Kyphoplasty

[NJPAIN]

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1. What system (company) do you all use?
2. Do any of you practice in a state like NJ where a one room facility is considered "an extension of a surgical practice" rather than licensed ASC? If so, are you able to qualify for "office-based" rates rather than ASC rates?

 

[lobelsteve]

Georgia. Office based.
Using Stryker HV cement kits with electric mixer and Neurotherm parallax with manual mixer/shaker. Both work fine. Neurotherm cement takes longer to set so I wait 5 minutes after balloon placed to inject or start mixing once needle is in anterior body.

 

[Pain Applicant1]

I use Stryker too. Why pay for the electric mixer? It takes about one minute to mix by hand. My rep would charge me $400 forthe electric mixer. $400 to save 1 minute of work = bad investment. What am I missing?

 

[Birdstrike]

Error

 

[PinchandBurn]

I use kyphon. They have this curette device that you put in (not curved stylette). IT's pretty nice, allows you to get midline.

 

[clubdeac]

Agree with Steve. Just did the first kypho today in the new practice with the Neurotherm parallax system and manual mixer/shaker. Lady with multiple myeloma s/p radiation to T10. Still had pain from VCF so oncologist sent her to me. I used 2mg versed and lots of local. Bone was hard as cement due to the radiation. It was my first time using that system and one criticism would be their little hammer. I was whacking away!! Definitely needed a bigger stick! Finally got the needle where it needed to be with good fill. Took for freaking eva!

Now this will entertain you all. Next case was a simple, or so I thought, left L4 TFESI. Well, 30 seconds after injection patient went into full anaphylaxis. Patient turned beat red and diaphoretic with a drop in bp to 60/40. Fortunately my nurse was a former NICU nurse and immediately got IV access. I stabbed the guy's thigh with our epi pen, shot in 50mg benadryl and got EMS there before he croaked. OMG! What a great morning....have seen a lot of vasovagals in my day but can honestly say this was my first full blown anaphylaxis

 

[lobelsteve]

Agree with Steve. Just did the first kypho today in the new practice with the Neurotherm parallax system and manual mixer/shaker. Lady with multiple myeloma s/p radiation to T10. Still had pain from VCF so oncologist sent her to me. I used 2mg versed and lots of local. Bone was hard as cement due to the radiation. It was my first time using that system and one criticism I have would be their little hammer. I was whacking away!! Definitely needed a bigger stick! Finally got the needle where it needed to be with good fill. Took for freaking eva!

Now this will entertain you all. Next case was a simple, or so I thought, left L4 TFESI. Well, 30 seconds after injection patient went into full anaphylaxis. Patient turned beat red and diaphoretic with a drop in bp to 60/40. Fortunately my nurse was a former NICU nurse and immediately got IV access. I stabbed the guy's thigh with our epi pen, shot in 50mg benadryl and got EMS there before he croaked. OMG! What an great morning....have seen a lot of vasovagals in my day but can honestly say this was my first full blown anaphylaxis

Well done. Kick save. I keep Rosenthal's article on everyones desk and in the procedure suite. If my nurse panics I tell to grab the article and start reading it out loud. By then I've got epipen in them and have the kit out.

 

[pastafan]

Not entertaining at all. Good work. Having handled anaphylactic reactions in the OR where everything is optimized to treat I have a healthy respect for doing the same in an office setting successfully.

 

[Pacman27]

Agree with Steve. Just did the first kypho today in the new practice with the Neurotherm parallax system and manual mixer/shaker. Lady with multiple myeloma s/p radiation to T10. Still had pain from VCF so oncologist sent her to me. I used 2mg versed and lots of local. Bone was hard as cement due to the radiation. It was my first time using that system and one criticism it have would be their little hammer. I was whacking away!! Definitely needed a bigger stick! Finally got the needle where it needed to be with good fill. Took for freaking eva!

Now this will entertain you all. Next case was a simple, or so I thought, left L4 TFESI. Well, 30 seconds after injection patient went into full anaphylaxis. Patient turned beat red and diaphoretic with a drop in bp to 60/40. Fortunately my nurse was a former NICU nurse and immediately got IV access. I stabbed the guy's thigh with our epi pen, shot in 50mg benadryl and got EMS there before he croaked. OMG! What a great morning....have seen a lot of vasovagals in my day but can honestly say this was my first full blown anaphylaxis

Curious what did you inject in your TFESI, was it the contrast?

 

[bedrock]

Well done. Kick save. I keep Rosenthal's article on everyones desk and in the procedure suite. If my nurse panics I tell to grab the article and start reading it out loud. By then I've got epipen in them and have the kit out.

Steve, do u have a reference for the rosenthal article?

 

[emd123]

For 99% of acute allergic reactions, all you need is 50 mg of IV (or IM) Benadryl, and an IV or IM shot of your steroid of choice (solumedrol 125 mg is a delicious choice) and a 911-call and meat-wagon ride to your nearest ER.

