IV Sedation for Pain Procedures

[Ligament]

As I was laying in the dentists office getting a root canal, I thought constantly how lucky I was to have Nitrous for sedation, and wished I have IV sedation as well.

I take no pain meds on a regular basis, have no chronic pain issues, but have a dental pain phobia that requires sedation. Without the nitrous, I would have perceived the root canal as near torture.

It made me very glad I offer all my patients IV sedation if they ask for it. I imagine many of them feel the same way I do when I get dental procedures.

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[101N]

I feel the same way.

 

[lobelsteve]

Pkitties. Muhahaha.

 

[101N]

Does that translate into 'wuss'? If so, no argument here. But still glad I can offer it cause I've got plenty of them.

One of the last ones to complain HAD sedation for a Rt S1 TFESI. I kid you not it takes me 5min tops from entering the room. In her post-procedure comments she said that she 'silently cried throughout the procedure' and 'it was worse than child birth'.

 

[Dr Manhattan]

do you offer IV sedation in the office via sedation nurse, or in ASC?

versed 2.0mg is what we use. usually range from 2-4, rarely go past 6. max is 8. only in the ASC, no sedation in office.

what do you guys use and in what setting?

 

[Pacman27]

Curious to see what you guys are using in the office... I am comfortable using most IV sedation as I still practice anesthesia. I have started with PO Valium, but not seeing a great benefit. Just seems like a pain to put an IV in a patient for medial branch blocks, but I will start doing shortly as some patients dont want the procedure

Also, anyone bill 99144?

Thanks

 

[Ducttape]

Some insurance will not allow sedation for diagnostic blocks. For example, no iv opioids for care core.

 

[Dr Manhattan]

why would you not be able to bill 99144 if providing IV sedation? billing for PO valium would be ridiculous

 

[lobelsteve]

Does that translate into 'wuss'? If so, no argument here. But still glad I can offer it cause I've got plenty of them.

One of the last ones to complain HAD sedation for a Rt S1 TFESI. I kid you not it takes me 5min tops from entering the room. In her post-procedure comments she said that she 'silently cried throughout the procedure' and 'it was worse than child birth'.

Narcotic deficiency syndrome. I yelled at a guy 2 weeks ago for yelling and squirming on an S1. Needle was in paraspinals at the time. He apologized at follow-up and so did I. He was 75% better and ready for PT.

 

[lobelsteve]

Curious to see what you guys are using in the office... I am comfortable using most IV sedation as I still practice anesthesia. I have started with PO Valium, but not seeing a great benefit. Just seems like a pain to put an IV in a patient for medial branch blocks, but I will start doing shortly as some patients dont want the procedure

Also, anyone bill 99144?

Thanks

Sedate a diagnostic MBB? Sounds like the payment review fairy may frown on that. Think again.

 

[SSdoc33]

i dont care what the patients say, but a 30 second hip injection is NOT worse than childbirth. ive heard this several times. when patients say things like that, how can you believe anything that comes out of their mouth? there comes a time for some paternalism in our field, when you have to tell the patients the best course of action. not always, but definitely in certain cases. IMHO, giving conscious sedation for a simple injection falls into that category.

 

[bedrock]

i dont care what the patients say, but a 30 second hip injection is NOT worse than childbirth. ive heard this several times. when patients say things like that, how can you believe anything that comes out of their mouth? there comes a time for some paternalism in our field, when you have to tell the patients the best course of action. not always, but definitely in certain cases. IMHO, giving conscious sedation for a simple injection falls into that category.

agree completely

 

[bedrock]

Curious to see what you guys are using in the office... I am comfortable using most IV sedation as I still practice anesthesia. I have started with PO Valium, but not seeing a great benefit. Just seems like a pain to put an IV in a patient for medial branch blocks, but I will start doing shortly as some patients dont want the procedure
s

Ridiculous to use IV sedation for a DIAGNOSTIC block. You invalidate the results and I would agree that an insurance company shouldn't pay for IV sedation for a MBB.

