Carotid artery and CESI

[bedrock]

How do you all approach CESI in patients with significant carotid artery blockages?

Particularly if you use a oakworks or similar frame?

Not for a patient acutely had a CVA, but what about someone with a stroke last year and 50% occlusion?

Or mild dementia possibly due to mini TIA, has notable carotid artery blockages, but no recent major vascular events?

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[lobelsteve]

How do you all approach CESI in patients with significant carotid artery blockages?

Particularly if you use a oakworks or similar frame?

Not for a patient acutely had a CVA, but what about someone with a stroke last year and 50% occlusion?

Or mild dementia possibly due to mini TIA, has notable carotid artery blockages, but no recent major vascular events?

Ignore it?
Zero Fs given.
What is your concern?

 

[bedrock]

Ignore it?
Zero Fs given.
What is your concern?

Had a previous patient with carotid occlusion who had a stroke during a CESI.

No F given until it happens to you.

 

[lobelsteve]

Had a previous patient with carotid occlusion who had a stroke during a CESI.

No F given until it happens to you.

Did the ceai cause the stroke?
No one oreders carotid US pre procedure. No restrictions on degree of stenosis in SIS manual.

Bad luck is just that. Would be concerned for stellate and hemodynamics. Not cesi.

 

[Orin]

Had a previous patient with carotid occlusion who had a stroke during a CESI.

No F given until it happens to you.

When I used to pass gas, we'd stress about brain perfusion with prone positioning, but the goal was to keep the neck neutral and avoid hypotension. You'll have to explain what happened in the CESI to cause a stroke.

I assume you think the chin was tucked too much and the great vessels kinked?
How do you know they didn't hypo-perfuse due to low BP from sedation or local anesthetic on the cardiac accelerators?

The Oakworks positioner can be modified to reduce the degree of neck flexion, so I would just keep track of the degree of bending/pressure on the neck, using patient feedback to verify they're perfusing their brain.

 

[callmeanesthesia]

Had a previous patient with carotid occlusion who had a stroke during a CESI.

No F given until it happens to you.

Done under sedation so patient was not able to express feeling half their body shutting down? I have a hard time believing an awake patient in the prone position for 5-10 minutes would spontaneously stroke without having had that happen sometime in their everyday life already.

 

[PinchandBurn]

When I used to pass gas, we'd stress about brain perfusion with prone positioning, but the goal was to keep the neck neutral and avoid hypotension. You'll have to explain what happened in the CESI to cause a stroke.

I assume you think the chin was tucked too much and the great vessels kinked?
How do you know they didn't hypo-perfuse due to low BP from sedation or local anesthetic on the cardiac accelerators?

The Oakworks positioner can be modified to reduce the degree of neck flexion, so I would just keep track of the degree of bending/pressure on the neck, using patient feedback to verify they're perfusing their brain.

Cesi is less than 5min. Doubtful unless session used tht something bad can happen for such a short neck flexion period.

But bedrock...I hear you. We hv all had experiences tht shape us forever !

 

[RoloTomassi]

Could just be bad luck it happened at that moment rather than an hour before or after

 

[Ducttape]

the only concern i would have would be the stress and anxiety and the transient hypertension you get from the steroids, although stroking out from that would not happen immediately.

fwiw, 50% occlusion is not of any concern. mild-moderate narrowing.

 

[Agast]

Were they on plavix that was stopped for the procedure? If they weren’t placed on some sort of preventative after diagnosis by a specialist, I wouldn’t feel culpable for contributing to their issues. I’d feel more guilty if I had them hold a blood thinner.

I had a patient whom we got updated cardiac clearance and permission to hold his plavix the month before. He really wanted me to repeat his injection. I thought to myself he didn’t look that hot, but he was in a lot of pain. He had a heart attack and died 5 days after his epidural. I consider that one to be my fault because I didn’t like his color and could have pushed harder for more PT first. His wife was also one of my patients and she described to me how he literally expired next to her in bed. Really really sad.

 

[Ducttape]

either holding the plavix or the effects of the steroid.

sorry.

hopefully the epidural helped so he wasnt in pain when he died.....

 

[Agast]

either holding the plavix or the effects of the steroid.

sorry.

hopefully the epidural helped so he wasnt in pain when he died.....

