Chronic Pain Case

[Planktonmd]

Also, and a little off topic, just talked to a former colleague who did pain fellowship. She's up in Canada and they do 1 hour ketamine/lido infusions for chronic pain patients. They see them every 2 months. Bill $200/treatment, and patient pays $30. They do like 10-20/day. Damn... went into the wrong fellowship... haha.

Many years ago I used to do Lidocaine infusions on outpatient basis once a week for patients with severe neuropathic pain.
We gave large doses approaching the toxic dose, and we frequently had to slow down the infusion or stop it because of toxicity symptoms.
But those guys had pain relief that lasted several days and kept coming back, and insurance covered it!

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[Noyac]

Many years ago I used to do Lidocaine infusions on outpatient basis once a week for patients with severe neuropathic pain.
We gave large doses approaching the toxic dose, and we frequently had to slow down the infusion or stop it because of toxicity symptoms.
But those guys had pain relief that lasted several days and kept coming back, and insurance covered it!

What symptoms showed up that caused you to back off? Tinnitus? Oral?
Any seizures?

 

[Planktonmd]

What symptoms showed up that caused you to back off? Tinnitus? Oral?
Any seizures?

Once they say they have metallic taste or numbness in the face or lips that would be a good point to stop or slow down the infusion.
Never saw fully blown seizures.

 

[Noyac]

So you were able to do a hypogastric and impar block under fluoro? I've never done one before. Would love to try one, but can't imagine doing one unless I had one of the chronic pain guys there helping out. How did you go about doing it? Use fluoro? And if so, how did you go about doing it resource wise?

So I don't do chronic pain any longer per se'.
I didn't do a pain fellowship but I did 6 months of pain in my CA-3 year. I don't call myself a pain doc and I am way out matched by anyone that has done a good Pain fellowship. I have worked with people that did some pain fellowships that were less than stellar though. I would call my pain skills bread and butter but the point i was trying to make is that it only helps you in the future to know as much as possible about things other than general anesthesia. I work in a level 3 trauma center in a fairly remote part of the country. It is a tremendous burden for pts to travel for simple pain management. With have some PM&R guys that do some blocks only. Their training is really quite different from an anesthesia pain person. So they do all the bread and butter stuff.

As far as the two blocks, yes I did them under Fluoro in the OR with a circulating nurse and an X-ray tech. Probably not the cheapest way to do it but I don't have a pain clinic. I do most of my other stuff at the surgery center when possible. It's not that often these days. I basically book them in gaps in the schedule or at the end of the day when an OR closes.

Have you done any pain blocks other than LESI? A good one to know is a lumbar sympathetic block. And the stellate ganglion block. On occasion an orthopods will have a pt post-OP who is having CRPS like symptoms. It is very helpful to understand the process and to be able to assess the pt for them. They are usually pretty good at assessment as well. But they are not so good at medications and treatments. About once or twice a year I get these referrals. If you can perform the needed block early and make the appropriate medication rec's you can save these pts a lot of trouble and you become a bit more indispensable to the practice.

 

[Noyac]

Once they say they have metallic taste or numbness in the face or lips that would be a good point to stop or slow down the infusion.
Never saw fully blown seizures.

That's what I thought. But I'm sure you have had the pt in the OR were you push 100mg of lido on induction and they get that taste right? It doesn't take much in some pts.

 

[Planktonmd]

That's what I thought. But I'm sure you have had the pt in the OR were you push 100mg of lido on induction and they get that taste right? It doesn't take much in some pts.

Yes but when we did it for chronic pain we did not bolus, we simply infused over 1-2 hours.

 

[MoMoGesiologist]

In addition to whatever acute stuff you settle on, consider starting him on methadone. Like ketamine you get some NMDA agonism, but unlike ketamine he can go home with it.

If you start methadone inpatient, who will prescribe and manage it outpatient? At my hospital, at least the ICU, no one wants to start methadone because the primary team who will inherit the patient on the floor is uncomfortable managing it and it's unclear what happens after the patient leaves the hospital. I guess if you set the patient up with a pain clinic after discharge, that would be different though.

 

[pgg]

If you start methadone inpatient, who will prescribe and manage it outpatient? At my hospital, at least the ICU, no one wants to start methadone because the primary team who will inherit the patient on the floor is uncomfortable managing it and it's unclear what happens after the patient leaves the hospital. I guess if you set the patient up with a pain clinic after discharge, that would be different though.

