MAC Anesthesia with chronic pain pts

[hellohelpwithfuture]

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I was wondering since my interest is in chronic pain.

• Does the presence of chronic pain change the way an anesthesiologist treats the pt?

• Especially with MAC anesthesia when the pt is awake and sometimes the procedure would appear that the pt only needs local anesthetic, but because of comorbidities (ie, chronic pain) would make the procedure not tolerable?

• As I am doing chronic pain research now, in a lot of pain conditions, the pain becomes centralized so any stimuli (even not associated with the origin of the pain) would be heightened compared to a pt w/o chronic pain, and thus would need a heavier pain med during the procedure?

• Is an IV pain med a majority of the time given, becouse the pt is already in pain, before the procedure even starts?

• Most of the time these pts are already on similar meds that would be used during the procedure for sedation/pain control, do you end up giving way higher doses than normally or switch to a different type of anesthesia?

 

[lobelsteve]

Routine use of sedation for pain procedures is done for the benefit of the physician (or their CRNAs) $$$, and not for the patient.
I do over half of my kyphoplasty procedures in office fluoro with local. SCS trials with local. ESI and RF- local. MBB must be done with local only, sedation negates the diagnostic utility.
Caveat: I said routine use. I have 1-2 patients per year I bring to ASC or OR for RF for sedation. I do SCS implant and some kypho under general or MAC. I leave that up the Anesthesiologist.

My viewpoint is controversial and can be costly to the shady pain clinic doctors. Patient is not allow to set the expectations. That is the job of the doctor.

 

[Lecithin5]

I agree with lobel above regarding mac in pain patients for pain procedures. Regarding MAC in pain patients for non-pain procedures (let’s say, a procedure that justifiably needs mac), it often is more challenging in pain pts. I try to maximize adjuncts, and if amenable, use regional. These patients can have such high tolerances that ‘standard’ analgesic and sedative doses don’t do much. And I make it clear to surgeons that they need to localize well (boy, is it refreshing to see a surgeon who knows how to use local!). To answer your other questions, yes, higher doses are often given. They often complain in the preoperative area of pain-be it from acute on chronic or just their baseline chronic pain... And centralized pain patients are the most challenging of all- a simple IV insertion can be a nightmare. I still alwayd try to avoid geneal anesthesia if possible, but sometimes you’re forced to convert

 

[hellohelpwithfuture]

I agree with lobel above regarding mac in pain patients for pain procedures. Regarding MAC in pain patients for non-pain procedures (let’s say, a procedure that justifiably needs mac), it often is more challenging in pain pts. I try to maximize adjuncts, and if amenable, use regional. These patients can have such high tolerances that ‘standard’ analgesic and sedative doses don’t do much. And I make it clear to surgeons that they need to localize well (boy, is it refreshing to see a surgeon who knows how to use local!). To answer your other questions, yes, higher doses are often given. They often complain in the preoperative area of pain-be it from acute on chronic or just their baseline chronic pain... And centralized pain patients are the most challenging of all- a simple IV insertion can be a nightmare. I still alwayd try to avoid geneal anesthesia if possible, but sometimes you’re forced to convert

Yes that answers the question. I wanted to know for non-pain procedures is it different and I guess it is.

 

[Lecithin5]

Yes that answers the question. I wanted to know for non-pain procedures is it different and I guess it is.

Well, putting aside whether pain procedures really need mac (as I said above, I’m in the Lobel camp), it actually isn’t much different. A pain patient is a pain patient, whether they receive mac for a pain procedure or a non-pain procedure. They are generally a headache to deal with.

 

[jwk]

Routine use of sedation for pain procedures is done for the benefit of the physician (or their CRNAs) $$$, and not for the patient.
I do over half of my kyphoplasty procedures in office fluoro with local. SCS trials with local. ESI and RF- local. MBB must be done with local only, sedation negates the diagnostic utility.
Caveat: I said routine use. I have 1-2 patients per year I bring to ASC or OR for RF for sedation. I do SCS implant and some kypho under general or MAC. I leave that up the Anesthesiologist.

My viewpoint is controversial and can be costly to the shady pain clinic doctors. Patient is not allow to set the expectations. That is the job of the doctor.

Happy New Year!

Kyphos with local only? Interesting - I didn't know those were done in the office, since I assumed they required sedation for trocar placement.

 

[nimbus]

Well, putting aside whether pain procedures really need mac (as I said above, I’m in the Lobel camp), it actually isn’t much different. A pain patient is a pain patient, whether they receive mac for a pain procedure or a non-pain procedure. They are generally a headache to deal with.

That’s when it’s best to give them a nice MAC with an LMA and sevo😉

 

[Aether2000]

I also do kyphoplasty in the office under local. LOTS of local (lidocaine) and once the cannula is through the skin, local is applied to the periosteum using a long needle through the cannula. Then additional local in the vertebral body.

Use of TIVA or GA or IV sedation in some practices is incorporated frequently, if not universally. It is not necessary in most cases, drives up the cost of health care, and depending on the procedure/approach/skills of the physician could slightly increase injury risk.

 

[Lecithin5]

I rarely use any sedation for procedures, including kypho- localizing the periosteum well (4% lido) does wonders. Also, while I acknowledge that there are some that truly may benefit from sedation, I try to avoid it because it can separate the contenders from pretenders, and selects for pts who are serious about getting better. A good chunk of patients out there undergo pain procedures just so I can get a little bit of sedation- I am sure of this (and also to get their candy from the doc...).

 

[Mman]

as OP was asking about chronic pain patients have surgical procedures under MAC (not pain procedures), I'd say they get treated the same as everyone else they just might need bigger doses of meds and/or addition of adjuvants to help produce the desired effects.

 

[Aether2000]

If you are asking if chronic pain patients are significantly psychologically disturbed, and have anxiety through the roof requiring different management, the answer is yes at least half the time. Chronic pain patients taking massive doses of opioids make fentanyl IV look like water, and may experience a bit more difficulty in controlling them. At least half the chronic pain patients I see are also taking benzodiazepines- some taking three or four different benzodiazepines in the same day, sometimes all prescribed by the same doctor. Propofol seems to have less effect in these patients or those using alcohol frequently. The benzophiles will also have virtually no response to usual doses of midazolam in some cases. Many anesthesiologists just say screw the MAC and go straight to general anesthesia in cases where the patients are not going to be controllable given their response to preop meds or intraop behavior.