Intrathecal chemotherapy

[Medstudent9]

Our anesthesia group was asked to do the LP for a patient receiving intrathecal chemotherapy after the medicine team was unable. IR declined the procedure. I have occasionally done diagnostic LPs to help out in the ED. We wouldn’t actually be pushing the drugs but this seems outside of anesthesia’s scope of practice.

Thoughts?

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[vector2]

Our anesthesia group was asked to do the LP for a patient receiving intrathecal chemotherapy after the medicine team was unable. IR declined the procedure. I have occasionally done diagnostic LPs to help out in the ED. We wouldn’t actually be pushing the drugs but this seems outside of anesthesia’s scope of practice.

Thoughts?

How about asking the oncologist who's doing the chemo to do his own LP? I don't mind assisting if he fails but it's his patient and his procedure.

 

[AdmiralChz]

Biggest question - why did IR decline? This is an elective, scheduled procedure they should be able to work into their schedule. But if it’s an anatomic consideration or some other soft contraindication this should be investigated.

 

[Arch Guillotti]

How about asking the oncologist who's doing the chemo to do his own LP? I don't mind assisting if he fails but it's his patient and his procedure.

???

Do oncologists ever routinely do LP's?

 

[Arch Guillotti]

Biggest question - why did IR decline? This is an elective, scheduled procedure they should be able to work into their schedule. But if it’s an anatomic consideration or some other soft contraindication this should be investigated.

IR should provide a rationale for why they are declining. Sounds weak.

 

[POW16]

I have seen them do it in peds hospitals.

 

[Arch Guillotti]

I have seen them do it in peds hospitals.

That's the only time I have seen it done.

 

[vector2]

???

Do oncologists ever routinely do LP's?

Good q. I've never had to tap anyone for adult onc nor have I seen adult pts booked on the IR schedule for LP chemo. I just assumed they do their own like the peds onc folks. Bone marrow biopsy and intrathecal chemo is part of their fellowship training requirements but I guess a bunch of them just farm LPs out to medicine or IR once they become staff.

 

[AdmiralChz]

I’m no heme/one specialist but LP chemo treatments are much more rare in the adult realm than in Peds. Would need to know much more about what one is getting into here.

 

[btbam]

The heme/onc NPs do all our LPs on peds patients. Not sure I’ve ever seen the attending do one.

 

[Orin]

Depends on the cancer but there are a few that may benefit from IT methotrexate or something else

Putting a needle in spinal fluid is firmly within your scope of practice.

Administering intrathecal chemotherapy is firmly outside it.

You could also provide sedation for the pediatric patient while it is done if that helps you feel better about it.

 

[Medstudent9]

Biggest question - why did IR decline? This is an elective, scheduled procedure they should be able to work into their schedule. But if it’s an anatomic consideration or some other soft contraindication this should be investigated.

Unfortunately I don’t know - all I have to look at is the medicine progress notes that say “IR declined” pretty much verbatim. This procedure is in the future and I don’t know that it will be my assignment (we are a group of about 20) so my scope to investigate is limited.

I only looked into it out of curiosity like “why would you need anesthesia for an LP?” Thinking it was a sedation request. Then I saw they wanted us to *do* the procedure or at least the intrathecal tap portion.

I am not positive who in my group said yes - I wouldn’t have - but we are a say yes culture.

More of an academic question, is this normal anesthesia scope of practice or not? It’s bad enough we end up being line jockeys for medicine floor patients (CVCs, PIVs)...

 

[IMGASMD]

Unfortunately I don’t know - all I have to look at is the medicine progress notes that say “IR declined” pretty much verbatim. This procedure is in the future and I don’t know that it will be my assignment (we are a group of about 20) so my scope to investigate is limited.

I only looked into it out of curiosity like “why would you need anesthesia for an LP?” Thinking it was a sedation request. Then I saw they wanted us to *do* the procedure or at least the intrathecal tap portion.

I am not positive who in my group said yes - I wouldn’t have - but we are a say yes culture.

More of an academic question, is this normal anesthesia scope of practice or not? It’s bad enough we end up being line jockeys for medicine floor patients (CVCs, PIVs)...

I am quite interested in the answer too. It’s bad enough we are called by ED to manage PDPH from IR dept of other hospitals. Now suppose to cover a procedure that IR does under fluoro, and we are trained to do blind?

 

[2Fast2Des]

Unfortunately I don’t know - all I have to look at is the medicine progress notes that say “IR declined” pretty much verbatim. This procedure is in the future and I don’t know that it will be my assignment (we are a group of about 20) so my scope to investigate is limited.

I only looked into it out of curiosity like “why would you need anesthesia for an LP?” Thinking it was a sedation request. Then I saw they wanted us to *do* the procedure or at least the intrathecal tap portion.

I am not positive who in my group said yes - I wouldn’t have - but we are a say yes culture.

More of an academic question, is this normal anesthesia scope of practice or not? It’s bad enough we end up being line jockeys for medicine floor patients (CVCs, PIVs)...

