celiac plexus block in the office

[nvrsumr]

Would you do the block in an office procedure suite? Classic transaortic approach. Just lido and steroid. Splanchnic instead? Would be done for noncancer abdominal pain. I get a number of zebras Id consider performing the block on but not enough to make a hospital trip worth the time.

As a fellow I did a couple of these in what was basicially an outpatient procedure suite but technically part of the hospital. The neurolysis was always done in an OR.

Obviously this is controversial but curious if anyone would and why.

Thanks

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[lobelsteve]

Have never done one in a setting than the office fluoro suite.
Will use retro-aortic approach or retro-caval approach. Sometimes I see red.
The vessels are self-sealing. Aorta is with a thick media muscle layer, never heard of a leak as scary as it sounds.

As far as neurolysis, my preference is Phenol or ETOH- but done with IR under CT.
Have not done one in 2 years for non-pancreatic cancer. And for some reason there is no shortage of that terrible diagnosis by me.

IV, monitoring, and a 22G 7" needle is all it takes.

 

[Jcm800]

Would you do the block in an office procedure suite? Classic transaortic approach. Just lido and steroid. Splanchnic instead? Would be done for noncancer abdominal pain. I get a number of zebras Id consider performing the block on but not enough to make a hospital trip worth the time.

As a fellow I did a couple of these in what was basicially an outpatient procedure suite but technically part of the hospital. The neurolysis was always done in an OR.

Obviously this is controversial but curious if anyone would and why.

Thanks

Done it. Don't like it, but will do it. I don't do this block for non malignant pain. I try to avoid aorta, but if I get it, no biggie

 

[Ligament]

I'd suggest a splanchnic first since you are in office. Warn your nurses about the post op hypotension.

 

[drf]

I've done a lot of diagnostic and neurologic celiacs. I had a run of failed neurolytics done by others using a more classical L1 approach that ended up on my day for repeat. On repeat I performed retrocrural splanchnics at the bottom of T12 and they all worked. I think tumor burden often screws with the celiac anatomy and decreases spread. As such I've switched to more or less only doing splanchnics. I've also done repeats on enough 6-12% phenol blocks with 100% etoh to personally have switched to only etoh neurolytics.

Since cancer patients are often uncomfortable prone on the table I do a diagnostic followed by neurolytic at the same time. I place the needles, give 10-15 ml of bupivicaine per side, and wait 5-10 minutes. If the pain has decreased significantly, I perform a LE motor exam. If everything is working, I inject the same volume of 100% etoh. 95% of the time the marcaine allows the etoh injection to be painless. The rest of the time 50-100 fentanyl and another 2-3 ml bupi fixes it.

I've also had enough frail cancer patients get significantly hypotensive that I want at least a 20g and I run it wide open for the case. I also scope out a good vein ahead of time if I have to slam in my own 18g or 16g if needed. I've had to do this 2-3 times.

A final interesting case. Young male with chronic etoh pancreatitis who hit the ER twice a week for IV Dilaudid. Once he got to the ER with a BAL of 300 and when he got dilaudid he had a respiratory arrest. Narcan infusion and ICU followed. My notes were clear that he should not get any SAOs. I actually did a bilateral splanchnics pRF and he stopped going to the ER for 6-8 months. I was shocked that it worked. Recently came back to the office asking not for narcs but for a repeat pRF.

 

[embolize]

I have done a few. We do them under CT (block and lysis) in a similar manner to what has been described (usually retro-aortic and retro-caval at the same time). The results tend to be pretty dramatic, but it definitely seems like a lot of time spent in the hospital for a busy outpatient guy.

I am most afraid of hitting the cava personally.

 

[Ligament]

. I actually did a bilateral splanchnics pRF and he stopped going to the ER for 6-8 months. I was shocked that it worked. Recently came back to the office asking not for narcs but for a repeat pRF.

drf, how are you getting paid for pRF, since it is a 64999 code? Secondly, do you have any further comments on the neurotherm "pulsed dose" vs. regular pRF on other machines...are you seeing significant improvement with "pulsed dose"?

thanks!

 

[Jcm800]

i switched to ETOH also. I have had no significant failures using L1, often single needle. maybe just lucky...

I've done a lot of diagnostic and neurologic celiacs. I had a run of failed neurolytics done by others using a more classical L1 approach that ended up on my day for repeat. On repeat I performed retrocrural splanchnics at the bottom of T12 and they all worked. I think tumor burden often screws with the celiac anatomy and decreases spread. As such I've switched to more or less only doing splanchnics. I've also done repeats on enough 6-12% phenol blocks with 100% etoh to personally have switched to only etoh neurolytics.

