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  • Lumbar Puncture guidelines regarding anticoagulation and bleeding risk

    Posted by jtucker_0 on September 27, 2019 at 8:23 am

    My hospital is moving toward adopting the SIR Consensus Guidelines Part II (2019) regarding management of anticoagulation and bleeding risk in patients undergoing image guided procedures. My question regards lumbar punctures specifically. LPs are placed in the low bleeding risk category which means: INR less than 2.0 – 3.0 is acceptable. Platelet threshold is 20,000. Essentially the only anticoagulant withheld is coumadin (other than ReoPro, Aggrastat, and several others which I rarely see). Plavix and Lovenox are NOT withheld at all. This is a significant change from our current accepted guidelines regarding LPs specifically. Is this the trend most facilities are moving toward following the publication of the new SIR guidelines?

    Unknown Member replied 3 years, 10 months ago 13 Members · 21 Replies
  • 21 Replies
  • btomba_77

    Member
    September 27, 2019 at 8:47 am

    The guidelines were written by a friend and colleague of mine….
     
    we have always followed pretty much to the letter here as updates come out.
     
    (haven’t read the new stuff in detail though)

    • ruszja

      Member
      September 27, 2019 at 12:58 pm

      I like the guideline as it takes some of the personal bias out of it. That being said, at 20k platelets and an INR of 2.99 I don’t sleep all that well after a LP.

      • Unknown Member

        Deleted User
        September 27, 2019 at 7:08 pm

        Hard to get others in group to accept it. Still have a few that cancel a para for ASA, contrary to our guidelines. Havent introduced the new ones yet, but will.

        But agree with fw, 20k platelets makes me skeevy.

        • Tim11

          Member
          September 27, 2019 at 8:36 pm

          Do you guys check INR/platelets on all patients before LP?

          • ruszja

            Member
            September 27, 2019 at 8:39 pm

            Quote from dayman

            Do you guys check INR/platelets on all patients before LP?

             
            None of these are cheap&cheerful outpatients. They are sick enough to have labwork and once it’s there, you’ll have to willfully ignore it.

            • Tim11

              Member
              September 27, 2019 at 8:45 pm

              Oh I agree with following the guidelines on people who already have the labs done. My question was because there are differing opinions in my group on who needs labs to be approved for LP. Patient on Coumadin is obvious. What about the 75 yo cancer patient for intrathecal chemo? 30 yo for IIH? Just trying to see what others do.

              • Unknown Member

                Deleted User
                September 27, 2019 at 9:57 pm

                We dont check labs on LPs unless already done, or reason to suspect abnormal.

              • Unknown Member

                Deleted User
                September 27, 2019 at 10:04 pm

                We dont check labs on LPs unless already done, or reason to suspect abnormal.

                • zeze23_386

                  Member
                  September 27, 2019 at 11:00 pm

                  Big academic center in CA.

                  For inpatients: Our absolute lower limit of platelets is 50k but will occasionally do LP if platelets are as low as 40k and transfusion is hanging right before we start, and there is a very strong clinical indication to proceed and ordering inpatient team is comfortable doing frequent neuro checks or calling NSG for suspected epidural hematoma. Prefer to have INR <= 1.5.

                  For outpatients, however, we dont routinely check labs unless there is some reason to suspect they are abnormal, as a previous poster also stated.

  • tcooper_76

    Member
    September 21, 2020 at 11:19 am

    Quote from Rads4105

    My hospital is moving toward adopting the SIR Consensus Guidelines Part II (2019) regarding management of anticoagulation and bleeding risk in patients undergoing image guided procedures. My question regards lumbar punctures specifically. LPs are placed in the low bleeding risk category which means: INR less than 2.0 – 3.0 is acceptable. Platelet threshold is 20,000. Essentially the only anticoagulant withheld is coumadin (other than ReoPro, Aggrastat, and several others which I rarely see). Plavix and Lovenox are NOT withheld at all. This is a significant change from our current accepted guidelines regarding LPs specifically. Is this the trend most facilities are moving toward following the publication of the new SIR guidelines?

    Correct me if I am wrong…but if you read the details in the SIR Consensus part II, shouldn’t the platelet threshold be 50K for LP, not 20K?

    • msc5405

      Member
      September 21, 2020 at 1:02 pm

      Bleeding anywhere within the central nervous system has the potential for devastating neurologic consequences; therefore, multiple societies have chosen to classify pain procedures such as vertebral augmentation and procedures with risk of epidural bleeding as being associated with high bleeding risk ( [link=https://www.jvir.org/article/S1051-0443(19)30407-5/fulltext#bib32]32[/link]
      ), and the AABB has chosen to recommend a fairly liberal platelet count of 50 × 109/L as the threshold for lumbar puncture ( [link=https://www.jvir.org/article/S1051-0443(19)30407-5/fulltext#bib69]69[/link]
      ). This is supported by the C17 guidelines committee ( [link=https://www.jvir.org/article/S1051-0443(19)30407-5/fulltext#bib84]84[/link]
      ), which recommends transfusion at a platelet count threshold of 50 × 109/L for diagnostic lumbar puncture for newly diagnosed pediatric patients with leukemia and a threshold for transfusion of 20 × 109/L for pediatric patients in stable condition requiring lumbar puncture. Similar studies and recommendations are not available to establish an INR threshold.
       
