Fentanyl sedation

[bedrock]

Apparently the world just ran out of fentanyl. We can’t get any. Are you guys using IV morphine?

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[Baron Samedi]

No IV sedation for anything in clinic ever

 

[GottaHaveIt]

My ASC has been using IV dilaudid.

 

[Agast]

Who is administering the sedation? Is this clinic or ASC?

 

[TheLoneWolf]

No IV sedation for anything in clinic ever

Same

 

[bedrock]

Who is administering the sedation? Is this clinic or ASC?

ASC

not sure why people were just assumed this was clinic.

 

[Agast]

ASC

not sure why people were just assumed this was clinic.

Can they use precedex?

 

[BobBarker]

Buy the 10ml and divide the dosages.

 

[lobelsteve]

In ASC: not your problem. Let Anes form their plan.

 

[deleted131481]

In ASC: not your problem. Let Anes form their plan.

Be careful they may choose propofol.

 

[lobelsteve]

Be careful they may choose propofol.

So what. Better sedation, easy on/easy off.
We are talking for kypho and SCS, right?

 

[MD87]

I do all my sedation procedures at ASC. With the new CMS guidelines, what do you guys think - who will get audited if patients are getting sedation, me or the ASC/anesthesia? I do about 90% of my procedures without sedation, but I inherited a number of patients who refuse to not get IV sedation, regardless of how hard I try to convince them.

 

[nopain1234]

No IV sedation for anything in clinic ever

Debatable

 

[Agast]

I do all my sedation procedures at ASC. With the new CMS guidelines, what do you guys think - who will get audited if patients are getting sedation, me or the ASC/anesthesia? I do about 90% of my procedures without sedation, but I inherited a number of patients who refuse to not get IV sedation, regardless of how hard I try to convince them.

Patients are still allowed to have sedation, Medicare just won’t pay for it. Cash is not regulated.

 

[nopain1234]

Debatable

I know a guy who does kyphos in office without sedation

It’s borderline torture

You should hear the patients describe their experience. I’m not into being the cause of someone’s PTSD when a few squirts of versed/fent/prop will help them get through it with virtually zero risk

 

[RoloTomassi]

I know a guy who does kyphos in office without sedation

It’s borderline torture

You should here the patients describe their experience. I’m not into being the cause of someone’s PTSD when a few squirts of versed/fent/prop will help them get through it with virtually zero risk

I'm relatively liberal with sedation compared to the folks here, but I do office kypho with local and PO benzo. Done right, it's not that painful, probably less than RFA. Others here can share same experience. I think it's safer not mixing with respiratory depressants given the pulm risks.

 

[GoBeers]

I'm relatively liberal with sedation compared to the folks here, but I do office kypho with local and PO benzo. Done right, it's not that painful, probably less than RFA. Others here can share same experience. I think it's safer not mixing with respiratory depressants given the pulm risks.

How do you handle the balloon and cement component? My patients are always telling me there is intense pressure and pain when I do it

 

[nopain1234]

I’ve done thousands of office procedures with IV sedation. No adverse outcomes from an anesthesia or pain perspective.

I’m not knocking ppl for avoiding sedation. But I think it’s massively overblown how dangerous some people make it out to be.

I do all my US guided regional blocks with 2 versed/100 fent. That dangerous too?

 

[RoloTomassi]

How do you handle the balloon and cement component? My patients are always telling me there is intense pressure and pain when I do it

Just go slow. Some recommend lido in VB before but I don't because it's so vascular.

 

[BobBarker]

20ml lido and oral benzo very helpful for office kypho. It is still much more pleasant for everyone to have propofol however.

 

[nopain1234]

I'm relatively liberal with sedation compared to the folks here, but I do office kypho with local and PO benzo. Done right, it's not that painful, probably less than RFA. Others here can share same experience. I think it's safer not mixing with respiratory depressants given the pulm risks.

Interesting a lot of IR guys do kyphos under GA.

Guess I’m somewhere in the middle

 

[lobelsteve]

How do you handle the balloon and cement component? My patients are always telling me there is intense pressure and pain when I do it

You are doing it wrong. Do half in office and half in OR. Local does fine. Set expectations and use 10cc of 1% for single level unipedicular approach.

 

[Baron Samedi]

I’ve done thousands of office procedures with IV sedation. No adverse outcomes from with a anesthesia or pain perspective.

I’m not knocking ppl for avoiding sedation. But I think it’s massively overblown how dangerous some people make it out to be.

I do all my US guided regional blocks with 2 versed/100 fent. That dangerous too?

No, but its super annoying when your patient transfers to another doc and now they expect IV sedation for an epidural because "thats the way I've always had it."

 

[GoBeers]

You are doing it wrong. Do half in office and half in OR. Local does fine. Set expectations and use 10cc of 1% for single level unipedicular approach.

local and advancing through soft tissue is fine; but whenever I balloon, the patient is uncomfortable. i vaguely remember trying adding lidocaine through the trocar but it would just spill out. do you just hand hold and go slowly?

 

[lobelsteve]

local and advancing through soft tissue is fine; but whenever I balloon, the patient is uncomfortable. i vaguely remember trying adding lidocaine through the trocar but it would just spill out. do you just hand hold and go slowly?

Pressure with balloon inflation is common. Tell them it is normal and you will make it go away in a few seconds. Ok to add in 1cc lidocaine down the kypho needle before balloon inflation. If high pressures (over 200) or plana type vertebrae, I stop when I see contrast in the balloon. Otherwise, pump it up to safe margins or patient tolerance.