Do you defer Pain procedures in Patients with High Blood sugars if > 300 on the day of procedure.
High Blood sugar
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Had a patient tell me her sugar went to 900 after an RF (6mg Celestone total used). I was calling BS on her because home units go to 500 or 600 then just read HIGH. She confirmed her sugars by going to her Endocrine office and having them check. Apparently, she uses a pump and this happens a lot for her. Thought she would be Honking or in DKA with that.
We check INR's at the bedside for all coumadin patients, but never check sugars unless a DM patient is sick and we already cancelled the procedure.
We check INR's at the bedside for all coumadin patients, but never check sugars unless a DM patient is sick and we already cancelled the procedure.
we also dont check.
maybe dont use any steroid for her RF, then?
im not all that familiar with the bedside INR checking thingy. some sort of newfangled device i dont know about? we always get INR drwn day of the procedure. is there some sort of finger stick out now or something?
its a Point of care machine. Its small and nifty. cost like 5-8k. we looked at, but you gotta check a lot of INRs to break even. we decided against it...but the convenience is awesome. Its like a finger stick. suppose to have excellent accuracy.
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My office has a full lab, 20 docs, and one of those machines that we can borrow and bring to the suite. Looks like a glucose meter. Finger stick and 60 seconds later you have an INR. The machine is free when you do 100 or so per month, they make their money on the consumables. Another benefit of working in a big group.
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Approved, as accurate as any test for this.
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Few Questions. I've now seen several people at several different institutions/practices do RF. No one has advocated the use of steroids while doing RF. Their reasons
1) You've supposedly already done a MBB/Facet injections with steroids. Now you want to see the efficacy of the RF. If you also place steroids in the cannulla, then how do you know whether its the RF or the steroids that's doing the job.
2) Steroid placement to preemptively strike against possible dysesthesia doesnt have good data. The likelihood of geting a RF induced dysesthesia is low to begin with, so to just give steroids to everyone has been said to be overkill. Again, where I'm at we've done tons of RF. Also where I've rotated through people have done tons of RF. None of them can recall the last time they 've had a dyesthesia from a RF.
3) Now you've just given steroids and in the event the RF doesnt work, you can't just go back to doing a MBB/facet injection immediately because you just gave steroids. You've got to now, 'space it out'.
4)r/o infection, adrenal insuff, the usual stuff.
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You left off AVN. But these theoretical risks are less than the perceived risk of dysesthesia for me and my patients. If I were having the procedure done, I'd do it exactly like I do it for my patients and the way I was trained. Remember, many institutions do things very differently, keep an open mind, but call BS when you see it. These are good questions and I've tried to provide good answers. There is no evidenced based rationale for the addition of steroid in an MBB or RF, but I would not want it done to me without it. This is peppered in the literature on MBB and RF hen reading the techniques sections of the articles.
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I am. The heresy. Similar to any nerve block.
3-6mg Celestone in 2cc bupi, then 0.5cc of the mix at each level.
If they get of the table and the pain is better, it's positive.
If they are better the next morning, it's a toss-up.
If they are better at 1 week, it's placebo or steroid.
If they are better at 2 weeks, it's placebo or steroid.
If they are better at 2 months, it's placebo or steroid.
If pain returns between 6-24hrs, it's positive.
If no pain relief, it's negative.
I've had MBB's last 6 months to 8 months.
If there is something I can do to help prevent folks from coming back in pain 3 days after the MBB, and not alter my long term success using RF (9-18 mo), then I see no problems. Things I've learned in practice: 50% dextrose post-RF did not seem to make the RF last longer. Burning 120 sec vs 240 sec did not seem to make a difference except in reburns. Adding a drop of Celestone did not alter RF success rates, but reduced complaints of post-RF dysesthesia. I tried lowering the temp from 80 to 75 but did not make a difference (cooking is cooking). Again, I'm not the first or only pain doc adding steroid to dx blocks. Just food for thought, and yes I'm being defensive.
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i have been adding small dose of steroids post RF... not so much for the dysesthesias... just a LOT less post-RF complaints of neck/back pain (the outer layer of bone can be quite sensitive to inflammation), and as you know RF of a medial branch does not mean that the bone will be insensate due to the innervation of the bone...
i really doubt 10mg of triamcinolone split over 3 levels every 12-18 months is going to cause AVN, adrenaly suppression... show me the data on that...
but i do not use steroids for MBB... probably because Bogduk would whip me with a wet noodle.
i really doubt 10mg of triamcinolone split over 3 levels every 12-18 months is going to cause AVN, adrenaly suppression... show me the data on that...
but i do not use steroids for MBB... probably because Bogduk would whip me with a wet noodle.
