2019 ASIPP guideline on interventional pain sedation

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
likely to drive procedures from office to more expensive asc. cardiac monitoring is overkill.
 
Last edited:
Morally bankrupt, but all authors pain millionaires. Lots of cash flowing into their ASCs. Guidelines supported by # of Ferraris and not science.
But y'know, I know some other guys:
 

Attachments

Ducttape said:
i would never do moderate or deep sedation without cardiac monitoring. its just setting you up for a lawsuit.
Click to expand...
You're right, but the ASA doesn't mandate cardiac monitoring for everyone or even capnography necessarily for moderate/deep sedation if "precluded or invalidated by the nature of the patient, procedure, or equipment"

The best part is that the ASA guidelines cited explicitly exclude literature about sedation for pain procedures or blocks.

Anesthesiology

anesthesiology.pubs.asahq.org anesthesiology.pubs.asahq.org

"
Exclusion criteria:
  • Procedures using minimal sedation (e.g., anxiolysis for insertion of peripheral nerve blocks, local or topical anesthesia)
  • Procedures where deep sedation is intended
  • Procedures where general anesthesia is intended
  • Procedures using major conduction anesthesia (i.e., neuraxial anesthesia)
  • Procedures using sedatives in combination with regional anesthesia
  • Nondiagnostic or nontherapeutic procedures (e.g., postoperative analgesia, pain management/chronic pain, critical care, palliative care)
"

I'm not disagreeing that it's probably safest to do it the way suggested above, but I'm not sure what it really gets in terms of benefit
 
I hardly ever use sedation for procedures. Maybe the occasional PO Xanax if the patient is extremely anxious about the procedure despite reassurance. Only IV sedation for RFAs, kypho, stim trials and that is usually just versed and occasionally some fentanyl. That being said everyone gets pulse ox and bp cuff and with IV sedation capnography
 
nvrsumr said:
likely to drive procedures from office to more expensive asc. cardiac monitoring is overkill.
Click to expand...

We do cardiac, pulse ox, and EtCo2 monitoring in the office in our accredited office-procedure room. No biggie. Talk to your admin about it. Now that it is out there, it will be relied upon by expert witnesses for forming opinions about standard of care.
 
Last edited:
No sedation for me. I will occasionally give a PO Ativan 0.5mg 1 hr prior and another 0.5mg 20 min prior.

You guys running IV sedation are absurd, especially if you endorse pain psychology for chronic pain. Let's make this shot a huge deal by fasting the night prior and running an expensive set up for a 3 min injxn. Let's reinforce that the lumbar spondylosis and facet arthropathy are a SUPER HUGE DEAL by making this tiny procedure an endeavor. Your stenosis requires this bulky event at a surgical center with multiple people involved in the process.

It is total BS.

I have a buddy who does propofol for injxns. It is infuriating.
 
100% agree. If our clinic can do 10,000 injections a year with 9,500 done with zero sedation of any kind then why are some of us using IV sedation for every procedure!
 
SommeRiver said:
No sedation for me. I will occasionally give a PO Ativan 0.5mg 1 hr prior and another 0.5mg 20 min prior.

You guys running IV sedation are absurd, especially if you endorse pain psychology for chronic pain. Let's make this shot a huge deal by fasting the night prior and running an expensive set up for a 3 min injxn. Let's reinforce that the lumbar spondylosis and facet arthropathy are a SUPER HUGE DEAL by making this tiny procedure an endeavor. Your stenosis requires this bulky event at a surgical center with multiple people involved in the process.

It is total BS.

I have a buddy who does propofol for injxns. It is infuriating.
Click to expand...

What's best for the patient?

It's the black swan event you have to plan for and for which you will be held to SOC. 90% of my procedure don't require sedation or IV's, etc and I'm office-based. But, sympathetic blocks, RF's, stims, etc I do use sedation. I'm using Nitrous now which is great.

If something goes wrong, even if it is completely unrelated to the procedure itself, lack of preparation will be viewed as preparing to fail.
 
nobody is saying to use IV sedation routinely, and nobody is saying we should use anything more than moderate sedation.

the ASIPP guideline says,

"Due to the nature of chronic pain and anxiety, many patients undergoing interventional techniques may require mild to moderate sedation".

how do you determine whether or not a patient is one of the "many" patients who may "require" mild to moderate sedation? Just like anything we do in medicine, you evaluate your patient, discuss with your patient and document the risk, benefit and alternative of a plan.

if you don't feel comfortable to offer mild to moderate sedation via IV sedation, you tell your patients, and let your patients decide whether or not they will do the procedure with you. it's not about you, it's about your patients.

but if you omit the step of offering and discussing sedation option, you are not following the guideline which you will be hold against to.
 
drusso said:
What's best for the patient?