Regarding all other procedures, it's like what was said above, this is where a little paternalism is needed in pain medicine. A lumbar ILESI or S1TFESI isn't going to kill anybody, and the procedure takes 5 minutes. 1-2mg of Xanax goes a long way, but the most important thing is providing appropriate expectations. "Yes it will hurt a little, just like the knee injection you got last year, for which you didn't need twilight IV sedation".

 

[Taus]

For those who do not use IV sedation in office, what are you giving orally for RF? I've had a few patients recently who could not tolerate cervical RF with oral valium and superficial local. I have been taught not to be liberal or go deep with local as that can prevent accurate sensory and or motor stim.

 

[Ducttape]

For those who do not use IV sedation in office, what are you giving orally for RF? I've had a few patients recently who could not tolerate cervical RF with oral valium and superficial local. I have been taught not to be liberal or go deep with local as that can prevent accurate sensory and or motor stim.

I don't do a lot of cervical RFA but part of the mbb, IMO, is to assess if a patient could reasonably tolerate an RFA. I have had a few positive mbb that were for all intents and purposes never going to be able to go through an RFA.

 

[Yo GabbaPentin]

For those who do not use IV sedation in office, what are you giving orally for RF? I've had a few patients recently who could not tolerate cervical RF with oral valium and superficial local. I have been taught not to be liberal or go deep with local as that can prevent accurate sensory and or motor stim.

Sometimes what you are taught is just not applicable in the real world.

We used no sedation at all in fellowship for almost anything since it's "safer." If you want your patients to come back, then they need to be as happy as possible. A RF with no sedation and minimal local will rarely be a happy camper!

 

[clubdeac]

I give most all that request something, 10mg po valium. I was told by another doc last week that this then invalidates the consent i have them sign before the procedure. What do you guys think??

 

[lobelsteve]

Sometimes what you are taught is just not applicable in the real world.

We used no sedation at all in fellowship for almost anything since it's "safer." If you want your patients to come back, then they need to be as happy as possible. A RF with no sedation and minimal local will rarely be a happy camper!

Done 1000s. You are doing it wrong if you cannot get 2 joints cauterized with a single syringe of local an no sedation.

 

[lobelsteve]

I give most all that request something, 10mg po valium. I was told by another doc last week that this then invalidates the consent i have them sign before the procedure. What do you guys think??

Makes the potential lawsuit 1% more difficult. It might play a role but could not win or lose a lawsuit.

 

[Ducttape]

i have them bring pills in prescription bottle, come early to appointment (with a driver). i get consent BEFORE they take pill, then give them cup of water to down the pills. wait 20 min. noone is magically different, maybe a bit more relaxed. after the injection, they dont really feel like getting the benzo next time...

 

[Yo GabbaPentin]

Done 1000s. You are doing it wrong if you cannot get 2 joints cauterized with a single syringe of local an no sedation.

On all patients under 35 yrs old, I have been using the rusty railroad spike brand of cannulas. I think they might whine less if I actually did use a railroad spike.

 

[emd123]

Makes the potential lawsuit 1% more difficult. It might play a role but could not win or lose a lawsuit.

Agree. They can argue that, but must show the patient was impaired. They could also argue that since you have them on "pain pills," all consents they signed, ever, were invalid. That doesn't make it a valid or strong argument.

Clubdeac, if you really think this is true, instruct them to come in, sign consent, then and only then take the PO benzo, then wait 45 before you do the procedure. On the other hand, these are routine meds for plenty of people, signing all kinds of legal documents all the time.

Also, why use Valium 10 PO with a very long half life? Why not Xanax 0.5 mg, #2, 1-2 tabs PO 45 min prior to procedure?


