Monitoring guidelines for interventional procedures in private practice

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Hi, I wanted to know if anyone was aware of monitoring guidelines for interventional pain procedures in private practice. I'm looking into joining a group private practice and have noticed that there are some private groups who do not use any monitoring for their blocks as it is done under local, including cervical and sympathetic blocks. At our academic center, we basically place continuous pulse Ox and BP on all of our patients. I do realize it might not be necessary for peripheral injections, etc, but are there guidelines or standards of care for the higher risk procedures, such as cervical MBBs, CESIs, all sympathetic blocks? I would like to incorporate these specific procedures when i start practicing, but in training we do use monitoring and place IVs in all these patients. I wouldn't feel comfortable doing it in private practice without any monitoring.
How are most private practices set up? Is monitoring required for cervical and sympathetic blocks? Thx
 
Neck procedures get an IV and pulse ox so I can watch for (and treat) vagal response. Sedation cases get the works, full ASA monitors. Everything else no monitoring other than talking to me.
 
Ferrismonk said:
Neck procedures get an IV and pulse ox so I can watch for (and treat) vagal response. Sedation cases get the works, full ASA monitors. Everything else no monitoring other than talking to me.
Click to expand...
I was unaware that vagal responses only happen in cervical procedures
 
All my procedures are done in-office with lots of local and no IV sedation. Kypho's and stim trials get PO xanax. Therefore no IV or monitoring needed 99% of the time. Exceptions = sympathetic blocks for which I put in a saline lock and pulse ox. To date, I've not ever had to give an IV fluid bolus for hypotension in those, but I still do it as a precaution because I was trained to. Another exceptions would be a COPDer or someone who I'd otherwise be worried about their O2 sat while laying prone. In that case, I"ll put a pulse ox on them, but no IV.

I have enough equipment I can run a full code in my procedure room (defibrillator, intubation box, ACLS meds, O2 tank, IVF) just because coming from an EM background, I felt better having all that stuff when I started out in my Pain practice because I felt weird without it, but I don't think it's necessary to have all that routinely if you're not using IV meds and especially if you're not prepared or comfortable using it.

Also, I've tailored my protocols to be as low risk as possible (no local in ESI mixtures, etc), consistent with an outpatient, in-office practice, so complications are less likely to begin with. If you monitoring people and placing IVs for the occasional vagal episode, I think that's overkill. You have those people lay down with the head of the bed down and they're back to normal in minutes without treatment.

Don't IV sedate.
Don't put local in ESIs.
Do IVs for sympathetics and you should be fine.
 
Do what you think the average juror will think is the medical standard of care for his/her mother when a needle is poked a millimeter from her spinal cord.
 
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In office?

Maybe a manual BP cuff and automatic defib device.

In ASC?

BP cuff, pulse ox, ET CO2 monitor, iv, oral airways, ETT, glidescope, LMA, surgical airway kit, epi/ vasopressin/ atropine/ adenosine/ Intralipid, defib, ext pacemaker, extra nurses/ techs, etc....
 
nvrsumr said:
Do what you think the average juror will think is the medical standard of care for his/her mother when a needle is poked a millimeter from her spinal cord.
Click to expand...

I think that they would think you were following the law if you were. I also think that you should consult with your local medical board and/or state medical society determine what, if any, requirements or accreditations are necessary to provide in-office conscious sedation:

For example,

Oregon Secretary of State Administrative Rules
 
What makes sense is dependent on what block you are doing and what medications are being used. For instance, any interlaminar epidural that uses local anesthesia with the steroid in the epidural space has the potential to become a sympathetic block and a high spinal due to unrecognized subdural supra-arachnoid injection. Use of a high volume in these blocks has the potential to produce a high spinal block from unrecognized subarachnoid injection from needle movement after the epidurogram (use of luer lock syringes). In lumbar and cervical cases where local is used in the epidural space, it is logical to use BP monitoring. For TFESI with particulates, both BP and pulse oximetry are logical, regardless if local anesthetics are injected. In TFESI with dexamethasone without local, no monitoring should be required as long as there is no sedation. Medial branch blocks or intra-articular facet injections or SI injections would not benefit from monitoring. LSB and SGB- BP and Pulse ox always. With kyphoplasty, BP and pulse ox monitoring are logical given the 40% leakage of cement outside the vertebral body (Early clinical outcome and complications related to balloon kyphoplasty. - PubMed - NCBI), that can go into the lungs
 
Sadly, at my hospital-owned ASC where I do procedures, full monitors for everybody all the time. You should see the pre-procedure checkin process. It's absurd.
 