It's the black swan event you have to plan for and for which you will be held to SOC. 90% of my procedure don't require sedation or IV's, etc and I'm office-based. But, sympathetic blocks, RF's, stims, etc I do use sedation. I'm using Nitrous now which is great.

If something goes wrong, even if it is completely unrelated to the procedure itself, lack of preparation will be viewed as preparing to fail.
Click to expand...

Please explain what IV sedation is providing you that a tab of PO Ativan wouldn't...

What is best for the patient is to limit the amount of impact the medical industry has in his or her life.

The routine use of IV sedation is for the ASC and its shareholders, not the pt.
 
drpainfree said:
nobody is saying to use IV sedation routinely, and nobody is saying we should use anything more than moderate sedation.

the ASIPP guideline says,

"Due to the nature of chronic pain and anxiety, many patients undergoing interventional techniques may require mild to moderate sedation".

how do you determine whether or not a patient is one of the "many" patients who may "require" mild to moderate sedation? Just like anything we do in medicine, you evaluate your patient, discuss with your patient and document the risk, benefit and alternative of a plan.

if you don't feel comfortable to offer mild to moderate sedation via IV sedation, you tell your patients, and let your patients decide whether or not they will do the procedure with you. it's not about you, it's about your patients.

but if you omit the step of offering and discussing sedation option, you are not following the guideline which you will be hold against to.
Click to expand...

Did you seriously embolden the word require as if to say that some ppl by law are guaranteed the right to IV sedation for a caudal ESI? I don't inject ppl like that so they can find another doctor. If I schedule an injxn with a pt and they make demands they will be removed from the schedule and can find another doctor bc they do not have the right to make decisions for me. I will give them Ativan in rare circumstances and by the way...This has never been a problem for me or any of the other guys in my practice, and none of us run sedation. We have 2 fully loaded ASC so we have access to it but refuse to offer it.
 
SommeRiver said:
Please explain what IV sedation is providing you that a tab of PO Ativan wouldn't...

What is best for the patient is to limit the amount of impact the medical industry has in his or her life.

The routine use of IV sedation is for the ASC and its shareholders, not the pt.
Click to expand...

1) They lay stiller during scs trials and RF's. Less carping.

2) That's ideological driven, collectivist, anti-doctor bollocksology.

3) I never said "routine." I don't practice in an ASC. I do consult for office-procedure practices who want to meet state requirements for administering sedation in the office.

 
I didn't, ASIPP did with its guideline.

Again, you have to have that discussion with your patients and document the discussion. You have the right to not offer it, your patients have the right to NOT get it done by you.

Yes, I would and do turn away patients who demand anything but mild to moderate sedation.
 
drusso said:
1) They lay stiller during scs trials and RF's. Less carping.

2) That's ideological driven, collectivist, anti-doctor bollocksology.

3) I never said "routine." I don't practice in an ASC. I do consult for office-procedure practices who want to meet state requirements for administering sedation in the office.

Click to expand...

Stim trials are obviously a different ball game, and I do MAC for trials and implants. RFA is straight local.

The collectivist statement is a joke. I am extremely anti collectivist and pro individual, and the fact remains that the medical industry will take a bite out of your behind if you let it, and you're experienced enough to know that by now...especially as a pain MD.

A pt with chronic back pain comes in for an L5-S1 TFESI and I want it to be a nothing burger experience so I don't reinforce catastrophic beliefs regarding pain.

"Your pain is so bad we have to make you NPO, give you an IV, run sedation, and make this experience into this whole parade so you can feel better."

Whatever dude...
 
drpainfree said:
I didn't, ASIPP did with its guideline.

Again, you have to have that discussion with your patients and document the discussion. You have the right to not offer it, your patients have the right to NOT get it done by you.

Yes, I would and do turn away patients who demand anything but mild to moderate sedation.
Click to expand...