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[lobelsteve]

Had first patient ask for sedation this morning for CESI. Not unreasonable if they are at risk of popping up and driving Tuohy through spine by hitting the II. Was not going to get behind to start after snowmagedden 2014. Toradol 60mg and Robaxin 200mg and she did fine.

SML

 

[PinchandBurn]

Sometimes what you are taught is just not applicable in the real world.

We used no sedation at all in fellowship for almost anything since it's "safer." If you want your patients to come back, then they need to be as happy as possible. A RF with no sedation and minimal local will rarely be a happy camper!

I agree with this.

RFA can be painful.

I think RFA and SCS trials are reasonable to do IV sedation for. Typically the needles we use are significantly larger for these procedure. Also, if the patient is calm,but communicative (must be documented), then I mitigate the risk of the patient suddenly moving and pithing the cord.

Also, there is the compassion factor and the patient satisfaction factor. As Gabba mentioned, people will not come back. I think as long as you are using moderate sedation and the patient is communicative, it's reasonable. Plus, from a practical standpoint, typically one can be more efficient.

Academia and real world are vastly different when it comes to patient satisfaction and efficiency of practice.

If one uses 'heavy sedation' or MAC, that's a different story...

 

[clubdeac]

I agree with Steve and emd; it probably doesn't change the risk. I was just surprised that this other physician thought it did. Albeit he wasn't a pain doc. And I don't know why I use valium. Just mimicked what the radiologists gave to all their claustrophobic MRI patients. I agree though, xanax would seem better with its shorter half life and quicker onset of action. I disagree however with everyone proposing that IV sedation may help prevent jerking and bucking. It's been my experience that the sedated folks are the most likely to buck and jerk. They don't have the inhibition to tell them otherwise and when they get caught off guard by a brief sharp stick, they jump reflexively. It always seemed more dangerous when I used IV sedation unless I completely snowed them. I now never use IV sedation. Just po meds

 

[Ramzy]

Clubdeac,
Diazepam has a shorter onset of action (diazepam is very lipophilic and enters CNS readily) than alprazolam, reverse is true for duration of action

-random pharmacist reading random threads

Lol

 

[101N]

A lot of this - like opioids - is influenced by the standards in your community. The original pain group
in my area has been very liberal with both sedation and opioids. Patients often say "I want to be out. Just like when Dr. so & so did it."

 

[Ducttape]

I agree with this.

RFA can be painful.

I think RFA and SCS trials are reasonable to do IV sedation for. Typically the needles we use are significantly larger for these procedure. Also, if the patient is calm,but communicative (must be documented), then I mitigate the risk of the patient suddenly moving and pithing the cord.

Also, there is the compassion factor and the patient satisfaction factor. As Gabba mentioned, people will not come back. I think as long as you are using moderate sedation and the patient is communicative, it's reasonable. Plus, from a practical standpoint, typically one can be more efficient.

Academia and real world are vastly different when it comes to patient satisfaction and efficiency of practice.

If one uses 'heavy sedation' or MAC, that's a different story...

how are you going to document sensory or even motor potentials with IV sedation?

i know this is not a concern with private insurances. but truth be told, those patients with private insurance in my experience are less likely to request iv sedation.

 

[PinchandBurn]

how are you going to document sensory or even motor potentials with IV sedation?

i know this is not a concern with private insurances. but truth be told, those patients with private insurance in my experience are less likely to request iv sedation.

Again, all of these patients are communicative. Typically they get like 2mg of midazolam and 50mcg of fentanyl (if that). These patients are usually able to communicate without any difficulty.

I have no problem getting Sensory or Motor potentials. Per ISIS, sensory is typically not seen to be as important anyways. I definitely do the motor up to 2volts, make certain no lower extremity movement occurs and all that is seen is multifus movement.

All other procedures (ESIs, MBBs,joint injections) are done with no sedation or 1mg of Xanax....