It's true, I'm presuming the availability of a chronic pain clinic, and a patient willing to follow up with them. At my previous institution we had a busy pain clinic in house, staffed by anesthesiologists who were part of our department. Followup with them was easy to arrange. They'd see patients prior to discharge.

Elsewhere, followup and continued prescription of the methadone might be trickier. But
1) There are still real benefits to using methadone perioperatively, and I think they're worth it.
2) Even if arranging optimal postop/outpatient management isn't easy, it's worth trying.

 

[sigrhoillusion]

So I don't do chronic pain any longer per se'.
I didn't do a pain fellowship but I did 6 months of pain in my CA-3 year. I don't call myself a pain doc and I am way out matched by anyone that has done a good Pain fellowship. I have worked with people that did some pain fellowships that were less than stellar though. I would call my pain skills bread and butter but the point i was trying to make is that it only helps you in the future to know as much as possible about things other than general anesthesia. I work in a level 3 trauma center in a fairly remote part of the country. It is a tremendous burden for pts to travel for simple pain management. With have some PM&R guys that do some blocks only. Their training is really quite different from an anesthesia pain person. So they do all the bread and butter stuff.

As far as the two blocks, yes I did them under Fluoro in the OR with a circulating nurse and an X-ray tech. Probably not the cheapest way to do it but I don't have a pain clinic. I do most of my other stuff at the surgery center when possible. It's not that often these days. I basically book them in gaps in the schedule or at the end of the day when an OR closes.

Have you done any pain blocks other than LESI? A good one to know is a lumbar sympathetic block. And the stellate ganglion block. On occasion an orthopods will have a pt post-OP who is having CRPS like symptoms. It is very helpful to understand the process and to be able to assess the pt for them. They are usually pretty good at assessment as well. But they are not so good at medications and treatments. About once or twice a year I get these referrals. If you can perform the needed block early and make the appropriate medication rec's you can save these pts a lot of trouble and you become a bit more indispensable to the practice.

Where I trained and where I currently work there was a acute/chronic pain team. Even if I had a patient who I thought would benefit from any sort of block done under fluoro we'd probably consult them. I don't even know how I would go about booking an OR to do those kind of blocks on my own... nor do I think they would even let me. Not saying I wouldn't mind doing them, but just even think we have the steps available to do them besides getting the pain team involved.

 

[Noyac]

Where I trained and where I currently work there was a acute/chronic pain team. Even if I had a patient who I thought would benefit from any sort of block done under fluoro we'd probably consult them. I don't even know how I would go about booking an OR to do those kind of blocks on my own... nor do I think they would even let me. Not saying I wouldn't mind doing them, but just even think we have the steps available to do them besides getting the pain team involved.

You have something that not every anesthesia dept has, a pain team. Not much need for you to do these sorts of blocks.

 

[cleansocks]

With the Ganglion Impar block you can hope for 6 months of relief which by that time the tumor will have shrunk and the pain will have resolved or at least deminished tremendously.
I have done celiac plexus blocks with a neurolytic (phenol) and those last a lifetime. Unfortunately, that lifetime isn't 6 months so it's hard to know how long they last.
The Impar could be performed with a neurolytic in someone that isn't terminal to my understanding but I'm not sure if it returns or if it even matters. You would think that by 6 months the issue would be resolved or improved.
So I think your 6 month theory is really dependent. Again, IDK.

Jealous.

My 30 resident per class Ivory tower didn't even let us have electives.

Being a few years out I appreciate how limiting that was. Very hard to learn new things on your own, no matter how many conferences you attend.

 

[deleted162650]

So you were able to do a hypogastric and impar block under fluoro? I've never done one before. Would love to try one, but can't imagine doing one unless I had one of the chronic pain guys there helping out. How did you go about doing it? Use fluoro? And if so, how did you go about doing it resource wise?

Also, and a little off topic, just talked to a former colleague who did pain fellowship. She's up in Canada and they do 1 hour ketamine/lido infusions for chronic pain patients. They see them every 2 months. Bill $200/treatment, and patient pays $30. They do like 10-20/day. Damn... went into the wrong fellowship... haha.

My group just opened our own ketamine clinic. We floated the idea to the hospital who liked the idea and provided us with the facility to do it at the hospital within the system that does a lot of psych. We have a depression protocol and a chronic pain protocol. It's all cash pay and we more or less split the proceeds with the hospital.