So ASIPP is now the law of the land, or is it just the law if it supports YOUR practice?
 
drpainfree said:
nobody is saying to use IV sedation routinely, and nobody is saying we should use anything more than moderate sedation.

the ASIPP guideline says,

"Due to the nature of chronic pain and anxiety, many patients undergoing interventional techniques may require mild to moderate sedation".

how do you determine whether or not a patient is one of the "many" patients who may "require" mild to moderate sedation? Just like anything we do in medicine, you evaluate your patient, discuss with your patient and document the risk, benefit and alternative of a plan.

if you don't feel comfortable to offer mild to moderate sedation via IV sedation, you tell your patients, and let your patients decide whether or not they will do the procedure with you. it's not about you, it's about your patients.

but if you omit the step of offering and discussing sedation option, you are not following the guideline which you will be hold against to.
Click to expand...

You lost that argument last time it came up. 1% rate of sedation is appropriate. 10% should be max. More than that and you are benefitting more than your patients.
 
drpainfree said:
both.
Click to expand...

ASIPP can b.l.o.w. me bc I'm not changing my practice. I will give you a tablet or two of Ativan, and I do that maybe twice a month. This has never been a problem in my rural practice of pain. I guess my Georgia pts are just harder than yalls.
 
lobelsteve said:
You lost that argument last time it came up. 1% rate of sedation is appropriate. 10% should be max. More than that and you are benefitting more than your patients.
Click to expand...

I didn't lose the argument last time when I brought it up. I informed of your practice was not up to the SOC with multiple evidences.

Now ASIPP just published their guideline, loud and clear.

Nobody is putting 1% or 10% as a quota.

ASIPP guideline says "many" patients may require mild to moderate sedation.

You can't skip the part whether you discuss R/B/A of IV sedation as the part of your neuroaxial injection procedure.
 
lobelsteve said:
You lost that argument last time it came up. 1% rate of sedation is appropriate. 10% should be max. More than that and you are benefitting more than your patients.
Click to expand...

Agreed. I seem to remember this same poster saying he tells pts to be quiet so he can concentrate on his procedures.

As for myself, my procedure time is spent talking to my pts about my kids, movies, books, etc, and they like that bc they get to know me. Most pts absolutely want to get to know the ppl treating them and procedure time is goof off time and is usually fun.

Yall do what yall want...
 
SommeRiver said:
ASIPP can b.l.o.w. me bc I'm not changing my practice. I will give you a tablet or two of Ativan, and I do that maybe twice a month. This has never been a problem in my rural practice of pain. I guess my Georgia pts are just harder than yalls.
Click to expand...

Nobody is asking you to change your pracctice.

You need to defend your practice with rationale.

Why not document your discussion po benzo is a legitimate alternative to mild to mod IV sedation?
 
drpainfree said:
Nobody is asking you to change your pracctice.

You need to defend your practice with rationale.

Why not document your discussion po benzo is a legitimate alternative to mild to mod IV sedation?
Click to expand...

Why would I? I only offer it if they specifically request it. I don't preempt that discussion. I tell people that "I numb it up real good."

No problems...
 
drpainfree said:
I didn't lose the argument last time when I brought it up. I informed of your practice was not up to the SOC with multiple evidences.

Now ASIPP just published their guideline, loud and clear.

Nobody is putting 1% or 10% as a quota.

ASIPP guideline says "many" patients may require mild to moderate sedation.

You can't skip the part whether you discuss R/B/A of IV sedation as the part of your neuroaxial injection procedure.
Click to expand...
Guidelines also state that opioids may be appropriate for some patients with chronic pain. That doesn’t mean I’m obligated to discuss that as an option for all (or any) patients. But that’s exactly what you are arguing with sedation.
 
if you are going to use sedation, you need to be prepared. agreed, drusso.

but you really shouldnt need it, so it is a moot point.

sedation for RFs is not necessary. sedation for ESIs or less is a joke, sedation for mbbs should not be permitted as it messes with the results.
 
drpainfree said:
but if you omit the step of offering and discussing sedation option, you are not following the guideline which you will be hold against to.
Click to expand...

hard to understand your grammar, but you seem to suggest that if we DONT offer sedation, we are somehow legally liable. is this really the hill you want to die on?

go ahead and sedate everyone if you want, but to say that those who DONT sedate are somehow wrong is ludicrous.
 