 

[Dr Manhattan]

Why not use Triazolam 0.25mg? Has a shorter half life than valium. Fast onset (.5-2 hours). 1-2 hour half life
Anyone else have experience with this?
All I have used for patients is Valium, but I am considering switching to this for patients who may need oral sedation:
Triazolam 0.125mg. Take 2 tablets one hour before procedure. Take third tablet just prior to procedure if needed.

Thoughts?

 

[Ducttape]

Again, all of these patients are communicative. Typically they get like 2mg of midazolam and 50mcg of fentanyl (if that). These patients are usually able to communicate without any difficulty.

I have no problem getting Sensory or Motor potentials. Per ISIS, sensory is typically not seen to be as important anyways. I definitely do the motor up to 2volts, make certain no lower extremity movement occurs and all that is seen is multifus movement.

All other procedures (ESIs, MBBs,joint injections) are done with no sedation or 1mg of Xanax....

Under care core national guidelines, pg 127, section I E 2, it states " performed without iv opioids for conscious sedation."

It is a little confusing. The subsection is discussing mbb not the RFA but nowhere in the mbb section is there a statement about sedation.

 

[epidural man]

i dont care what the patients say, but a 30 second hip injection is NOT worse than childbirth. ive heard this several times. when patients say things like that, how can you believe anything that comes out of their mouth? there comes a time for some paternalism in our field, when you have to tell the patients the best course of action. not always, but definitely in certain cases. IMHO, giving conscious sedation for a simple injection falls into that category.

I tend to agree with you.

However.....

There is something about needles that really freaks people out. It's like snakes or something....something about our teoleogical upbringing that makes some of us fear them.

I have seen Marines - who will bust down doors and take a bullet in the arse with not fear whatsoever....have no fear of loosing a leg or arm and face death in the face...that will cry like a baby from my tiny 25 gauge spinal needle.

 

[lobelsteve]

I tend to agree with you.

However.....

There is something about needles that really freaks people out. It's like snakes or something....something about our teoleogical upbringing that makes some of us fear them.

I have seen Marines - who will bust down doors and take a bullet in the arse with not fear whatsoever....have no fear of loosing a leg or arm and face death in the face...that will cry like a baby from my tiny 25 gauge spinal needle.

Pretty sure they weren't Marines. Navy maybe. Army for sure. But not Marines. HOORAH.

 

[Silent Cool]

As I was laying in the dentists office getting a root canal, I thought constantly how lucky I was to have Nitrous for sedation, and wished I have IV sedation as well.

I take no pain meds on a regular basis, have no chronic pain issues, but have a dental pain phobia that requires sedation. Without the nitrous, I would have perceived the root canal as near torture.

It made me very glad I offer all my patients IV sedation if they ask for it. I imagine many of them feel the same way I do when I get dental procedures.

Too bad you're in Seattle and not Colorado:

http://www.endospec.com/our-services/i-v-sedation-services/

Out of curiosity, what would you pay for sedation? $300 bucks? $400?

 

[Silent Cool]

As I was laying in the dentists office getting a root canal, I thought constantly how lucky I was to have Nitrous for sedation, and wished I have IV sedation as well.

I take no pain meds on a regular basis, have no chronic pain issues, but have a dental pain phobia that requires sedation. Without the nitrous, I would have perceived the root canal as near torture.

It made me very glad I offer all my patients IV sedation if they ask for it. I imagine many of them feel the same way I do when I get dental procedures.

Also, do you contract with a CRNA to provide the sedation or do you manage it yourself?

 

[Aether2000]

IV sedation is not for the benefit of the physician, but for the patient. It is not necessary for all patients but it is not contraindicated either. The patient's perception of pain is not accurately determined by the physician (several studies). The long term recall of the event is not related to duration of the pain but to the peak pain degree, therefore duration is irrelevant from the patient's standpoint. IV sedation may be given without interference with diagnostic blocks if a short acting non-mu receptor agonist is employed (eg. methohexital, propofol). There are large studies (Toronto Hospital) in which general anesthesia was used for RF with no adverse events. There will be some neuritis that will occur statistically after RF with or without sedation.