The timing made me think it was the plavix. It was especially sad, because he and his wife were the primary caregivers for their little granddaughter (I think her parents had drug problems). So he was extra motivated to fix his back pain in order to keep up with her. When he died, she would crawl into bed with her grandma so that grandma wouldn't be lonely, and say she hoped she would "dream about Paw Paw in heaven." I pay a lot more attention to health status now.

 

[lobelsteve]

Were they on plavix that was stopped for the procedure? If they weren’t placed on some sort of preventative after diagnosis by a specialist, I wouldn’t feel culpable for contributing to their issues. I’d feel more guilty if I had them hold a blood thinner.

I had a patient whom we got updated cardiac clearance and permission to hold his plavix the month before. He really wanted me to repeat his injection. I thought to myself he didn’t look that hot, but he was in a lot of pain. He had a heart attack and died 5 days after his epidural. I consider that one to be my fault because I didn’t like his color and could have pushed harder for more PT first. His wife was also one of my patients and she described to me how he literally expired next to her in bed. Really really sad.

Dont hold plavix for lumbar esi.

 

[bedrock]

Dont hold plavix for lumbar esi.

TFESI no hold. ILESI definitely hold.

Still some debate about caudals and thinners in some circles.

 

[lobelsteve]

TFESI no hold. ILESI definitely hold.

Still some debate about caudals and thinners in some circles.

Nope. Shouldn’t even hold for CESI. I’m still chicken but data supports more risk in stopping the anti platelet or thinners. No reason to hold for lumbar. Despite completely misguided ASRA.

 

[Ducttape]

do you have documentation about not holding from SIS yet?

 

[bedrock]

Nope. Shouldn’t even hold for CESI. I’m still chicken but data supports more risk in stopping the anti platelet or thinners. No reason to hold for lumbar. Despite completely misguided ASRA.

What does this standard come from? I agree ASRA is too conservative, but I didn’t think SIS was so bold as to not hold thinners for any spinal procedure

 

[lobelsteve]

https://watermark.silverchair.com/pnw227.pdf?token=AQECAHi208BE49Ooan9kkhW_Ercy7Dm3ZL_9Cf3qfKAc485ysgAAAswwggLIBgkqhkiG9w0BBwagggK5MIICtQIBADCCAq4GCSqGSIb3DQEHATAeBglghkgBZQMEAS4wEQQMX3_LL203ELqE5WmQAgEQgIICf69cqdFJ1FzvAIo04KoiyxVqI8e-1v-74PIVF8-h3QEvJFE_Eaibu5-gcFq05q73cKRTLDMOi8w_K5hWpEvIZ8BfY8W1f6uTk0WGlz2ZVmh7Pd8que1zCxWcBDkzpzGdGPQ31azM7yPeBFvntTHSmP6uZUiuv_UEFbMylwi1OY0foReB6YuTbCD1KzEF13twn18jeInXmC6NXWHzsSYxtBobIMFgFGO1q52eFJhsmIzy7ZA3fRvvhax0B0O6shsAx1sq_WtBC54rA6JPd599w7mvMuLii8lb4fzTTC5qJd9dAA3_8qeojmKQm5vqETz_inZ8YENfdiEHX7ZazDEkdNBQdWjGS8vA5YwQF3FGIU6eRcC5_kfzMi4hOC8_U-TfqRUceg3N2tX4ooq1zpVZhuzhJK6YY8vjED2PYa176x7oZ6BZQk1uRmzT_7AMKKjkVdVys5zZUr_84GmhYeH5cyJB6-XCpIG_GVJLc0BwIvzkrwXvBaXNWYdDOO9d8RDFLQHnK994zOmRXDn7mu2HW8PtX2HNJ_tWr9ZMB9uxJRbd_xb8g7TdXOpotQ2H3k2BXg8aWb7a0l7s0APVouPH3OeF01mso9YAdU0tlrIw9POsufX9SFRvgbx6p6jRGf0o-nS2djMmECHrloUM9TAVl2yPbu_VuP7GxFiiRVWxNcjNzhYHtHo4M6zazQKF3Mn8xw-h8iX3nMkQj1-6oWqMidRP1oJTp3Q-jbwvZsphVAd_dezZuAyHtpTLfoZ0siHP-9Ary6Ri994wH5vH5csW36OsDmvOj0KCK-u8KmNoeTfs6zHfwQ_dkLasra3A9BzIiWS8CJRUy2NApStH_X3tLA

 

[MitchLevi]

I'm holding Rx thinners for all ILESI.