drrosenrosen said:
Sadly, at my hospital-owned ASC where I do procedures, full monitors for everybody all the time. You should see the pre-procedure checkin process. It's absurd.
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I'm with you. The time and pain involved with BP monitoring is greater than that of the injection itself most of the time. Score one for @drusso
 
emd123 said:
All my procedures are done in-office with lots of local and no IV sedation. Kypho's and stim trials get PO xanax. Therefore no IV or monitoring needed 99% of the time. Exceptions = sympathetic blocks for which I put in a saline lock and pulse ox. To date, I've not ever had to give an IV fluid bolus for hypotension in those, but I still do it as a precaution because I was trained to. Another exceptions would be a COPDer or someone who I'd otherwise be worried about their O2 sat while laying prone. In that case, I"ll put a pulse ox on them, but no IV.

I have enough equipment I can run a full code in my procedure room (defibrillator, intubation box, ACLS meds, O2 tank, IVF) just because coming from an EM background, I felt better having all that stuff when I started out in my Pain practice because I felt weird without it, but I don't think it's necessary to have all that routinely if you're not using IV meds and especially if you're not prepared or comfortable using it.

Also, I've tailored my protocols to be as low risk as possible (no local in ESI mixtures, etc), consistent with an outpatient, in-office practice, so complications are less likely to begin with. If you monitoring people and placing IVs for the occasional vagal episode, I think that's overkill. You have those people lay down with the head of the bed down and they're back to normal in minutes without treatment.

Don't IV sedate.
Don't put local in ESIs.
Do IVs for sympathetics and you should be fine.
Click to expand...


I don't think we should generalize. I have a significant percentage of young, male patients. A good percentage of them would vasovagal if I did not give them anxiolytics, such as midazolam. I tell my patients when you receive IV sedation from me, you are not going to sleep (although half them would doze off for 1-2 minutes), but you will be RELAXED. It's crucially important for someone with borderline HR of 50/low 60s and BP in 100/60s. These patients would NOT c/o of anxiety, nervousness. In fact, they might tell you they are feeling fine while having vasovagal reaction.

One time I had a young, 20+ male patient on the table, doing a cervical MNBB without IV sedation (actually, I offered and he wanted IV sedation, but he forgot to skip lunch). I saw his HR/BP dropping gradually down to 40s in the middle of procedure, and I asked him how he felt. He said he felt fine. I didn't want to take chance and broke out a pack of ammonia salt. He hated it, but BP/HR came up.

Then he said, "Oh, I did feel a little nauseated earlier"!

The second time we did IV sedation, no problem at all. In fact, his HR was borderline 50/60s once we put on monitor before we even started the procedure. Once I gave him 2mg of Versed IV, his HR gradually came up into 70s. It gave me enough buffer zone for the procedure. No issue at all.

I topicalize very well, but I require all my younger, male patients to get IV sedation for neuro-axial procedure.
 
drpainfree said:
I don't think we should generalize. I have a significant percentage of young, male patients. A good percentage of them would vasovagal if I did not give them anxiolytics, such as midazolam. I tell my patients when you receive IV sedation from me, you are not going to sleep (although half them would doze off for 1-2 minutes), but you will be RELAXED. It's crucially important for someone with borderline HR of 50/low 60s and BP in 100/60s. These patients would NOT c/o of anxiety, nervousness. In fact, they might tell you they are feeling fine while having vasovagal reaction.

One time I had a young, 20+ male patient on the table, doing a cervical MNBB without IV sedation (actually, I offered and he wanted IV sedation, but he forgot to skip lunch). I saw his HR/BP dropping gradually down to 40s in the middle of procedure, and I asked him how he felt. He said he felt fine. I didn't want to take chance and broke out a pack of ammonia salt. He hated it, but BP/HR came up.

Then he said, "Oh, I did feel a little nauseated earlier"!

The second time we did IV sedation, no problem at all. In fact, his HR was borderline 50/60s once we put on monitor before we even started the procedure. Once I gave him 2mg of Versed IV, his HR gradually came up into 70s. It gave me enough buffer zone for the procedure. No issue at all.

I topicalize very well, but I require all my younger, male patients to get IV sedation for neuro-axial procedure.
Click to expand...