 

[Silent Cool]

Also, do you contract with a CRNA to provide the sedation or do you manage it yourself?

BUMP. Still curious about this.

 

[ampaphb]

Pain Med. 2014 Feb 13.
The Effect of Sedation on the Accuracy and Treatment Outcomes for Diagnostic Injections: A Randomized, Controlled, Crossover Study.
Cohen SP, Hameed H, Kurihara C, Pasquina PF, Patel AM, Babade M, Griffith SR, Erdek ME, Jamison DE, Hurley RW.

DESIGN:
Randomized, crossover study in which 73 patients were allocated to receive a diagnostic sacroiliac joint or sympathetic nerve block performed either with or without sedation using midazolam and fentanyl. Those who obtained equivocal relief, good relief lasting less than 3 months, or who were otherwise deemed good candidates for a repeat injection, received a subsequent crossover injection within 3 months (N = 46).

SETTING AND PATIENTS:
A tertiary care teaching hospital and a military treatment facility.

RESULTS:
In the primary crossover analysis, blocks performed with sedation resulted in a larger mean reduction in pain diary score than those done without sedation (1.2 [2.6]; P = 0.006), less procedure-related pain (difference in means 2.3 [2.5]; P < 0.0001), and a higher proportion of patients who obtained > 50% pain relief on their pain diaries (70% vs. 54%; P = 0.039). The increased pain reduction was not accompanied by increased satisfaction (sedation mean 3.9 [1.1] vs. 3.7 [1.3]; P = 0.26). Similar findings were observed for the parallel group (N = 73) and omnibus (all sedation vs. no sedation blocks, N = 110) analyses. No differences in outcomes were noted between the use and non-use of sedation at 1-month.

CONCLUSIONS:
The use of sedation during diagnostic injections may increase the rate of false-positive blocks and lead to misdiagnoses and unnecessary procedures, but has no effect on satisfaction or outcomes at 1-month.

 

[SSdoc33]

I think sedation is vastly over utilized..... But isn't this the same Cohen who doesn't want us to ever get MRIs? Thinks that an inter laminar is as good as a transfoarminal?

 

[Aether2000]

Cohen's conclusion is incorrect. If one adds sedation with fentanyl/midazolam results in...... then the conclusion would be accurate. Also inadequate sedation may indeed have been the cause of no difference in patient satisfaction. One mg of midazolam, when sedation is promised to the patient may be enough to cause dissatisfaction.

 

[PinchandBurn]

I think sedation is vastly over utilized..... But isn't this the same Cohen who doesn't want us to ever get MRIs? Thinks that an inter laminar is as good as a transfoarminal?

No. You have it switched. There was recently a Pro and Con for TFESI. Candido was on the CON side, Cohen was on the PRO side.

 

[Aether2000]

Ahhh I see. I was going by the lead author and the conclusion of the article, that is usually supported by the lead author. A debate would be a more interesting format.

 

[cbest]

No. You have it switched. There was recently a Pro and Con for TFESI. Candido was on the CON side, Cohen was on the PRO side.

Can you post the abstract of the Pro and Con for TFESI article? Thanks!

 

[olafa]

Just curious, For those providing in office PO sedation, do you still have your patient go NPO couple hours prior??

 

[emd123]

Just curious, For those providing in office PO sedation, do you still have your patient go NPO couple hours prior??

No. They can eat. 1-2 tab, Xanax 0.5 mg PO. It's for anxiety, not "sedation." There's no loss of consciousness, no suppression of gag, no risk of aspiration. The Rx is prescribed ahead of time. They take it PTA. I don't dispense. It's no different than a patient taking their prn anxiety benzo, like people do all the time at home. They're not NPO for that. Npo for PO Xanax= overkill. They must have a driver though.