Continue aspirin.

Never hold for a TFESI or caudal.

 

[SC Tian]

https://watermark.silverchair.com/pnw227.pdf?token=AQECAHi208BE49Ooan9kkhW_Ercy7Dm3ZL_9Cf3qfKAc485ysgAAAswwggLIBgkqhkiG9w0BBwagggK5MIICtQIBADCCAq4GCSqGSIb3DQEHATAeBglghkgBZQMEAS4wEQQMX3_LL203ELqE5WmQAgEQgIICf69cqdFJ1FzvAIo04KoiyxVqI8e-1v-74PIVF8-h3QEvJFE_Eaibu5-gcFq05q73cKRTLDMOi8w_K5hWpEvIZ8BfY8W1f6uTk0WGlz2ZVmh7Pd8que1zCxWcBDkzpzGdGPQ31azM7yPeBFvntTHSmP6uZUiuv_UEFbMylwi1OY0foReB6YuTbCD1KzEF13twn18jeInXmC6NXWHzsSYxtBobIMFgFGO1q52eFJhsmIzy7ZA3fRvvhax0B0O6shsAx1sq_WtBC54rA6JPd599w7mvMuLii8lb4fzTTC5qJd9dAA3_8qeojmKQm5vqETz_inZ8YENfdiEHX7ZazDEkdNBQdWjGS8vA5YwQF3FGIU6eRcC5_kfzMi4hOC8_U-TfqRUceg3N2tX4ooq1zpVZhuzhJK6YY8vjED2PYa176x7oZ6BZQk1uRmzT_7AMKKjkVdVys5zZUr_84GmhYeH5cyJB6-XCpIG_GVJLc0BwIvzkrwXvBaXNWYdDOO9d8RDFLQHnK994zOmRXDn7mu2HW8PtX2HNJ_tWr9ZMB9uxJRbd_xb8g7TdXOpotQ2H3k2BXg8aWb7a0l7s0APVouPH3OeF01mso9YAdU0tlrIw9POsufX9SFRvgbx6p6jRGf0o-nS2djMmECHrloUM9TAVl2yPbu_VuP7GxFiiRVWxNcjNzhYHtHo4M6zazQKF3Mn8xw-h8iX3nMkQj1-6oWqMidRP1oJTp3Q-jbwvZsphVAd_dezZuAyHtpTLfoZ0siHP-9Ary6Ri994wH5vH5csW36OsDmvOj0KCK-u8KmNoeTfs6zHfwQ_dkLasra3A9BzIiWS8CJRUy2NApStH_X3tLA

this expired, can you post the title, I may be able to post the paper, btw, do you hold blood thinner prior to the leads pull from the trial?

 

[MitchLevi]

this expired, can you post the title, I may be able to post the paper, btw, do you hold blood thinner prior to the leads pull from the trial?

I'm def NOT doing trials on thinners. You didn't ask me of course, but I figured I'd jump in and answer it. I thought trials were obvious.

 

[SC Tian]

I'm def NOT doing trials on thinners. You didn't ask me of course, but I figured I'd jump in and answer it. I thought trials were obvious.

Holding blood thinners is for sure for the trial, do you hold the blood thinner during the trial period until the leads pull?

 

[bedrock]

Holding blood thinners is for sure for the trial, do you hold the blood thinner during the trial period until the leads pull?

Entire time. Procedure plus all days of trial period.

 

[MD87]

Per SIS @ Jamaica meeting (I was in the anticoagulation breakout group headed by Furman and Schneider) and they are all still holding blood thinners for cervical ILESI, many are holding for lumbar ILESI. None for cervical or lumbar TFESI.

 

[MD87]

I'm holding Rx thinners for all ILESI.

Continue aspirin.

Never hold for a TFESI or caudal.

Do you use 25g or 22g for TFESI? The biggest study I looked at that didn't stop blood thinners for lumbar TFESI used 25g needles. Not sure it should matter either way, just curious. I almost always use 22g for lumbar TFESI, but would consider using a 25g if performing on a patient taking blood thinners.

