Intracept /kypho procedure prep

[bedrock]

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I’ve been doing my intracept under GETA, full surgical scrub, and preop ancef. Similar to SCS.

I observed a few kyphoplasty today and the doc wore lead, used sterile gloves and a basic clear 2 x 2 sterile drap and that’s it.

So I’m wondering if I’m doing more than is necessary for these cases, both intracept and kypho.

Who level of surgical scrub do you all do for your intracept cases and for your Kyphoplasty cases? Preop antibiotics?

If nothing else I wonder if a surgical mask is really necessary for both procedures?

 

[rmsdudqkr]

Intracept: in OR, so full surgical scrub, IV ancef, MAC anesthesia

Kypho: in clinic procedure room, I throw on a sterile gown and and use 2 c arms with sterile drapes on those and the patient, no IV ancef.

I don’t think there is a right or wrong way as long as everything is sterile, but I guess my preference is purely based on SOS.

 

[Ronin1]

Intracept HOPD procedure room. Iv sedation so we give ancef. I gown up after surgical hand prep. You better wear a mask..

 

[RoloTomassi]

With Intracept def full sterile drape, scrub, Ancef, c-arm bonnet + c-armor. Way too much c-arm movement, instrument exchanges, probe wire flopping around, blood splatter to go light. Kypho same.

 

[BobBarker]

Yes, full Monty. A gown costs less than $2

 

[Taus]

Intracept: full Monty in OR

Kypho: in office procedure room. Avaguard pump on wall for scrub. IM ceftriaxone, full gown, drape, c arm cover. Mask. All very cheap. I put a half drape on a countertop to layout all the equipment. Same set up as office scs trials

 

[BobBarker]

Intracept is such a blood bath. I would want a gown, mask, etc just to protect myself.

 

[Baron Samedi]

Intracept: full Monty in OR

Kypho: in office procedure room. Avaguard pump on wall for scrub. IM ceftriaxone, full gown, drape, c arm cover. Mask. All very cheap. I put a half drape on a countertop to layout all the equipment. Same set up as office scs trials

Curious about the IM abx -- are you not getting IVs on these? Sedation?

 

[BobBarker]

I give IM Rocephin for trials and kyphos in office. No IV sedation.

 

[bedrock]

I give IM Rocephin for trials and kyphos in office. No IV sedation.

No IV sedation for all kyphos and all scs trials ?

 

[SpineandWine]

I give IM Rocephin for trials and kyphos in office. No IV sedation.

What’s dose of IM rocephin?
PO sedation of choice?

I just do IV sedation as I work in HOPD

 

[Taus]

I give IM Rocephin for trials and kyphos in office. No IV sedation.

Same. 1g IM. No IV for either.

Po triazolam. 0.25 x 2
Typically 0.5mg 45-60 min pre
0.25 for very elderly/frail, may give the 2nd pill prn.
Rarely I’ll rx 3 tabs, for younger, rx/etoh tolerant. I don’t give 3rd tab unless they really appear to need it shortly before.

 

[BobBarker]

No, no IV sedation for trials or kyphos. 10mg diazepam usually for oral sedation. Lots of people have done either with just local. The trials are not painful at all with local only.

 

[Taus]

No, no IV sedation for trials or kyphos. 10mg diazepam usually for oral sedation. Lots of people have done either with just local. The trials are not painful at all with local only.

Yep. I prefer heavier on Kypho

 

[bedrock]

Can other docs comment on how they handle sedation on kypho patients?

I’m going to start offering kypho next month. If Medicare patients never need IV sedation, then I’m not going to bother with the hassle of getting nurses to assist with those cases in our procedure room. (I do most of my cases in our ASC). There are some political issues getting ASC RN to help with infrequent cases in a procedure room that isn’t the ASC)

I observed 4 kypho yesterday. Must got IV 2+50, some needed more fent.

