PRE PROCEDURE INSTRUCTIONS

Anti-Platelet Medication:
● Non-Steroidal Anti-inflammatory (NSAID)
● Examples are Naproxen (Aleve), Ibuprofen (Motrin), Meloxicam (this has some inhibitory action on Cox 1 enzyme as well as Cox 2 inhibition), Salsalate, Celebrex, etc. These agents do not offer any additional risk of spinal hematoma or bleeding to the patients undergoing epidural injections. ** Meloxicam needs to be stopped 48 hours before the procedure

Thienopyridine Derivatives:
● Ticlopidine should be stopped 14 days before the procedure, except for the SI joint or Lumbar facet joint injections)
● Clopidogrel should be stopped 7 days before the procedure except for the SI joint injection and Lumbar facet joint injections
● Platelet GP IIB – IIIA Receptor Antagonist (Inhibits the final common pathway before platelet aggregates):Abciximab (ReoPro), Eptifibatide (Integrilin) and Tirofiban (Aggrastat). These medications have profound effect on platelet aggregation. Stop these medicines for at least 48 hours before interventional procedures. THESE AGENTS ARE NOT TO BE USED AT LEAST FOR 4 WEEKS FOLLOWING A SPINAL PROCEDURE (EPIDURAL OR SPINAL)

Fibrinolytics:
● Exogenous plasminogen activator e.g., Streptokinase, and Urokinase
● Endogenous plasminogen activator e.g., alteplase and tenecteplase

● Unfractionated Heparin (UFH) IV and SC
● If patient is receiving 5000 IU of UFH subcutaneously (sc) twice a day: No contraindication to the pain management procedures is present if they stop about 3 – 6 hours before the procedure. The heparin should be stopped until after the block
● If Heparin dose exceeds 10,000 IU per day and if the therapy exceeds 5 days, then we need to get PTT and CBC to make sure that there is no possibility of bleeding
● Low molecular weight Heparin (LMWH): Anti Xa
● This has prolonged ½ life of about 6 hours. Protamine cannot reverse this. It may be as long as 12 hours. In renal failure patients it is even longer
● Duration also depends on length of use. Prolong use cause fibrinolysis. This is used for bridging dose for patients who are on Warfarin
● There is no good test for this. Anti-Xa level is not indicative of bleeding diathesis
● Patients who are on Enoxaparin 1mg/kg q 12 hours or 1.5mg/kg q daily, stop at least for 24 hours before procedure, otherwise only after 10 – 12 hours after the last dose of LMWH, patient can have the procedure done

Warfarin:● Stop the medicine for 5 days. Request PT, PTT & INR. If the INR is less than 1 then schedule for procedure except for facet joint injection, INR of 1.4 is okay
● Dabigatran (Padraxa): Direct thrombin inhibitor
● This medicine need to be stopped at least for 5 days prior to the spinal injection. ½ life is 12 – 17 hours and therefore x5 = 5 days approximately 
Newer Anticoagulants:● Thrombin inhibitors: Lepirudin, bivalirudin and argatroban. Pre procedure PTT has to be done. If normal then wait for 3 – 4 hours prior to the procedure
● Fondaparinux: Factor Xa inhibition
● Intervention has to be done as per the protocol in clinical trials. Single pass, atraumatic, and avoidance of catheter has to be done

Herbal Medication:● Garlic: No garlic supplement at least for 5 days prior to the spinal injection
● Ginkgo biloba: It should be stopped for 2 days prior to the procedure
● Ginseng: It has to be stopped 24 hours prior to the procedure
* Bibliography:Second Consensus Conference on Neuraxial Anesthesia and Anticoagulation April 25 – 28, 2002. Regional Anesthesia in the Atnicoagulated Patient: Defining the Risks. American Society of Regional Anesthesia and Pain Medicine.Sharma, Anil MD; Spinal Injection and Anticoagulants. 13 – 18, Sine Line, May – June 2011.

No procedure should be scheduled within 3 weeks after vaccination with live vaccine such as Flu-mist (nasal spray), Chicken Pox (Varicella), Shingles (Varicella Zoster), Small Pox, Measles- Mumps-Rubella (MMR), BCG. Similarly patients should not have these vaccination at least for 4 weeks after receiving the epidural steroid injection including transforaminal steroid injection. Immune suppressant dose of steroid is 2mg /kg or 20 mg/day of Prednisone equivalent. For reference click here. There are no restrictions of procedrue receiving killed or attenuated vaccines as long as they are in good health. Patient may have Flu vaccine as per their PCP’s recommendations.