I just tell people "get ready for the Big Hurt!!"

if they run away, they don't get the injection. 😀


fwiw, id suggest either do a lot of sedations or do none. I do roughly 1 IV sedation once every other week, and the problem I have is that each time I do one (for celiac. LSBs, SGBs primarily because I feel iv should always go in for high volume LA block, and SCS), the ASC nurses run around as if their heads are cut off asking "what do you want", "what kind of monitoring", "are you going to see them first", "how much sedation", "can you help start the IV"....
 
callmeanesthesia said:
Guidelines also state that opioids may be appropriate for some patients with chronic pain. That doesn’t mean I’m obligated to discuss that as an option for all (or any) patients. But that’s exactly what you are arguing with sedation.
Click to expand...

for post-surgical and for terminally-ill patients, sure the guideline says it might be appropriate. you bet, I would discuss the pros and cons of opioid tx for these subset of patients.
 
SSdoc33 said:
if you are going to use sedation, you need to be prepared. agreed, drusso.

but you really shouldnt need it, so it is a moot point.

sedation for RFs is not necessary. sedation for ESIs or less is a joke, sedation for mbbs should not be permitted as it messes with the results.
Click to expand...

so you decide everything for your patients? it's what's going to come back to bite you.
 
SSdoc33 said:
hard to understand your grammar, but you seem to suggest that if we DONT offer sedation, we are somehow legally liable. is this really the hill you want to die on?

go ahead and sedate everyone if you want, but to say that those who DONT sedate are somehow wrong is ludicrous.
Click to expand...

ASIPP guideline doesn't say those who DONT sedate is wrong. ASIPP says "many" patients may require mild to moderate sedation. Whatever you do is your business, but you gotta keep that guideline in mind and defend your position why you do not even discuss the option of mild to moderate sedation.
 
there is no need to defend the lack of use of sedation if the standard of care is to not use sedation.

the phrase "may" strongly implies that sedation or the discussion of sedation is not standard of care.
 
drpainfree said:
so you decide everything for your patients? it's what's going to come back to bite you.
Click to expand...

how exactly? how is not offering sedation going to "bite me back"? you get into trouble WITH sedation, not without it.

i dont have a gun to the patient's head. if they dont want the shot, they dont have to have it. but if they are going to get one, it will be the safest way possible -- without sedation. the patients dont get that choice under my care. they dont tell me how to practice.
 
Ducttape said:
there is no need to defend the lack of use of sedation if the standard of care is to not use sedation.

the phrase "may" strongly implies that sedation or the discussion of sedation is not standard of care.
Click to expand...


again, however you practice is your business. just realize the guidelines out there and figure out how you will defend your position.

enough said, I'm out.
 
drpainfree said:
again, however you practice is your business. just realize the guidelines out there and figure out how you will defend your position.

enough said, I'm out.
Click to expand...
Why would one ever have to defend not using sedation? silly
 
Orin said:
You're right, but the ASA doesn't mandate cardiac monitoring for everyone or even capnography necessarily for moderate/deep sedation if "precluded or invalidated by the nature of the patient, procedure, or equipment"

The best part is that the ASA guidelines cited explicitly exclude literature about sedation for pain procedures or blocks.

Anesthesiology

anesthesiology.pubs.asahq.org anesthesiology.pubs.asahq.org

"
Exclusion criteria:
  • Procedures using minimal sedation (e.g., anxiolysis for insertion of peripheral nerve blocks, local or topical anesthesia)
  • Procedures where deep sedation is intended
  • Procedures where general anesthesia is intended
  • Procedures using major conduction anesthesia (i.e., neuraxial anesthesia)
  • Procedures using sedatives in combination with regional anesthesia
  • Nondiagnostic or nontherapeutic procedures (e.g., postoperative analgesia, pain management/chronic pain, critical care, palliative care)
"

I'm not disagreeing that it's probably safest to do it the way suggested above, but I'm not sure what it really gets in terms of benefit
Click to expand...


helpful

One of my main payors Medicaid pays $25 so not everyone who provides IV sedation is doing it for monetary benefit. Doubt I break even.
 
I offer my patients IV moderate sedation. If they don't want it, great. It is very simple.

Frankly I'd rather they not opt for it, but I leave it up to them. My life would be simpler if they did not opt for it.

I have a lot who would not pursue treatment if IV moderate sedation was not an option.

I'd opt for it myself, if I was getting a spine procedure and I was a layperson.
 