I think that Kyphoplasty would have been a much bigger struggle for some patients with just a Xanax or halcion.

 

[Baron Samedi]

Can other docs comment on how they handle sedation on kypho patients?

I’m going to start offering kypho next month. If Medicare patients never need IV sedation, then I’m not going to bother with the hassle of getting nurses to assist with those cases in our procedure room. (I do most of my cases in our ASC). There are some political issues getting ASC RN to help with infrequent cases in a procedure room that isn’t the ASC)

I observed 4 kypho yesterday. Must got IV 2+50, some needed more fent.

I think that Kyphoplasty would have been a much bigger struggle for some patients with just a Xanax or halcion.

My experience is limited (n=4 so far), but my cases have been getting 2 of versed and somewhere between 5-20mg of ketamine in 5mg increments. I'm having trouble picturing people tolerating the balloon inflation without a bit of something.

 

[powermd]

What is the goal in antibiosis for kypho? Is it protection of the surgical site during, or after the procedure? Both? Because I don't see how IM antibiotics are going to reach adequate blood levels fast enough to protect the patient during the procedure. IV maybe after it circulates a few times. I place an IV and do Ancef because it's fun to draw up.

 

[Taus]

What is the goal in antibiosis for kypho? Is it protection of the surgical site during, or after the procedure? Both? Because I don't see how IM antibiotics are going to reach adequate blood levels fast enough to protect the patient during the procedure. IV maybe after it circulates a few times. I place an IV and do Ancef because it's fun to draw up.

IM ceftriaxone works just as well.

 

[Taus]

My experience is limited (n=4 so far), but my cases have been getting 2 of versed and somewhere between 5-20mg of ketamine in 5mg increments. I'm having trouble picturing people tolerating the balloon inflation without a bit of something.

N of 18…. 17 went just fine. 1 had to coax through. Po high dose benzo only.

That said….. if I had IV sedation available, I do think that’s preferable for ability to titrate. It’s not in the cards in my set up.

 

[bedrock]

N of 18…. 17 went just fine. 1 had to coax through. Po high dose benzo only.

That said….. if I had IV sedation available, I do think that’s preferable for ability to titrate. It’s not in the cards in my set up.

If I don't use IV sedataion for kypho, I'm still definitely going to give them a PO Benzo and a single PO opioid. (Specfic opioid type is something they have tolerated in the past)

 

[BobBarker]

I give the kyphos nitrous also

 

[mygalperin]

I’ve been doing my intracept under GETA, full surgical scrub, and preop ancef. Similar to SCS.

I observed a few kyphoplasty today and the doc wore lead, used sterile gloves and a basic clear 2 x 2 sterile drap and that’s it.

So I’m wondering if I’m doing more than is necessary for these cases, both intracept and kypho.

Who level of surgical scrub do you all do for your intracept cases and for your Kyphoplasty cases? Preop antibiotics?

If nothing else I wonder if a surgical mask is really necessary for both procedures?

Hi, rule of thumb - anything that is done intrabone or intradisc has to be done using full sterile technic, even if it is done in the office, it is not worse risk of infection to save money on the supply and an extra person - surgical tech. The procedure you observed was proboly done by an interventional radiologist, that opens the whole new topic for discussion.

 

[Taus]

If I don't use IV sedataion for kypho, I'm still definitely going to give them a PO Benzo and a single PO opioid. (Specfic opioid type is something they have tolerated in the past)

As my experience grows, about 30 cases thus far, I am in agreement with you. My elderly patients do perfectly fine with just PO benzo on 1-2 level cases. The younger ones with early osteoporosis (done several 50-70yo), have benefited from having some oral opioid along with the benzo. The access is generally fine, particularly as I change to hand drill early if they are not liking the mallet, but the balloon and cement has been rough on a few younger ones I did without opioid along with the benzo.

