Cite this post as:
Guest Author. Confounding Questions in Resus – When is it safe to Perform an LP with Anti-Platelet Agents on Board. EMCrit Blog. Published on May 16, 2018. Accessed on March 19th 2024. Available at [https://emcrit.org/emcrit/cqir-lp-asa-plavix/ ].
Financial Disclosures:
Dr. Scott Weingart, Course Director, reports no relevant financial relationships with ineligible companies.
This episode’s speaker(s), (listed above), report no relevant financial relationships with ineligible companies.
CME Review
Original Release: May 16, 2018
Date of Most Recent Review: Jan 1, 2022
Termination Date: Jan 1, 2025
You finished the 'cast,
Now Join EMCrit!
As a member, you can...
- Get CME hours
- Get the On Deeper Reflection Podcast
- Support the show
- Write it off on your taxes or get reimbursed by your department
.
Get the EMCrit Newsletter
If you enjoyed this post, you will almost certainly enjoy our others. Subscribe to our email list to keep informed on all of the Resuscitation and Critical Care goodness.
This Post was by the EMCrit Crew, published 6 years ago. We never spam; we hate spammers! Spammers probably work for the Joint Commission.
Thanks for the review. Good tip on using Whitacre to lower bleeding.
It’s easy to say no to LP for elective procedure in anesthesia but what do you do in ER when you are ruling out meningitis or subarachnoid? I think you get informed consent but you still go ahead with the procedure as risks of missing diagnosis outweigh risks of procedure.
there really is never an emergent LP in EM. For infection, you empirically treat. For SAH r/o, please just perform the CTA and avoid having to stick a needle in, in the first place. LP will eventually (thankfully) disappear from SAH w/u in the future.
Barring major CIs (e.g. clopi as above), isn’t it better to get LP in suspected infection for culture as early as possible to maximise yield?
Hm, I very much agree with Tim and Myura. ASA is no problem, but Clopidogrel is a contraindication? I don’t really understand the underlying arguments. Of course I would prefer if a patient did not have any of those at board, but if a LP is urgent, I have never worried about antiplatelet monotherapy (and never seen related complications). And about suspected bacterial meningitis (or herpes encephalitis) – of course treatment comes first. But LP as confirmation (or negation) of the suspected diagnosis is very important for the further clinical course, so I definitely would not wait a few days… Read more »
While an LP need not be done emergently in meningitis, it can’t wait for days either. Blood cultures are negative pretty regularly, leaving you with two weeks of blindly treating a possibly neurologically injured patient. Worse is the possibility that the patient has something else entirely going on, and we ‘re not clued in to it.
The nice part about these issues is you don’t have to remember all things:
ASRA (american society of regional anesthesia) has the most evidence-based guidelines around LP dangers…. in an app!
https://www.asra.com/page/150/asra-apps
If 100 patients have no issue, what’s the upper ratio of patients with the issue? usually divided by 3 if no events are recorded
So can be as high as 1:33 incidence of bleed with LP
Classic Article:
If nothing goes wrong, is everything alright?
https://jamanetwork.com/journals/jama/article-abstract/385438
Any neurologic signs mean immediate MRI and possible emergent spinal decompression.
Cost:Benefit always
https://www.jwatch.org/na46713/2018/05/17/lumbar-puncture-patients-receiving-dual-antiplatelet Please see above case series – 100 pts had LP on DAPT. The original report came out before your article so you must have missed it on your case review. This also points out the flaw in trying to extrapolate the anesthesia data (which per my review itself is not exactly medicine based) to your question. Also, to not do an LP on a pt with meningitis falls below the standard of care. True, if it’s gonna take too long, start abx first. But afterwards attempt the LP. Even if the culture comes back negative “on abx”, a totally… Read more »
Thank you for your comment. That is an interesting albeit small study which is in fact referenced in my above post. It does show that 100 patients did not have any significant negative outcomes but again was performed by nurses who do this procedure daily which is certainly different than a physician who is competent in this procedure but performs it only occasionally. This section is meant to bring about discussion on topics for which the evidence lacks. I look forward to any future studies that may clarify the safety of performing this procedure in this patient population.
I know what the guidelines say, I’ve read it and I’ve read this post and the comments.
But even accepting that monotherapy with clopidogrel truly increases clinically relevant bleeding risk, which is hard to believe looking at the data, don’t you think that the statement “continue aspirin, stop clopidogrel” lacks biologic plausibility given the fact that aspirin has a (slightly) higher bleeding risk?