Oral sedation for procedures.

[donaldduck]

I am wondering what y’all are using for oral sedation for your procedures. I’m experiencing a lot of patients who just can’t tolerate local only.

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[BobBarker]

10mg diazepam most of the time. Have used up to 20mg.

 

[jsaul]

Same as Bob
10mg Valium rarely 1.5 or tabs

 

[plasma.]

I use Lorazepam. Diazepam has a much longer half life.

 

[MitchLevi]

Valium 5-10mg, and you can mix in a phenergan to boost it

 

[bedrock]

I use Lorazepam. Diazepam has a much longer half life.

xanax, shorter half life than all other benzos

 

[TheLoneWolf]

Never experienced someone who truly couldn't tolerate good localization and time in a busy, take all comers private practice. Everyone got Iv fentanyl and midazolam in fellowship and we had multiple issues with patients coming in for the buzz and demanding heavy iv sedation on repeat injections.

I've had a small handful forcefully demand sedation from me, I offer to send them to psych to deal with underlying psych issues if they feel they can't tolerate it.

 

[bedrock]

Never experienced someone who truly couldn't tolerate good localization and time in a busy, take all comers private practice. Everyone got Iv fentanyl and midazolam in fellowship and we had multiple issues with patients coming in for the buzz and demanding heavy iv sedation on repeat injections.

I've had a small handful forcefully demand sedation from me, I offer to send them to psych to deal with underlying psych issues if they feel they can't tolerate it.

I respect your option but I disagree. A little Xanax goes a long way. I have many patients who will struggle and or vagal severely if they don’t at least get an oral benzo.

And yes, a minority of patients need iv sedation to get through a tougher case like cervical RFA. Even with slow deliberate technique.

What about stim trials?

I feel it is a bit harsh to just dismiss 100% of their concerns as psych problems.

BTW, 98% of the patients I’m referencing are not on COT.

 

[lobelsteve]

Vagal is more the doctor than the patient.

 

[Ronin1]

I think anesthesia trained guys are more comfortable with the concept of iv sedation in general. I mean who really cares if the patient is awake and cooperative through a RFA etc and they got some oral or iv sedation.
People get general anesthesia for surgeries that could easily be done with MAC or local all the time.

As long as your setup allows you to safely give a little sedation it’s fine. It does slow me down though as far as getting an iv etc.

 

[Laryngospasm]

I like the long duration diazepam for muscle relaxation after laying in an often uncomfortable position for the patients and any other post procedure spasm.

 

[Agast]

You can give a little old lady tizanidine 4mg and its a pretty good sedative without giving them a benzo.

 

[paindoc34]

Is an anesthetic record necessary when doing PO sedation?

 

[RoloTomassi]

It's also not just about "can they get through it". The goal is for them to have a pleasant experience. It's no different than dentists that advertise some sort of sedation. The less they feel the happier, and that's important in my competitive market.

I offer everything from local, NO, PO, MKO, IV, MAC, GETA. Depends on the patient and the procedure.

 

[specepic]

xanax, shorter half life than all other benzos

What mg range?

 

[gaspasser127]

It's also not just about "can they get through it". The goal is for them to have a pleasant experience. It's no different than dentists that advertise some sort of sedation. The less they feel the happier, and that's important in my competitive market.

I offer everything from local, NO, PO, MKO, IV, MAC, GETA. Depends on the patient and the procedure.

What do you offer for ESI, facets, MBBs, and SIJ?

 

[callmeanesthesia]

You can give a little old lady tizanidine 4mg and its a pretty good sedative without giving them a benzo.

I had a little old lady who took 4 mg tizanidine prior to procedure (not at my instruction) and I had to send her to the ER for symptomatic hypotension.

 

[Agast]

I had a little old lady who took 4 mg tizanidine prior to procedure (not at my instruction) and I had to send her to the ER for symptomatic hypotension.

You’re supposed to counteract that by stabbing her in the back

 

[PinchandBurn]

I respect your option but I disagree. A little Xanax goes a long way. I have many patients who will struggle and or vagal severely if they don’t at least get an oral benzo.

And yes, a minority of patients need iv sedation to get through a tougher case like cervical RFA. Even with slow deliberate technique.

What about stim trials?

I feel it is a bit harsh to just dismiss 100% of their concerns as psych problems.

BTW, 98% of the patients I’m referencing are not on COT.

I 100% agree with this.

If you're in PP you need to do it.

I dont do it for any esi. But for CERVICAL RFA, kypho, scs trial...very reasonable to do IV sedation and it can be done safely. Only at an academic setting can you wait 30min for local to kick in.

The reality is even with liberal localization Some people need some sedation.

I never do it for ESI and MBBs

Almost never have to do it for Lumbar RFA

If I give oral xanax it's usually 1-2mg right before the procedure

 

[paindoc007]

It's also not just about "can they get through it". The goal is for them to have a pleasant experience. It's no different than dentists that advertise some sort of sedation. The less they feel the happier, and that's important in my competitive market.