 

[mygalperin]

As my experience grows, about 30 cases thus far, I am in agreement with you. My elderly patients do perfectly fine with just PO benzo on 1-2 level cases. The younger ones with early osteoporosis (done several 50-70yo), have benefited from having some oral opioid along with the benzo. The access is generally fine, particularly as I change to hand drill early if they are not liking the mallet, but the balloon and cement has been rough on a few younger ones I did without opioid along with the benzo.

Why no snesthesilogist?

 

[mygalperin]

I give the kyphos nitrous also

 

[mygalperin]

.

 

[Taus]

Why no snesthesilogist?

Not feasible in my office procedure suite set up due to space constraints and regulations. >90% have been perfectly fine with just the oral regimen and copious local. Fine-tuning my regimen.

 

[bedrock]

Why no snesthesilogist?

Why no snesthesilogist?

Because almost all pain physicians in the country do not utilize an anesthesiologist.

The standard of care is to not use them for Kyphoplasty.

 

[BobBarker]

They just cause problems in the office. Not worth it.

 

[mygalperin]

Because almost all pain physicians in the country do not utilize an anesthesiologist.

The standard of care is to not use them for Kyphoplasty.

I ve done since 2004 about 700 kyphos , all under in sedation provided by an anaesthesiologist w/o any issues, pt is not moving, comfortable on cement injection, leaves for home no longer than 2 hours. You as a surgeon does not need to pay attention to how pt is doing.

 

[callmeanesthesia]

I ve done since 2004 about 700 kyphos , all under in sedation provided by an anaesthesiologist w/o any issues, pt is not moving, comfortable on cement injection, leaves for home no longer than 2 hours. You as a surgeon does not need to pay attention to how pt is doing.

An awake patient is the best neuromonitoring.

 

[Ducttape]

you always need to pay attention to how the patient is doing, even with an anesthesiologist in the room. a good anesthesiologist will take care of the majority of issues, but situational awareness is important.

MAC for kypho is fine. do or do not do.



but stop operating if they are doing CPR. or if the mortician shows up.

 

[bedrock]

I ve done since 2004 about 700 kyphos , all under in sedation provided by an anaesthesiologist w/o any issues, pt is not moving, comfortable on cement injection, leaves for home no longer than 2 hours. You as a surgeon does not need to pay attention to how pt is doing.

It’s already been established by your previous posts that you don’t provide much of your spine procedures, by the national standard of care.

 

[lobelsteve]

I do my kypho in the hospital OR for the past year. Rarely will I entertain it in the office. I use local, MAC, or general.
The NS who do them in the OR always use general. The IR guys always use MAC. All anesthesia services provided by anesthesia department. OR staff nurses get mad when I use local only as it ties up 2 nurses to per policy to sit in the room and do nothing. No idea why.

 

[callmeanesthesia]

you always need to pay attention to how the patient is doing, even with an anesthesiologist in the room. a good anesthesiologist will take care of the majority of issues, but situational awareness is important.

MAC for kypho is fine. do or do not do.



but stop operating if they are doing CPR. or if the mortician shows up.

There is a fracture. I need to fix it.

There will be minimal blood loss.

 

[Ducttape]

even less when the heart stops pumping, so there is that. touche.

 

[callmeanesthesia]

even less when the heart stops pumping, so there is that. touche.

 

[mygalperin]

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It’s already been established by your previous posts that you don’t provide much of your spine procedures, by the national standard of care.

How is that so?

 

[1 Up]

Intracept or Kypho in procedure room. Full sterile prep, similar to OR. Pre op ancef. Anesthetize all the way down to periosteum. Sedation is versed, fentantyl, and small amounts of ketamine (2 mg at a time, up to 20 mg).

Magic.

 

[mygalperin]

Intracept or Kypho in procedure room. Full sterile prep, similar to OR. Pre op ancef. Anesthetize all the way down to periosteum. Sedation is versed, fentantyl, and small amounts of ketamine (2 mg at a time, up to 20 mg).

Magic.

Is your office certified?