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He'd just put out a cigarette ( after lighting the next one with it) on your forehead. Gotta love nik.
I am. The heresy. Similar to any nerve block.
3-6mg Celestone in 2cc bupi, then 0.5cc of the mix at each level.
If they get of the table and the pain is better, it's positive.
If they are better the next morning, it's a toss-up.
If they are better at 1 week, it's placebo or steroid.
If they are better at 2 weeks, it's placebo or steroid.
If they are better at 2 months, it's placebo or steroid.
If pain returns between 6-24hrs, it's positive.
If no pain relief, it's negative.
I've had MBB's last 6 months to 8 months.
If there is something I can do to help prevent folks from coming back in pain 3 days after the MBB, and not alter my long term success using RF (9-18 mo), then I see no problems. Things I've learned in practice: 50% dextrose post-RF did not seem to make the RF last longer. Burning 120 sec vs 240 sec did not seem to make a difference except in reburns. Adding a drop of Celestone did not alter RF success rates, but reduced complaints of post-RF dysesthesia. I tried lowering the temp from 80 to 75 but did not make a difference (cooking is cooking). Again, I'm not the first or only pain doc adding steroid to dx blocks. Just food for thought, and yes I'm being defensive.
right, so im not sure why you add steroid to ANY nerve block.
i hear what you are what saying, and you've clearly given this a lot of thought. however, you are adding in another vairable when you want to make things as cut-and-dried as possible. MBBs should initially be treated as a diagnostic procedure. by adding the steroid, you are theoretically providing a therapeutic inejction -- although this may not be due to purely z-joint related pain. you are dumping steroid along the spine which due to the simple added volume, you are going ot get more spread to adjacent structures.
also, this paradigm:
If they get of the table and the pain is better, it's positive.
If they are better the next morning, it's a toss-up.
If they are better at 1 week, it's placebo or steroid.
If they are better at 2 weeks, it's placebo or steroid.
If they are better at 2 months, it's placebo or steroid.
makes no sense, because patients can easily have identical reactions with just LA alone. i know mine have, and they never get steroid. if your goal is to have the MBB last longer by adding steroid you are trying to perform a theapeutic injection, and i believe that you are clouding your diagnostic picture.
also, studies have shown identical outcomes and duration of pain relief when comparing MBBs with and without steroid (yes, i bash lax every chance i get, but AM quoting his literature. so?)
the case for steroid post-RF is a better one, but i still dont see the utility. ive been telling myself that once i start getting post-RF dysesthesias that ill add steroid. ive been saying that 3 years now. ive also heard that the better the RF is done (larger guage RF needle, longer burn, etc) the more dysesthesias. i have not seen that to be the case.
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Very interesting discussions and very helpful to think about this, esp for those of us in training.
Looking back at the original question, I'd redirect and ask the question regarding epidurals since steroid dosage tends to be greater for ESI's than what's used for RFA's (well, for those that use it).
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yeah I do it anyway. I ask them if they check it regularly at home and if so, how their sugars have been the last week or two. If chronically elevated, they probably need to see their PCP and get their regimen adjusted. In this case I MAY hold off. If it's just a bad day I'll do it and tell them to watch their surgars closely for the next week and expect to need a little more insulin than normal.
back to the original topic. Had a patient with a sugar of 500 today for SCS implant, AFTER 40 units of insulin...i wonder what it was during the trial. Needless to say it got cancelled. He was told by the pre-op nurse not to take his evening dose of Lantus...oi vey.
i use steroids in all of my RF, but think steroids are silly in MBBs. If you are going to use steroids, put in the joint. If you are going to do a NERVE BLOCK, do a nerve block, with local. I have never understood the need to add steroid in stellates, mbbs, sciatic blocks. I think its just a secondary way to give success, that may have nothing to do with the primary block. Might as well give it IM.
RF, i cant tell you how my post-rf complaints have dropped since adding steroid. My partner used to have either neuritis or some issue post-RF like 30-40% time till he started adding steroid, and now it is a rarity...
i use steroids in all of my RF, but think steroids are silly in MBBs. If you are going to use steroids, put in the joint. If you are going to do a NERVE BLOCK, do a nerve block, with local. I have never understood the need to add steroid in stellates, mbbs, sciatic blocks. I think its just a secondary way to give success, that may have nothing to do with the primary block. Might as well give it IM.
RF, i cant tell you how my post-rf complaints have dropped since adding steroid. My partner used to have either neuritis or some issue post-RF like 30-40% time till he started adding steroid, and now it is a rarity...