Ligament said:
I offer my patients IV moderate sedation. If they don't want it, great. It is very simple.

Frankly I'd rather they not opt for it, but I leave it up to them. My life would be simpler if they did not opt for it.

I have a lot who would not pursue treatment if IV moderate sedation was not an option.

I'd opt for it myself, if I was getting a spine procedure and I was a layperson.
Click to expand...

Why ?
I have had TFESI and facet injections in past....no reason an IV needed
 
lonelobo said:
Why ?
I have had TFESI and facet injections in past....no reason an IV needed
Click to expand...

Because I'd be afraid of the pain if I was a layperson. It is reasonable. Just because you did not want it does not mean somebody else does not. I say offer the choice if safe for that patient.
 
Ligament said:
Because I'd be afraid of the pain if I was a layperson. It is reasonable. Just because you did not want it does not mean somebody else does not. I say offer the choice if safe for that patient.
Click to expand...
Well if a "layperson" can not handle an ESI without sedation, they should probably not be having Interventional treatments
 
This conversation goes to show you why pain is a joke of a field. No consensus on anything, even something as central to the field as interventional care.

It is a completely ridiculous statement to say that I would ever have to defend myself legally for NOT giving IV sedation.
 
I am really appreciating the frustration and passion in this discussion. Thank you all for sharing your perspectives. There is a lot of fear, a lot of loathing, a lot of anxiety, a lot of self doubt in medicine, in general, not just in this field. I don’t know how it got this way, but what brings me peace is that it won’t be this way forever. Someday the whole mess will be an obscure anecdote. Be at peace. Ride your bike. Call your kid. Take simple, rational steps. Do the right thing. Only you know what that is.
 
From the guidelines:

"It would not seem prudent to use sedation
for every patient without appropriate evaluation or
based solely on revenue considerations for the practice."

Ya think?
 
SommeRiver said:
This conversation goes to show you why pain is a joke of a field. No consensus on anything, even something as central to the field as interventional care.

It is a completely ridiculous statement to say that I would ever have to defend myself legally for NOT giving IV sedation.
Click to expand...

we may be a joke, but there is a concensus. drpainfree is the obvious 2+ standard deviation outlier.
 
Giving sedation is only an outlier on this forum. I think more office based docs(who use less sedation) on this forum than in the real world(i am office based). Very common practice.

Docs own shares of ASCs to get paid. Sedation pays. Partners will ask why the CRNA is in the break room instead of making everyone $
 
nvrsumr said:
Docs own shares of ASCs to get paid. Sedation pays. Partners will ask why the CRNA is in the break room instead of making everyone $
Click to expand...

I have ASC shares and don't use sedation in ASC cases other than stim. There are 5 ppl in my group doing interventions and 3 of us have ASC shares. No one offers sedation. I have multiple clinic sites and do both ASC and office procedures.

I use PO Ativan once or twice a month, and for stellates (I do one every 4 months) I have used IV Ativan once, but usually PO. I have not had a problem.

I just can't understand the rationale for letting a pt demand IV fentanyl and/or Versed just bc they're anxious about a procedure. Pts RARELY even broach that subject with me and I swear I believe your bedside manner plays a role in the anxiety.

Either that or people in Georgia are just tough.

I wonder if there is a correlation between clinic volume and pt anxiety. You spend 3 to 5 min in a room with a pt and walk out and I bet that patient has anxiety about it bc they don't know you. You're all about business and gone...

No other field other than Peds or Psych is bedside manner therapeutic, and I believe that as a fact.
 
hyperalgesia said:
From the guidelines:

"It would not seem prudent to use sedation
for every patient without appropriate evaluation or
based solely on revenue considerations for the practice."

Ya think?
Click to expand...

Yes!
 
You must log in or register to reply here.

Similar threads

bk03
Orthopedic Surgery vs Interventional Pain
2
Replies
82
Views
5K
sdnuser001
S
T
Non-interventional vs Interventional Pain
Replies
37
Views
4K
SeniorWrangler
SeniorWrangler
drusso
Pritzlaff's Doximitry Op_Ed on Pain Fellowship Match
Replies
26
Views
2K
gaspasser127
G
N
Sedation for MB RF
2
Replies
91
Views
6K
Dr. Ice
D
A
office based sedation regulations - TX
Replies
11
Views
1K
IAmTheOne1
I
Top