SCS Trial on ASA 81?

[Timeoutofmind]

Would you guys do an SCS trial on ASA 81 (pt s/p PCI with DES several years ago, cardiologist does not give permission to stop ASA 81)?

ASRA Regional guidelines say neuraxial blocks OK on ASA
ASRA chronic guidelines pretty useless in this situation

I would do a lumbar ESI/catheter no problem, but it makes me nervous that we are putting the leads up into the thoracic space where the cord is, and doing quite a bit of manipulation at times

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[Timeoutofmind]

Sorry can someone move to pain forum

 

[Hoya11]

Sorry can someone move to pain forum

I dont think you would run into any bleeding issues with ASA 81 despite the lead manipulations and entrance with the 14g tuohy. I would give 1g TXA.

But the real question is do you think it would help her enough to make the (still low) risk worth it, as most likely this thing will end up being removed or used as a bargaining chip for more opiates lets be honest

 

[Ducttape]

never stop low dose aspirin.

never.

don't worry, do the trial.

 

[Timeoutofmind]

I dont think you would run into any bleeding issues with ASA 81 despite the lead manipulations and entrance with the 14g tuohy. I would give 1g TXA.

But the real question is do you think it would help her enough to make the (still low) risk worth it, as most likely this thing will end up being removed or used as a bargaining chip for more opiates lets be honest

I like the TXA idea

I dont prescribe opioids

I make sure any weans are complete prior to SCS as it is a confounder I find

I agree people on opioids dont do great with any interventions in my experience

I have never explanted anyone I trialed as I have good selection criteria. My trial to perm ratio is very high.

People do great.

 

[244913]

never stop low dose aspirin.

never.

don't worry, do the trial.

what about ASA 325 mg? From what I've read plt normalize after 96 hours so the old 7-10 day rule is nonsense

Looks like latest from ASRA says 5-7 days

 

[studentologist]

Per ASRA 2018 guidelines, SCS is classified as a high risk procedure, for which they recommend discontinuing aspirin 6 days if it’s taken for primary prophylaxis or 4-6 days if it’s taken for secondary prophylaxis, after you’ve consulted with the prescriber of the aspirin.

 

[lobelsteve]

Expert advice from ASRA. Not believable though. Not based on literature, just opinion.
I have never stopped aspirin for any procedure. Ever.

 

[IN2B8R]

I do not hold ASA.


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[Orin]

I think it's probably more important to make sure you have a plan for detecting and managing a neuraxial hematoma when it happens to your patients.

The data are weak for prevention of this rare event, and unfortunately the ASRA guidelines are based on data/thought patterns created by folks who are doing similar procedures as add-on events for a child birth or surgery. I prefer the NACC guidelines (The Neurostimulation Appropriateness Consensus Committee (NACC): Recommendations on Bleeding and Coagulation Management in Neurostimulation Devices. - PubMed - NCBI). This falls as ASA under secondary prophylaxis and it is acceptable to continue it.

Assuming the cardiologist understands the risk/benefit question here, you as the neuraxial specialist can stratify the further risk the patient has for neuraxial bleeding and your ability to manage it if it happens. You can counter offer the cardiologist with a 4 day hold for placement and then restart during the trial as the pull is less likely to be as traumatizing as lead steering.

The real question here is whether or not you should do a buried trial or just refer them for a paddle trial.

 

[Ducttape]

What cardiologist has ever said it was acceptable to stop asa, outside of asystole?

The “shared risk” in these situation is all yours. If you as the proceduralist insist on stopping ASA, you have all the risk that comes from a cardiovascular or cerebrovascular incident...

 

[emd123]

Would you guys do an SCS trial on ASA 81 (pt s/p PCI with DES several years ago, cardiologist does not give permission to stop ASA 81)?

ASRA Regional guidelines say neuraxial blocks OK on ASA
ASRA chronic guidelines pretty useless in this situation

I would do a lumbar ESI/catheter no problem, but it makes me nervous that we are putting the leads up into the thoracic space where the cord is, and doing quite a bit of manipulation at times

It was only a few years ago that ASRA guidelines allow for all nsaids during all neuraxial procedures. Baby aspirin during a stim trial not going to increase bleeding risk very much at all. Stopping it might increase your patient's risk of death by stroke or MI, though. That's what they mean above when they refer to "shared assessment and risk stratification," ie, you can continue it if your patient really needs it.

 

[BobBarker]

So you guys are saying continue ASA 81mg if the reason for being on it is real (cad/cva/pad) for all procedures including kypho, SCS, Vertiflex? I keep patients on all thinners for everything facet and joint already.

 

[emd123]

So you guys are saying continue ASA 81mg if the reason for being on it is real (cad/cva/pad) for all procedures including kypho, SCS, Vertiflex? I keep patients on all thinners for everything facet and joint already.

Weigh the pro's and con's and make the decision with the patient, based on each patient's situation, risk factors and risk tolerance. Shared risk assessment.

 

[Ligament]

Are you guys stopping NSAIDs for neuroaxial procedures now?

 

[Timeoutofmind]

Per ASRA 2018 guidelines, SCS is classified as a high risk procedure, for which they recommend discontinuing aspirin 6 days if it’s taken for primary prophylaxis or 4-6 days if it’s taken for secondary prophylaxis, after you’ve consulted with the prescriber of the aspirin.

View attachment 234230 View attachment 234231 View attachment 234232 View attachment 234233

Actually, its not that simple.

DC'ing the ASA in secondary prophylaxis in a patient with a h/o CAD s/p stents is associated with a significant and real risk of in stent thrombosis, even years after the stent was placed.

So its not "just ask the cards guy if its OK and then stop if he says it is."

Is the risk of epidural hematoma on ASA 81 with SCS trial higher than the risk of in stent thrombosis if you stop ASA? Tough question..Which is worse? Gotta be the MI...

Could just not offer the SCS in terms of R/B based on the above discussion I suppose. I face the same dilemma with CESIs

 

[Blitz2006]

So keeping ASA, does this apply for just 81, or 325 as well?



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