BOWEL PREP: Standard bowel prep instruction will be given to the patients.

List of Procedures that require bowel prep prior to the procedure:● Caudal epidural neuroplasty
● Ganglion impar injection or
● Radiofrequency treatment of ganglion impar
● Implantation of Intrathecal drug delivery system (morphine pump) or spinal cord stimulation device Lumbar sympathetic plexus block
● RF of rami communicantes
● RF of Lumbar sympathetic plexus block
● Minimally invasive lumbar decompression surgery (MILD)

Oral antidiabetics and non-insulin injectable should not be taken on the day of procedure until the normal diet is resumed.

Long-acting insulin should not be discontinued on the day before procedure unless patient gave history of hypoglycemia at night, in the morning or with missed meals and in patient on diet restriction preoperatively e.g., for bowel preparation.

Combination treatment with using insulin with oral antidiabetic may experience hypoglycemia if a meal is omitted as for example for bowel prep.

Blood glucose level of < 70 mg/dl is considered an alert value for hypoglycemia. This value should trigger treatment or intervention. Symptomatic hypoglycemia usually occurs at 45 – 55 mg/dl. These values are variable in poorly controlled diabetics. In patient with poorly controlled diabetes, hypoglycemia may be seen at a higher level. The symptoms of hypoglycemia are, sweating, palpitation, weakness, fatigue, confusion, and behavioral changes followed by seizure, loss of consciousness, brain damage, or death. Some diabetic patients may not manifest any of these symptoms because of defective glucose counter regulation leading to loss of warning symptoms of hypoglycemia also termed hypoglycemia unawareness.
Treatment for symptomatic hypoglycemia:
● 10-25 g of glucose to be repeated until blood glucose returns to normal and symptoms resolved
● Sugary drinks, sodas, electrolytes solutions, and fruit juices (e.g., 4 oz. apple juice)
● Patient who cannot ingest glucose and do not have an IV access, subcutaneous glucagon 1 mg may be administered while trying to establish IV access
● HYPERGLYCEMIA after glucose administration is detrimental and it should be avoided. This is more important in patients with ischemic brain damage
● Following treatment increase in blood glucose level is transient and should be monitored.

● If the patient is able to tolerate oral fluid then patient may be discharged as per discharge protocol. If patient is unable to tolerate oral intake and had subcutaneous rapid acting insulin during the procedure or before procedure, then patient should be observed at least for two hours as the effect of rapid acting insulin subsides within 1.5 hours (and 3-4 hours for regular insulin)
● Upon discharge, patient should return to preoperative antidiabetic treatment and management of potential hypoglycemia. They should be instructed to check blood glucose level frequently while fasting. Patient should carry hypoglycemia treatments while traveling to and from the surgical facility
● Oral hypoglycemic should be started only after patient has started eating. If the normal food intake is delayed then the normal or the usual antidiabetic treatment should be delayed
● Diabetic patient after receiving steroid may experience increase in blood sugar level within 2 – 4 hours. The increase may be more than 20%
● Diabetic patient with autonomic neuropathy can suffer severe hypotension resulting in hemodynamic instability worsening coronary artery or cerebrovascular disease. The DM is also a risk factor for development of epidural abscess, nerve injury from high dose of local anesthetic (ischemic). At our center we use less concentrated local anesthetic to prevent ischemic damage to the nerve
References:Joshi G, Chung F, Merrill D et al. Society of Ambulatory Anesthesia Consensus Statement on Perioperative Blood Glucose Management in Diabetic Patients Undergoing Ambulatory Surgery. Anesthesia & Analgesia, Dec 2010, vol 111.number 6, p 1378 – 87.Moghissi ES, Korytkowski MT, et al. Am Association of Clinical Endocrinologists and Am Diabetes Association consensus statement on inpatient glycemic control. Diabetes Care 2009;32:1119-31.Lukins MB, et al. Hyperglycemia in patients administered dexamethasone for craniotomy. Anesth Analg 2005;100:1129-33.Kindler CH, Seeberger MD, Staender SE. Epidural abscess complicating epidural anesthesia and analgesia. An analysis of the literature. Acta Anesthesiol Scand. L998;42:614-20.Kalichman MW, Calcutt NA. Local anesthetic-induced conduction block and nerve fiber injury in Streptozotocin-diabetic ratsKadoi Y. Anesthetic considerations in diabetic pateints. Part I: preoperative considerations of patents with diabetes mellitus. J Anesth (2010) 24: 739-747.