I offer everything from local, NO, PO, MKO, IV, MAC, GETA. Depends on the patient and the procedure.

Appreciate that honesty. Thank you

 

[strike5858]

Vagal is more the doctor than the patient.

Please elaborate, I just had a really ****ty day with like 5 middle age males all vaso -vagal. I give local and xanax po.

 

[Dr. Ice]

The “need” for some form of sedation tends to be directly proportional to the book ends of socioeconomic status, but I agree in pp we aim to please

 

[callmeanesthesia]

Please elaborate, I just had a really ****ty day with like 5 middle age males all vaso -vagal. I give local and xanax po.

I’ve had good luck with passive leg raise. If patient says they’re feeling hot and sweaty/lightheaded/nauseated at the end of the procedure, have them flip on their back and elevate their legs for about 30 seconds. The vasovagal will pretty reliably pass without them passing out. Not foolproof since sometimes those young guys seem fine until they try to stand, then just go down like a ton of bricks, but it does speed up recovery.

Another great trick I learned on here for patients known to be prone to vasovagal: Sudafed (the real stuff, not the phenylephrine kind).

 

[RoloTomassi]

What do you offer for ESI, facets, MBBs, and SIJ?

I offer the whole menu, so they can't be upset if it hurts and they opted for local, but I steer towards the minimum. Majority local. Then NO>PO/MKO>IV.

 

[drusso]

IM ketamine is also very effective.

 

[callmeanesthesia]

I offer the whole menu, so they can't be upset if it hurts and they opted for local, but I steer towards the minimum. Majority local. Then NO>PO/MKO>IV.

How do you deliver the nitrous? I’m interested but I know insurance probably won’t cover, and if it’s more than $20 I doubt most of my patients would. Looks like I can get disposable nasal masks for about $5 each on Henry Schein. From what I can find online it seems like the gas itself is only about $10 an hour including the tanks.

 

[BobBarker]

How do you deliver the nitrous? I’m interested but I know insurance probably won’t cover, and if it’s more than $20 I doubt most of my patients would. Looks like I can get disposable nasal masks for about $5 each on Henry Schein. From what I can find online it seems like the gas itself is only about $10 an hour including the tanks.

I used the cheapest disposable masks and anesthesia circuits available from medline. It think it costs every bit of $60/case if not more. I comp it for kypho and charge $75 otherwise. The plumbed, large cylinder systems that dentists use are much more efficient. I have a dream of having two procedure rooms with plumbed nitrous and bouncing back and forth with each patient paying $40 cash.

 

[RoloTomassi]

How do you deliver the nitrous? I’m interested but I know insurance probably won’t cover, and if it’s more than $20 I doubt most of my patients would. Looks like I can get disposable nasal masks for about $5 each on Henry Schein. From what I can find online it seems like the gas itself is only about $10 an hour including the tanks.

I use the ProNox system. Cost per case in disposables is 15-20 I think. Then there's the gas tanks from gas supplier. The unit itself is about 7k. It's works like a hookah. Cervicals were a bit tricky with one hand holding it but I'm used to it now.

 

[bedrock]

Another great trick I learned on here for patients known to be prone to vasovagal: Sudafed (the real stuff, not the phenylephrine kind).

How much of the real Sudafed? 1 or 2 tablets?

 

[callmeanesthesia]

How much of the real Sudafed? 1 or 2 tablets?

Not sure. Probably 1? Just enough to bolster the HR and vessel tone.

 

[callmeanesthesia]

I used the cheapest disposable masks and anesthesia circuits available from medline. It think it costs every bit of $60/case if not more. I comp it for kypho and charge $75 otherwise. The plumbed, large cylinder systems that dentists use are much more efficient. I have a dream of having two procedure rooms with plumbed nitrous and bouncing back and forth with each patient paying $40 cash.

I think I’ll call my dentist and ask how his set up works. I know he offers Nitrous.

Nitro-nomics: The real costs of using nitrous oxide in the dental office

Dr. Anthony Carroccia details the expenses of using nitrous oxide in the dental office and explains how to recoup some of those costs.

www.dentaleconomics.com

This article seems to say it could be a lot cheaper than $60/case.

I looked into Nitrox too but I was out off by the high initial cost. The only benefits to me are increased patient satisfaction (I’m in a low competition market though), and fewer people wanting procedures at the ASC (which I already limit to 1/2 day twice a month, some of which being implants).

 

[lobelsteve]

I 100% agree with this.

If you're in PP you need to do it.

I dont do it for any esi. But for CERVICAL RFA, kypho, scs trial...very reasonable to do IV sedation and it can be done safely. Only at an academic setting can you wait 30min for local to kick in.

The reality is even with liberal localization Some people need some sedation.