Since cancer patients are often uncomfortable prone on the table I do a diagnostic followed by neurolytic at the same time. I place the needles, give 10-15 ml of bupivicaine per side, and wait 5-10 minutes. If the pain has decreased significantly, I perform a LE motor exam. If everything is working, I inject the same volume of 100% etoh. 95% of the time the marcaine allows the etoh injection to be painless. The rest of the time 50-100 fentanyl and another 2-3 ml bupi fixes it.

I've also had enough frail cancer patients get significantly hypotensive that I want at least a 20g and I run it wide open for the case. I also scope out a good vein ahead of time if I have to slam in my own 18g or 16g if needed. I've had to do this 2-3 times.

A final interesting case. Young male with chronic etoh pancreatitis who hit the ER twice a week for IV Dilaudid. Once he got to the ER with a BAL of 300 and when he got dilaudid he had a respiratory arrest. Narcan infusion and ICU followed. My notes were clear that he should not get any SAOs. I actually did a bilateral splanchnics pRF and he stopped going to the ER for 6-8 months. I was shocked that it worked. Recently came back to the office asking not for narcs but for a repeat pRF.

 

[Jcm800]

double post...

 

[drf]

drf, how are you getting paid for pRF, since it is a 64999 code? Secondly, do you have any further comments on the neurotherm "pulsed dose" vs. regular pRF on other machines...are you seeing significant improvement with "pulsed dose"?

thanks!

In terms of payment, I think maybe an academic name has some pull in getting the preauth. Nevertheless, once or twice a month it's simply denied and we can't do it. I've done some peer to peers and had the insurance MD tell me to dial up the temp to make it lytic, for example for chest wall pain (scar neuroma or neuralgia), code the neurolysis, and they would approve. I code for block and 64999 unless I dial up the temp and code lysis. I've only done that on scars and medial branches.

When I started out pRF didn't seem to work. I used my fellowship learned settings and pulsed for 2 minutes. However after talking to the company and educating myself a bit more, I now ONlY use pulsed dose mode, accessible by pushing pulse twice. As a teaching point I will sometimes start with pulse mode and show the fellow that after about 10-20 seconds the registered voltage is 0-10. Then switch to pulsed dose mode and show a consistent 45v per pulse. I've also gone from 2 minutes to at least 4 but usually 8 minutes. I change the default settings to 480 doses, cycle it, recheck stim, then dose again.

Now it works. Every procedure day I have at least 3-4 US guided pRF repeats of various nerves because the patients think it is very helpful.

For a bigger nerve like common peroneal I'll place two needles touching it in two different locations then pulse both twice at the same time.

 

[drf]

i switched to ETOH also. I have had no significant failures using L1, often single needle. maybe just lucky...

So you're doing single needle transaortic? After randomly reviewing some CT abdomens showing aortic aneurysms in the needle path, I stopped doing those.

Likely your referring docs get you the patients earlier in the cancer process. Our oncologists are very comfortable dialing up the narcs. We usually don't get them until they are inpt for uncontrolled pain. I've done more than one in the last few months in which the pt died of the cancer during the same admission a week or two later. But they passed with much less pain and medications.

 

[Ligament]

In terms of payment, I think maybe an academic name has some pull in getting the preauth. Nevertheless, once or twice a month it's simply denied and we can't do it. I've done some peer to peers and had the insurance MD tell me to dial up the temp to make it lytic, for example for chest wall pain (scar neuroma or neuralgia), code the neurolysis, and they would approve. I code for block and 64999 unless I dial up the temp and code lysis. I've only done that on scars and medial branches.

When I started out pRF didn't seem to work. I used my fellowship learned settings and pulsed for 2 minutes. However after talking to the company and educating myself a bit more, I now ONlY use pulsed dose mode, accessible by pushing pulse twice. As a teaching point I will sometimes start with pulse mode and show the fellow that after about 10-20 seconds the registered voltage is 0-10. Then switch to pulsed dose mode and show a consistent 45v per pulse. I've also gone from 2 minutes to at least 4 but usually 8 minutes. I change the default settings to 480 doses, cycle it, recheck stim, then dose again.

Now it works. Every procedure day I have at least 3-4 US guided pRF repeats of various nerves because the patients think it is very helpful.

For a bigger nerve like common peroneal I'll place two needles touching it in two different locations then pulse both twice at the same time.

