD87]

Out of 275 patient encounters, 21 patients continued Plavix and 4 continued warfarin …. Not sure this paper proves any point other than journals will publish crappy retrospective studies.

Unless you are the right author. I submitted a paper with 200 of the same injection on blood thinners to them and they rejected it. Kennedy and Schneider can get this accepted though.

 

[ateria radicularis magna]

I don’t do any injections on a1c over 8 or bg over 200 on day of injection (occasional exceptions)

 

[lobelsteve]

Unless you are the right author. I submitted a paper with 200 of the same injection on blood thinners to them and they rejected it. Kennedy and Schneider can get this accepted though.

What injection?
I have 100s of MBB/RF/TFESI/SIJ

 

[MitchLevi]

Steroids are not equipotent with regard to glucocorticoid activity. Dex and beta are the worst.

I believe they're 27 and 33x the potency of hydrocortisone, and methylprednisolone is 5x? I could be off a little, but the point remains.

I swear, we talk all this stuff about dex vs particulate but I've sent at least 5 people to the hospital with uncontrolled afib bc of dex 10mg.

I have one TIA bc of dexamethasone - 10mg after an L4-S1 RFA.

Never had one issue with a particulate.

Dex commonly causes chest pain during CESI, and I recently had vaginal burning in a pt due to dex while I did a medial branch injxn to treat post cervical RFA neuritis.

Edit - If you have a pt on AC bc of afib and you DC the thinner and give a dexamethasone injxn you are putting your pt at risk of an embolism.

 

[deleted875186]

Unless you are the right author. I submitted a paper with 200 of the same injection on blood thinners to them and they rejected it. Kennedy and Schneider can get this accepted though.

Incredible, we need data like this for our injections to help move past conservative ASRA guidelines.

 

[MD87]

What injection?
I have 100s of MBB/RF/TFESI/SIJ

Caudal ESI- ended up published in Pain Physician in 2021 after rejected by Pain Medicine because they basically wanted 1000 injections on the same blood thinner for them to say it had value as a publication, which is obvious justly unrealistic.

Next publication up is cervical MBB/facets.

 

[bedrock]

Still would not have bled. Endres.

don't care. No way will I ever do a CESI on anticoagulated patient.

 

[Ducttape]

Steroids are not equipotent with regard to glucocorticoid activity. Dex and beta are the worst.

I believe they're 27 and 33x the potency of hydrocortisone, and methylprednisolone is 5x? I could be off a little, but the point remains.

I swear, we talk all this stuff about dex vs particulate but I've sent at least 5 people to the hospital with uncontrolled afib bc of dex 10mg.

I have one TIA bc of dexamethasone - 10mg after an L4-S1 RFA.

Never had one issue with a particulate.

Dex commonly causes chest pain during CESI, and I recently had vaginal burning in a pt due to dex while I did a medial branch injxn to treat post cervical RFA neuritis.

Edit - If you have a pt on AC bc of afib and you DC the thinner and give a dexamethasone injxn you are putting your pt at risk of an embolism.

i stopped using steroids with MBB/RFA.

noticed no difference in post op pain nor any difference in post procedure neuritis.

 

[MitchLevi]

i stopped using steroids with MBB/RFA.

noticed no difference in post op pain nor any difference in post procedure neuritis.

I do it occasionally still. Never with dexamethasone.

 

[lobelsteve]

I check INR. I don’t check FBS. But if elevated and they mention over 300, would reschedule.

You should check more often (and stop talking to yourself).

77 y/o WF presents for lumbar RF in office. Tells nurse she is jiitery and nauseous. FBS 403. Buhbye RF, hello UC/ER.

 

[MitchLevi]

You should check more often (and stop talking to yourself).

77 y/o WF presents for lumbar RF in office. Tells nurse she is jiitery and nauseous. FBS 403. Buhbye RF, hello UC/ER.

Meh...Symptomatic pt should be checked.

 

[lobelsteve]

Meh...Symptomatic pt should be checked.

Patient complained to nurses, they checked and sent her away before RF. Next RF was already getting put on table and just like that I am back on schedule.

 

[MitchLevi]

Patient complained to nurses, they checked and sent her away before RF. Next RF was already getting put on table and just like that I am back on schedule.