99% of people will be fine with just that.

0.3 mg of epinephrine subcutaneous is perfect if there's resp distress or hypotension like Club's patient, but the vast majority (even severe reactions) will turn around in a few minutes with Benadryl (and the steroid kicks in later).

I've taken care of (probably thousands) of acute allergic reactions and only had one die in front of me. It was someone with hereditary mastocytosis that magnified the allergic response dramatically, despite the most aggressive treatment. It was horrible.

Good work Club.

 

[clubdeac]

Was going to give 100mg solucortef next. My nurse was awesome help though. Not sure if it was the contrast or injectate. I did it pretty fast. Got good spread with ~0.5cc omnipaque and followed that with a 40mg depo and 1cc 0.25% marcaine mix. 30 seconds later he was going crazy!! I took the needle out immediately and threw off the sterile drape. It was crazy...I'm guessing it was from the contrast

 

[Birdstrike]

Was going to give 100mg solucortef next. My nurse was awesome help though. Not sure if it was the contrast or injectate. I did it pretty fast. Got good spread with ~0.5cc omnipaque and followed that with a 40mg depo and 1cc 0.25% marcaine mix. 30 seconds later he was going crazy!! I took the needle out immediately and threw off the sterile drape. It was crazy...I'm guessing it was from the contrast

Most likely contrast. Good work bro. You should've been an ER doctor! Red flag that chart. Lol

 

[lobelsteve]

Steve, do u have a reference for the rosenthal article?

http://www.practicalpainmanagement.com/printpdf/133

 

[emd123]

http://www.practicalpainmanagement.com/printpdf/133

Good article but I take serious issue with this line,

"The Advanced Cardiovascular Life Support (ACLS) guidelines have been the gold standard in preparing a physician to care for a patient in dire circumstances."

Really? You want another shot at writing that line?

A two day course that can be taken by physicians, nurses, medical students is the gold standard for skills in resuscitation and taking care of patients in "dire circumstances"?

I known he meant well, and said it out of respect for the course (which is a good course) but frankly, that's hilarious.

How about completing a residency in Emergency Medicine and passing those boards?

Or how about a critical care fellowship and passing those boards?

I'd nominated those two for for the gold standard, not a two day course for doctors and noctors alike.

But generally, I agree you need to be ready for when the inevitable patient crashes, are at least ready enough not to look like a doofus when you panic and it turns out your patient only vagaled. But I must say, it can be hard to do calmly and with poise, unless you've been through it too many times to count.

 

[Ducttape]

Was going to give 100mg solucortef next. My nurse was awesome help though. Not sure if it was the contrast or injectate. I did it pretty fast. Got good spread with ~0.5cc omnipaque and followed that with a 40mg depo and 1cc 0.25% marcaine mix. 30 seconds later he was going crazy!! I took the needle out immediately and threw off the sterile drape. It was crazy...I'm guessing it was from the contrast

statistically, by far , the contrast is the most likely cause of the reaction.
There are cases of true anaphylactic reaction to mar sine , but it's fairly rare. Likewise with depo.

 

[hyperalgesia]

Ok I just went to order a new epi-pen on Henry Schein because mine expired. $278?? Really?

 

[lobelsteve]

Ok I just went to order a new epi-pen on Henry Schein because mine expired. $278?? Really?

Rx to your nurse. Reimburse. 2 packs as low as a copay.

 

[emd123]

Ok I just went to order a new epi-pen on Henry Schein because mine expired. $278?? Really?

Why do you need a dummy proof epi pen? Just buy a small vial of epi. Don't you have a code box with one in it anyways? You just inject 0.3 mg subcu for allergic reaction or 1 mg IV if cardiac arrest.

 

[emd123]

Rx to your nurse. Reimburse. 2 packs as low as a copay.

Finally! Steve Lobel endorses fraud! Right here! Busted!

(Neener neener neener!)

 

[lobelsteve]

Finally! Steve Lobel endorses fraud! Right here! Busted!

(Neener neener neener!)

My nurse has peanut allergy. If she wants to give up her epipen to save the life of a patient it is her choice.



Im blowing smoke. I work for a large hospital system. I cannnot walk more than 10 yds in my office without finding a cart with an epipen. System wanted epipen to avoid problems drawing up meds in code situations. Only 2 people so far stuck their thumb with epi by holding pen upside down. I think design of pen haa changed since then. Phentolamine reverses vasospasm due to epi stick.

 

[hyperalgesia]

Why do you need a dummy proof epi pen? Just buy a small vial of epi. Don't you have a code box with one in it anyways? You just inject 0.3 mg subcu for allergic reaction or 1 mg IV if cardiac arrest.

This is just for the office setting where I do minor injections: joints, etc. My fluoro procedures are done in a facility. I guess I could get the vials but the auto-injector is much prettier...