Thanks for the info. I'm asking because I'm about to buy a Neurotherm machine specifically for pulsed dose mode. I see a lot of peripheral neuralgias and do lots of U/S guided nerve blocks now, and I need something to make the relief last longer for those folks in which blocks don't last. Yeah, I know I'm going to get ribbed for using pRF, but I need something to offer this subset of folks.

I don't expect to get pre-authed much less reimbursed for pulsed RF. Are you absolutely sure you are actually getting paid for the 64999 and not getting paid just for a block?

 

[drf]

The way the system works here is as long as the hospital gets at least one cent for the procedure, i get full wRVU credit for it. I don't know what the hospital system gets.

I do know some folks in PP simply have the patient pay for the needle and the pad and only bill for a block to insurance.

 

[epidural man]

Would you do the block in an office procedure suite? Classic transaortic approach. Just lido and steroid. Splanchnic instead? Would be done for noncancer abdominal pain. I get a number of zebras Id consider performing the block on but not enough to make a hospital trip worth the time.

As a fellow I did a couple of these in what was basicially an outpatient procedure suite but technically part of the hospital. The neurolysis was always done in an OR.

Obviously this is controversial but curious if anyone would and why.

Thanks

A few points.

I did over 50 celiac/splanchnic blocks as a fellow - all done out patient, many of those done with ETOH.

I think it is rare to ever need to do a celiac plexus block over a splachnic block.

I would never do ETOH for non-malignant pain, although with DSA, and pretreat with local and check neurological exam after injection - you are probably very unlikely to cause a problem - but I still don't feel justified.

 

[epidural man]

In terms of payment, I think maybe an academic name has some pull in getting the preauth. Nevertheless, once or twice a month it's simply denied and we can't do it. I've done some peer to peers and had the insurance MD tell me to dial up the temp to make it lytic, for example for chest wall pain (scar neuroma or neuralgia), code the neurolysis, and they would approve. I code for block and 64999 unless I dial up the temp and code lysis. I've only done that on scars and medial branches.

When I started out pRF didn't seem to work. I used my fellowship learned settings and pulsed for 2 minutes. However after talking to the company and educating myself a bit more, I now ONlY use pulsed dose mode, accessible by pushing pulse twice. As a teaching point I will sometimes start with pulse mode and show the fellow that after about 10-20 seconds the registered voltage is 0-10. Then switch to pulsed dose mode and show a consistent 45v per pulse. I've also gone from 2 minutes to at least 4 but usually 8 minutes. I change the default settings to 480 doses, cycle it, recheck stim, then dose again.

Now it works. Every procedure day I have at least 3-4 US guided pRF repeats of various nerves because the patients think it is very helpful.

For a bigger nerve like common peroneal I'll place two needles touching it in two different locations then pulse both twice at the same time.

👍

 

[nvrsumr]

Wanted resurrect this thread

Anyone want to describe their splanchnic block technique in a bit more detail? Post a pic? Pearls, warnings?

Much appreciated.

 

[Ligament]

Wanted resurrect this thread

Anyone want to describe their splanchnic block technique in a bit more detail? Post a pic? Pearls, warnings?

Much appreciated.

Only pearl I have is to use an EPIMED blunt tip needle for two reasons:
1. possibly decreases risk of pneumothorax
2. It does not catch on the periosteum and is therefore much more comfortable for the patient

 

[nvrsumr]

Thanks Ligament

Getting a referral for a spanchnic next week so brushing up

 

[Ligament]

Thanks Ligament

Getting a referral for a spanchnic next week so brushing up

my pleasure. On second thought blunt tip needle might cause a worse plural injury than quincke? not sure...

but definately helps with periosteal pain/catching

 

[nvrsumr]

Do you use a blunt tip on your lumbar MBBs?

 

[Ligament]

Do you use a blunt tip on your lumbar MBBs?

No, just a quincke. use the one insertion multiple sites technique.

 

[Ducttape]

No, just a quincke. use the one insertion multiple sites technique.

so is the quincke blunt by the time you get to the 2nd or 3rd mbb?

 

[Ligament]

so is the quincke blunt by the time you get to the 2nd or 3rd mbb?

Honestly no...no issues. just make sure you square up the endplates of each level you are doing as you change levels. I usually use a 5" 25ga or 22ga for 99% of patients, including fatties.

 

[Jcm800]

Honestly no...no issues. just make sure you square up the endplates of each level you are doing as you change levels. I usually use a 5" 25ga or 22ga for 99% of patients, including fatties.

Me to.