2016 FSA Posters

P014: PERIPHERAL INTERVENTIONAL PAIN INJECTION SAFETY IN PATIENTS ON ANTICOAGULATION THERAPY WITH CLOPIDOGREL
Robert Jongco, MD, William Grubb, DDS, MD, Matthew Johnson, MD, Carolyn Kloepping, MD, Michelle Brady, LPN; Rutgers - Robert Wood Johnson

Introduction: Current ASRA recommendations regarding cessation of anticoagulation for neuraxial blockade have been clearly established  to reduce the risk of epidural hematoma1. Neuraxial blockade is safe in patients taking NSAIDs, ASA or COX-2 inhibitors. Thienopyridines, which inhibit ADP-mediated platelet aggregation, such as clopidogrel and ticlodipine should be held for 7 and 10-14 days, respectively1. Despite good evidence for withholding anticoagulation for neuraxial procedures, little is written regarding its safety in other procedures and peripheral injections. The risk of spinal/epidural hematoma is rare in patients without coagulopathy following interventional pain procedures2. Clearfield showed no increased risk in hemarthroses following intra-articular injections in patients on Coumadin therapeutic INR3. Acupuncture has been shown to be safe in patients on active anticoagulation4. No data exists to examine the safety of trigger point injections in anticoagulated patients. Here, we examine the occurrence of ecchymosis in 5 patients anticoagulated on clopidogrel following peripheral injections for pain procedures.

Methods: Patients presenting for intramuscular/joint injections currently anticoagulated on clopidogrel were recruited consecutively. The areas to be treated were prepped with betadine. A 25-gauge needle was used to inject a mixture of 1% lidocaine and Depomedrol 40 mg following negative aspiration. Acupressure was held for 5 minutes at the injection site. Ecchymosis was marked circumferentially. The patient was contacted at 24 hours and asked to report any additional ecchymosis.

Results: Five patients have been enrolled and had various peripheral injections performed (trigger point injections, sacroiliac injections, acromioclavicular injections). None of the patients reported additional ecchymosis at 24 hours following the injection and acupressure.

Discussion/Conclusion: Performance of peripheral injections seems to be safe on patients taking anticoagulation with ADP-receptor inhibitors such as clopidogrel. No additional ecchymosis or bruising was noted at 24 hours following five minutes of acupressure.

 

References:

1. Narouze, Samer MD, PhD; Benzon, Honorio T. MD; Provenzano, David A. MD; Buvanendran, Asokumar MD; De Andres, José MD, PhD; Deer, Timothy R. MD; Rauck, Richard MD; Huntoon, Marc A. MD. “Interventional Spine and Pain Procedures in Patients on Antiplatelet and Anticoagulant Medications

Guidelines from the American Society of Regional Anesthesia and Pain Medicine, the European Society of Regional Anaesthesia and Pain Therapy, the American Academy of Pain Medicine, the International Neuromodulation Society, the North American Neuromodulation Society, and the World Institute of Pain”. Regional Anesthesia & Pain Medicine. May/June 2015 - Volume 40 - Issue 3 - pp 182–212 

2. Kyoung Hyup Nam, M.D., Chang Hwa Choi, M.D., Ph.D., Moon Seok Yang, M.D., and Dong Wan Kang, M.D., Ph.D. “Spinal Epidural Hematoma after Pain Control Procedure”. J Korean Neurosurg Soc. 2010 Sep; 48(3): 281–284.

3.  Daniel A. Clearfield, DO, MS, CAQSM, Joseph J. Ruane, DO and John Diehl, MD “Examining the Safety of Joint Injections In Patients on Warfarin”. Practical Pain Management  July 31, 2012 . http://www.practicalpainmanagement.com/treatments/interventional/injections/examining-safety-joint-injections-patients-warfarin?page=0,1

4. Young-Jee Kima, Soo-Kyung Kima, Seung-Yeon Cho, Seong-Uk Park, Woo-Sang Jung, Sang-Kwan Moon, Chang-Nam Ko, Ki-Ho Cho, Sang-Beom Kim, Won-Chul Shin, Jung-Mi Park. “Safety of acupuncture treatments for patients taking warfarin or antiplatelet medications: Retrospective chart review study”. European Journal of Integrative Medicine 6 (2014) 492–496