      Copy and pasted from the guidelines
      [link=https://www.jvir.org/article/S1051-0443(19)30407-5/fulltext]https://www.jvir.org/arti…43(19)30407-5/fulltext[/link]
       
       

      • cytek1

        Member
        September 21, 2020 at 1:22 pm

        Well thats clear as mud since LP is included in the low risk section but discussed in the high risk section.

        Going off common sense, I would say an LP should be considered a low risk procedure though.

        • Melenas

          Member
          September 21, 2020 at 4:58 pm

          Everything we do has risk. There is no real elevated risk doing a lumbar puncture to me. Small needle, image guided, not too many vessels in the way. 
           
          Other doctors laugh at us for being so cautious. Grow some va*I&a and just treat it as LOW risk. Follow the guidelines. If in that 1 in a billion chance some bad outcome happens refer to the SIR.
           
           

          • bola09

            Member
            September 21, 2020 at 5:29 pm

            My institution’s recently updated guidelines lists lumbar puncture in the high risk category.

            • rwalmsley_851

              Member
              September 21, 2020 at 6:10 pm

              Wise radiologist told me based on their experience that low platelets typically caused a bigger problem than high INR.

              • stlmchenry_510

                Member
                September 21, 2020 at 7:37 pm

                Risk is low with LP

                • msc5405

                  Member
                  September 21, 2020 at 8:34 pm

                  As always, it depends- if the clinicians really need CSF to assess infection/cancer, or if the patient will always have low platelets because of chemo, or if the INR will never be optimal then you do what you can to get near the best number, but give it a good try with a 22G needle. Consider doing it under CT or with a biplane if a c-arm is not available to make a single attempt. 
                   
                  Someone will attempt the LP if they think it’s really necessary. We should make our best attempts to help the clinicians out since it is generally a safer procedure in our hands.

      • tcooper_76

        Member
        September 22, 2020 at 6:59 am

        So LP is categorized as Low Risk Procedure. But there is a paragraph symbol (¶) notation next to it in TABLE 3 referring to “See discussion in text: Laboratory Parameters for High Bleeding Risk Procedures and Recommendation 3.”

        Discussion in section ‘Laboratory Parameters for High Bleeding Risk Procedures’ regarding LP:

        “Bleeding anywhere within the central nervous system has the potential for devastating neurologic consequences; therefore, multiple societies have chosen to classify pain procedures such as vertebral augmentation and procedures with risk of epidural bleeding as being associated with high bleeding risk (32), and the AABB has chosen to recommend a fairly liberal platelet count of 50 x 10^9/L as the threshold for lumbar puncture (69). This is supported by the C17 guidelines committee (84), which recommends transfusion at a platelet count threshold of 50 x 10^9/L for diagnostic lumbar puncture for newly diagnosed pediatric patients with leukemia and a threshold for transfusion of 20 x 10^9/L for pediatric patients in stable condition requiring lumbar puncture. Similar studies and recommendations are not available to establish an INR threshold.”

        Recommendation 3:

        “Appropriate preprocedural coagulation testing should be obtained for patients undergoing procedures with high bleeding risk (Table 3). The following laboratory value thresholds have been suggested: correct INR to within range of 1.51.8 or less and consider platelet transfusion if platelet count is < 50 x 10^9/L (Table 3). (Level of evidence, D; strength of recommendation, weak.)”

        Based on the fine print disclaimers, am I wrong in deducing for LP (even though it is a low risk procedure) parameters should be INR </= 1.8 and Platelets >/= 50K ?

        • loli.amaral_506

          Member
          September 24, 2020 at 10:01 pm

          As someone who does a lot of LP, I would be careful. Its simple until you get an epidural hematoma. We always check Platelets and INR and hold most anticoagulants and even hold full dose (but not baby) aspirin. 
           
          If something goes wrong the first question will be why didn’t you follow the society guidelines?  If it is truly urgent then its a risk vs benefit discussion with documentation. But there are very few true urgent indications for LP. 
           
           
           
           

          • cytek1

            Member
            September 24, 2020 at 10:46 pm

            Not sure theres any good recent papers to back up your approach, and plenty of recent ones to show no increased risk of bleeding with ASA or plavix. Probably prudent in a litigious world though.

            • Unknown Member

              Deleted User
              September 25, 2020 at 4:36 am

              A little off topic, but I once made a resident write a note in the chart that a patient did not have any clinical signs/symptoms of elevated ICP before I would do an LP. She had a normal head CT.
              He wrote the fundoscopic exam was normal with no signs of elevated ICP. Patients opening pressure was sky high, but she did not herniate.