 

[hyperalgesia]

How do you all approach CESI in patients with significant carotid artery blockages?

Particularly if you use a oakworks or similar frame?

Not for a patient acutely had a CVA, but what about someone with a stroke last year and 50% occlusion?

Or mild dementia possibly due to mini TIA, has notable carotid artery blockages, but no recent major vascular events?

The only concern I would have relates to holding the thinner, if he's taking one. The 50% carotid occlusion is totally meaningless as far as I'm concerned, even if it's 80% or 100%, as long as pt is alive.

You mentioned the Oakworks table so you must have some concerns about the positioning. I really wouldn't begin to speculate about that. I don't see neurologists providing pillow guidance for sleeping post CVA.

 

[MitchLevi]

Do you use 25g or 22g for TFESI? The biggest study I looked at that didn't stop blood thinners for lumbar TFESI used 25g needles. Not sure it should matter either way, just curious. I almost always use 22g for lumbar TFESI, but would consider using a 25g if performing on a patient taking blood thinners.

Always 25g unless it's a huge pt requiring a 7" needle, which is 22g.

 

[drrosenrosen]

Does SIS have something published that supports not holding for TFESI? I hold for all TFESI or ILESI still, but willing to change if there's good justification.

Steve - you hold for kyphos, don't you?

 

[MitchLevi]

Does SIS have something published that supports not holding for TFESI? I hold for all TFESI or ILESI still, but willing to change if there's good reason

Andres study. It's on the SIS site.

 

[lobelsteve]

Does SIS have something published that supports not holding for TFESI? I hold for all TFESI or ILESI still, but willing to change if there's good justification.

Steve - you hold for kyphos, don't you?

I do, but not sure I should. Not in canal, but can get cement leaks into canal at times, so there must be contiguous space. Unsure of the risk

 

[nvrsumr]

We need some legal protection. SIS, NASS, ASIPP, ASRA need to put a guideline that the standard of care -of which some on this board harp about incessantly -is not to hold thinners for tfesi. Until then you are likely to get sued if a bad outcome and lose.

 

[SC Tian]

what kind of injections do you need patients to have a driver? thanks

 

[lobelsteve]

We need some legal protection. SIS, NASS, ASIPP, ASRA need to put a guideline that the standard of care -of which some on this board harp about incessantly -is not to hold thinners for tfesi. Until then you are likely to get sued if a bad outcome and lose.

But you can get sued on either side of this coin. If you hold the thinners and have a heart attack or stroke, you might get sued. If you don’t hold the thinners and they bleed, you might get sued.

 

[RoloTomassi]

what kind of injections do you need patients to have a driver? thanks

Oral or iv sedation

 

[RoloTomassi]

But you can get sued on either side of this coin. If you hold the thinners and have a heart attack or stroke, you might get sued. If you don’t hold the thinners and they bleed, you might get sued.

Damned if you do, damned if you don't. No consensus on what is standard of care, so either could be argued as a deviation. Best to document the discussion of risk of holding and risk of not holding, and you and pt decided on X.

 

[lobelsteve]

Damned if you do, damned if you don't. No consensus on what is standard of care, so either could be argued as a deviation. Best to document the discussion of risk of holding and risk of not holding, and you and pt decided on X.

Correct for both sides of the argument. Realizing the risk of epidural hematoma requiring urgent surgery as decompression is better than realizing the risk of holding the blood thinning agents and realizing the risk of death/MI/CVA.

 

[drrosenrosen]

I have a very tricky one currently - patient has compression fracture, possibly from a met (new tumor in lung identified at same time as fracture), but also on anticoagulation for a mechanical mitral valve. She definitely has a higher risk for holding anticoagulants than your average bear, and I might have considered not holding. But her PCP already had her hold before I saw her so she can get lung biopsy this week as well.

 

[lobelsteve]

I have a very tricky one currently - patient has compression fracture, possibly from a met (new tumor in lung identified at same time as fracture), but also on anticoagulation for a mechanical mitral valve. She definitely has a higher risk for holding anticoagulants than your average bear, and I might have considered not holding. But her PCP already had her hold before I saw her so she can get lung biopsy this week as well.

Perfect scenario. Had same thing last month. Bx by IR downstairs of adrenal or kidney followed by T7 kypho by me.