Chance favors the prepared mind
NPO (Nothing to Eat or Drink by Mouth) instructions: Patient should NOT eat solid food for at least 6 hours before pain management procedure. Patients are however encouraged to drink CLEAR FLUIDS (including water, pulp–free juice and tea or coffee without milk) up to 2 hours before procedure.Ref: Smith I, Kranke P, Veld B etal. Peri-operative fasting in adults and children: guidelines from the European Society of Anesthesiology. European Journal of Anesthesiology, 2011, Vol 28, No 8, page 556 – 569.
PATIENT SHOULD TAKE ALL CARDIAC AND BLOOD PRESSURE MEDICATION WITH SIP OF WATER ON THE DAY OF PROCEDURE AS USUAL.
Patients with Recent History of Infection
Patient with history of infection associated with fever such as respiratory infection, soar throat from bacterial infection, urinary tract infection such as cystitis, pyelonephritis or kidney infection, etc, should be rescheduled until after the infection has resolved completely with or without antibiotic use. If they are put on antibiotics, then they need to finish the course of antibiotic prior to getting scheduled for the procedure. If a patient catches infection after the procedure, he or she should inform the physician.
Patients on Anticoagulants & or NSAID
● 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
● 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)
● Exogenous plasminogen activator e.g., Streptokinase, and Urokinase
● Endogenous plasminogen activator e.g., alteplase and tenecteplase
No Spinal or Epidural Procedures Within 10 Days of this Therapy
● 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)
Pre-procedure fasting blood glucose level, and glycosylated hemoglobin (HbA1c) need to be tested (preferably on the day of scheduling of the procedure).
Ideal blood glucose level should be fasting 90-130 mg/dL and postprandial or after food less than 180 mg/dL. HbA1c < 7% (range 4% – 7%) . A physician would make the final determination. If the HbA1c is > 8 % and the fasting blood glucose is more than 200 mg/ dl than the procedures involving implantable devices such as spinal cord stimulator, intrathecal drug delivery, percutaneous diskectomy, discogram, minimally invasive lumbar decompression procedure, caudal epidural neuroplasty, transforaminal injections, cervical epidural injections etc. would be rescheduled.
The staff at the center would enquire and make sure that the patient is able to check blood glucose level at home.
Blood glucose would be checked on patient’s arrival before the procedure and if necessary after the procedure. It would not be necessary to monitor blood glucose during the procedure for procedures < 2 hours.
LevelsHbA1c 5% = Blood Glucose of 90mg/dLHbA1c 6% = Blood Glucose of < 120mg /dLHbA1c 8% = Blood Glucose of < 180mg /dLHbA1c 10% = Blood Glucose of 240mg /dLHbA1c 13% = Blood Glucose of 330 mg/dL
Patients with the history of chronically elevated blood sugar level does not require intervention to reduce blood glucose level to a normal level since these patients have altered or abnormal counterregulatory response. On normalization rapidly they would suffer symptoms of hypoglycemia.
Pre-procedure Oral Antidiabetic and Non-insulin Injectable Therapy
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.
Discharge Consideration for Diabetic Patients
● 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.
● Metformin (Glucophage) 1⁄2 life 6 – 18 hours● Metformin Extended Release
Stimulates insulin secretion and decreases insulin resistance. ½ life 2 – 10 hours● Chlorpropamide (Diabenese)● Tolbutamide (Orinase)● Glimepride (Amaryl)● Glipizide (Glucotrol)● Glyburide (DiaBeta, Micronase)
Stimulates pancreatic insulin secretion. ½ life 1 hour:● Repaglinide (Prandin)● Nateglinide (Starlix)
Regulate carbohydrate and lipid metabolism, reduce insulin resistance and hepatic glucose production. ½ life: 3- 8 hours:● Rosiglitazone (Avandia)● Pioglitazone (Actos)
Reduces the intestinal absorption of ingested glucose. ½ life 2 – 4 hours● Acarbose (Precose)● Miglitol (Glyset)
Dipeptidyl peptidase – 4 (DPP-4)
Reduces breakdown of gastrointestinal hormone-incretins (glucagon like peptide type -1, enhance insulin secretion, decrease glucagon). ½ life 8 – 14 hours.● Sitagliptin (Januvia)● Saxagliptin (Onglyza)
Synthetic form of Exendin 4, which has actions similar to glucagon-like peptide type 1 (GLP-1). ½ life : 6 – 10 hours. Supresses glucagon and hepatic glucose production. Supresses appetite and delays gastric emptying
Synthetic form of amylin, a naturally occurring peptide that is cosecrected with insulin by beta cells. Suppresses PP glucagon production. Enhances effect of insulin. Supresses appetite and delays gastric emptying. ½ life 2 – 4 hours
*Metformin may be discontinued 24 hours prior to the treatment provided the patient has history of renal failure.
If necessary rapid acting insulin would be administered via sc route.Dosing schedule: Initial insulin dose would be based either sliding scale as per APTC protocol given below or rule of 1800 would be used. 1800 is divided by total daily dose of insulin. Each unit of insulin would reduce the blood glucose level by 25 to 30mg/dL. Rule of 1800 is applicable for rapid acting insulin only.GIK: 1000mL of 5% Dextrose + 16 units of regular Humulin (short acting)+ 20 mmol KCl @ 100 mL/hour.