Do you get to bill for the line jockey requests? I would imagine there is some reimbursement for throwing in a few US guided IVs/CVC other than being a helpful person

 

[urge]

Our anesthesia group was asked to do the LP for a patient receiving intrathecal chemotherapy after the medicine team was unable. IR declined the procedure. I have occasionally done diagnostic LPs to help out in the ED. We wouldn’t actually be pushing the drugs but this seems outside of anesthesia’s scope of practice.

Thoughts?

I would do it.

It’s just like doing another spinal.

Oncology will have all the stuff ready for you.

I remember as an intern in the ER one day we had a neurologist stabbing a teenage child for CSF for about 30 min. After she gave up my attending volunteered me to do the LP because I was “the anesthesia guy.” I had done a few spinals so I felt good giving it a try and BAM! Got it on the first try. It was a teenager with perfect landmarks. It’s not that I was particularly good, it’s mostly that they are particularly bad. They just don’t do that many.

 

[urge]

How about asking the oncologist who's doing the chemo to do his own LP? I don't mind assisting if he fails but it's his patient and his procedure.

Good q. I've never had to tap anyone for adult onc nor have I seen adult pts booked on the IR schedule for LP chemo. I just assumed they do their own like the peds onc folks. Bone marrow biopsy and intrathecal chemo is part of their fellowship training requirements but I guess a bunch of them just farm LPs out to medicine or IR once they become staff.

Why do you guys think oncology did not get involved in the LP? They are IM last time I checked.

As far as I can tell oncology tried and failed.

 

[Medstudent9]

Do you get to bill for the line jockey requests? I would imagine there is some reimbursement for throwing in a few US guided IVs/CVC other than being a helpful person

We do bill for those. It's the government system so the billing is in the encounter.

There's a code for peripheral venous access or central venous access. I don't personally see the money and I'm not sure my dept does either but it does go into our *numbers* (and my personal numbers) whenever we get audited to see if we are pulling our weight.

Private practice people could probably weigh in better - you can def bill for IVs or CVCs, extra with an US modifier, but I don't think the reimbursement is very much.

And for the IVs especially it's probably not worth dealing with a disgruntled floor patient who is mad as hell about being stuck with needles and is theatrically wincing with everything single thing you do...

 

[Medstudent9]

I would do it.

It’s just like doing another spinal.

Oncology will have all the stuff ready for you.

I remember as an intern in the ER one day we had a neurologist stabbing a teenage child for CSF for about 30 min. After she gave up my attending volunteered me to do the LP because I was “the anesthesia guy.” I had done a few spinals so I felt good giving it a try and BAM! Got it on the first try. It was a teenager with perfect landmarks. It’s not that I was particularly good, it’s mostly that they are particularly bad. They just don’t do that many.

I did one of those recently in the ED. I don't mind the procedure part (I like doing spinals after all) but it gets a bit hairy after you have the needle in... Mine was an obese patient so I did it sitting up because the landmarks are better and I was told it was for CSF culture. Then they asked me what the opening pressure was... totally inaccurate in a sitting patient. And I know you have to fill 4 tubes sequentially but how many mLs in each are necessary? That was mainly an issue because the patient had apparently normal CSF volume/pressure so filling the tubes drip by drip was... taking... freaking... forever. Annoying to both the patient and myself. Maybe they would have filled faster lateral decubitus I am not sure but that's a harder stick for someone who already got stabbed by the ED staff 4 times...

It made me wish the ED staff would stick around so I could get the spinal then say "here you go" and walk away.

 

[AdmiralChz]

Private practice people could probably weigh in better - you can def bill for IVs or CVCs, extra with an US modifier, but I don't think the reimbursement is very much.

And for the IVs especially it's probably not worth dealing with a disgruntled floor patient who is mad as hell about being stuck with needles and is theatrically wincing with everything single thing you do...

Yeah, we do this sort of stuff around the hospital and (attempt) to bill for it. We have found most insurance straight up denies IV reimbursement or it’s so low from Medicare/Medicaid it isn’t worth the effort. A-lines are marginally better and CVLs OK. Private insurance want proof of US use - for a-lines this is hard unless you are using a wire and have an assistant... and it only nets $3-5 extra on average.

Our time is absolutely better compensated in the OR, but these sorts of things keep a group in a positive light around the hospitals. A little goodwill goes a long way. We don’t get all that many requests from what I’ve seen - maybe a couple a week (usually on multiple failed attempts by primary team). On average - most in our group don’t even attempt to bill for a-line/PIV, but do for CVL but again the “US proof” can be tricky without an extra hand. If they need a PIV for any significant time beyond a day or two we usually encourage PICC or midline placement.

 

[IlDestriero]

I have helped before when the oncologist has failed with the LP. However I won’t do pressured, administration of anything, etc. Patients who are known to be difficult because of obesity, scoliosis, etc. get a trip to IR. IR declining the case is stupid. That’s absolutely something they can and should offer, when appropriate. Though it’s access and hand off to onco for them as well.

 

[ProtonPump]

To the OP's question an LP is fully within our scope of practice (and you've probably done a lot more spinals than the adult oncologists), I wouldn't administer the chemo but I would do the procedure if there wasn't a contraindication. If the team asked you to place a CVC to help them administer chemo on an emergency basis, I think we can all agree that placing a CVC is also within the scope and what they plan to do with the line after it's placed doesn't change my scope, I also would administer chemo through the CVC.