I never do it for ESI and MBBs

Almost never have to do it for Lumbar RFA

If I give oral xanax it's usually 1-2mg right before the procedure

30 min for local?
Go back to pharmacology class.

 

[Ducttape]

I use Lorazepam. Diazepam has a much longer half life.

if you are worried about someone going home, then use oral midazolam. half life is 1-4 hours, as opposed to lorazepam, 10-20 hours, or xanax 6-20 hours.

 

[pastafan]

I never referenced sedation in any note regarding PO med. It was given for anxiolysis prior to the procedure.

 

[BobBarker]

30 min for local?
Go back to pharmacology class.

Lidocaine is nearly instant for the skin. I have tested on myself. I injected the back of my left hand with my right hand. It stung a lot. It became numb immediately and stayed numb for several hours. There was a large area around the skin wheel that was numb also.

 

[drrosenrosen]

Since I adopted the 25ga quinke approach for my interlaminars, I use a 25ga 3.5 inch needle for 90% of my procedures, no local, and most pts are no sedation. I'll do a little IV versed for RFAs, occasionally oral anxiolysis with xanax for procedures if pt is insistent. Kyphos get IV versed and ketamine. Mostly I try to talk them out of sedation at all.

 

[Dr. Ice]

Since I adopted the 25ga quinke approach for my interlaminars, I use a 25ga 3.5 inch needle for 90% of my procedures, no local, and most pts are no sedation. I'll do a little IV versed for RFAs, occasionally oral anxiolysis with xanax for procedures if pt is insistent. Kyphos get IV versed and ketamine. Mostly I try to talk them out of sedation at all.

Agree, my caid patients invariably expect it because their last pain doc (always hospital employed) did it without there even being a conversation about it

 

[donaldduck]

So, what’s the dose of Xanax y’all are using and how long before the procedure do they need to take it for maximum effectiveness?

 

[plasma.]

Yes, would be interested in knowing xanax dosing and timing too. The shorter half life is a valuable.

 

[callmeanesthesia]

Yes, would be interested in knowing xanax dosing and timing too. The shorter half life is a valuable.

I do 0.5 mg 1-2 tabs for age <65, and 0.25 mg 1-2 tabs age 65 and up.

 

[SSdoc33]

>30K shots, and never used any sedation. yet the patients keep coming back somehow......

 

[plasma.]

>30K shots, and never used any sedation. yet the patients keep coming back somehow......

You must be very patient. I've had some patients so anxious that they are jumping off the table when I'm simply marking the entry site...

I agree it can be done without needing anxiolysis but I feel no need to make life more difficult for myself when 1-2 mg of Ativan will make things easier for both the patient and I.

 

[MitchLevi]

I swear this is a yall problem and not a pt problem

 

[PinchandBurn]

30 min for local?
Go back to pharmacology class.

You clearly didn't understand the sarcasm.

Again. None of my esi or Mbb require any sedation. My practice is mainly non opioid. Nonetheless there are people that have some hyperalgesia. A little oral or iv sedation for stims, kypho, cervical rfa is not unreasonable.

 

[SSdoc33]

You must be very patient. I've had some patients so anxious that they are jumping off the table when I'm simply marking the entry site...

I agree it can be done without needing anxiolysis but I feel no need to make life more difficult for myself when 1-2 mg of Ativan will make things easier for both the patient and I.

no. actually not patient at all.

i just dont inject hyperalgesic fibromyalgia patients who wont get better with shots anyway. if they are a mexican jumping bean with the pointer, why would a MBB help?

by not choosing to injecting these patients i am making life EASIER for myself.

remind me again how haggling with patients over sedation, clicking all the buttons to send in the prescription, making sure they are NPO, waiting for the oral or IV meds to take effect, putting in the IV, not getting paid for it, then making the patients wait around after the procedure to confirm they are not too doped up to leave is easier?

 

[Ducttape]

xanax 0.5-1 mg.

for those over 85, 0.25 mg.

 

[BobBarker]

If you really wanted, IM midazolam would be pretty good. I have thought about doing it.

 

[Ducttape]

not a bad idea, but the purpose for me of using the oral anxiolytics was to reduce the anxiety with the lidocaine.

 

[RoloTomassi]

It does make it easier and more pleasant for me, not hearing a scream with every needle movement, not having them contract their backs so hard it constantly changes my trajectory and staff constantly saying relax and breathe, not having them sit up with a face full of tears and running makeup, not having them vasovagal. Cash for anything more than local, prices that offset our inconvenience.

This is pretty much exclusively a <65 yo issue. And vasovagalers are usually repeat offenders that tell me it happens every time they have blood drawn or when they had a previous injection, so I don't think it's a me problem.

I've done IM midazolam when the patient was insistent on IV but we couldn't find a vein.

 

[bedrock]

How would the IM dozing of versed compare to IV dosing?

Same dose?
50% more with IM route vs IV route?