You must be awfully scary. Lots of unnecessary care and added risk.
 
lobelsteve said:
You must be awfully scary. Lots of unnecessary care and added risk.
Click to expand...

actually, the ones who are more likely to vasovagal are not the ones who are easily scared. They typically have very calm demeanor with strong parasympathetic tone. They are the very laid-back type.
 
drpainfree said:
I don't think we should generalize. I have a significant percentage of young, male patients. A good percentage of them would vasovagal if I did not give them anxiolytics, such as midazolam. I tell my patients when you receive IV sedation from me, you are not going to sleep (although half them would doze off for 1-2 minutes), but you will be RELAXED. It's crucially important for someone with borderline HR of 50/low 60s and BP in 100/60s. These patients would NOT c/o of anxiety, nervousness. In fact, they might tell you they are feeling fine while having vasovagal reaction.

One time I had a young, 20+ male patient on the table, doing a cervical MNBB without IV sedation (actually, I offered and he wanted IV sedation, but he forgot to skip lunch). I saw his HR/BP dropping gradually down to 40s in the middle of procedure, and I asked him how he felt. He said he felt fine. I didn't want to take chance and broke out a pack of ammonia salt. He hated it, but BP/HR came up.

Then he said, "Oh, I did feel a little nauseated earlier"!

The second time we did IV sedation, no problem at all. In fact, his HR was borderline 50/60s once we put on monitor before we even started the procedure. Once I gave him 2mg of Versed IV, his HR gradually came up into 70s. It gave me enough buffer zone for the procedure. No issue at all.

I topicalize very well, but I require all my younger, male patients to get IV sedation for neuro-axial procedure.
Click to expand...
He probably didn't vagal the second time, simply because he knew what to expect and wasn't caught off guard. It may have had nothing to do with the versed.

The treatment of vasovagal reactions is not versed. It's to lay people down, give them a bedpan, put the head of the bed down, and do nothing. Then when they say, "Hey, I feel better now. Can I get up?" you sit them up, check a BP. If okay, stand them up and check a BP. If also normal, which by definition it will be 100% of the time in a "young healthy male" with a vagal episode, then you say, "Goodbye." That's it.

If, while working in the ED for over 10 years, I routinely pushed versed IV for the 5,000 times I had young healthy people vagal episodes, it would have been wrong, I would have been mocked, laughed at and probably disciplined. My partners would have said, "Are you ---king kidding me? You had a young healthy male get vagal, and you literally treated that with IV ---king conscious sedation? What, the..."

Maybe this works for you, in your practice and in your patient population. But in mine:

Young. Healthy. Vagal = Lay Down, Head of Bed Down. Gets better with no treatment 100% of time. Bye-bye, home.

Nothing else.
 
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drpainfree said:
actually, the ones who are more likely to vasovagal are not the ones who are easily scared. They typically have very calm demeanor with strong parasympathetic tone. They are the very laid-back type.
Click to expand...
Absolutely true. Often cool, calm, collected, then when the procedure's over, "Doc, I feel sick."
 
SIS is developing "Standards" for every procedure now with extensive descriptions. It will probably be published after late in 2018
 
emd123 said:
He probably didn't vagal the second time, simply because he knew what to expect and wasn't caught off guard. It may have had nothing to do with the versed.

The treatment of vasovagal reactions is not versed. It's to lay people down, give them a bedpan, put the head of the bed down, and do nothing. Then when they say, "Hey, I feel better now. Can I get up?" you sit them up, check a BP. If okay, stand them up and check a BP. If also normal, which by definition it will be 100% of the time in a "young healthy male" with a vagal episode, then you say, "Goodbye." That's it.

If, while working in the ED for over 10 years, I routinely pushed versed IV for the 5,000 times I had young healthy people vagal episodes, it would have been wrong, I would have been mocked, laughed at and probably disciplined. My partners would have said, "Are you ---king kidding me? You had a young healthy male get vagal, and you literally treated that with IV ---king conscious sedation? What, the..."

Maybe this works for you, in your practice and in your patient population. But in mine:

Young. Healthy. Vagal = Lay Down, Head of Bed Down. Gets better with no treatment 100% of time. Bye-bye, home.

Nothing else.
Click to expand...


The reason I give sedation pre-operatively is to PREVENT vasovagal, not to treat.

We all know how to conservatively treat a vasovagal response (if you read my post carefully). Yes, I would laugh at you if you give versed to treat vasovagal.

My goal is to AVOID vasovagal response in the middle of my procedure which can lead to mid-procedure abort, not what I am looking for.

Besides, vasovagal in most people is not a life-threatening condition. In some young male patients who might have occult cardiac issues (Brugada syndrome, for example), vasovagal reaction can be a major event.

In OR we pre-sedate before we intube. In ER, half of patients who need to be intubated are already AMS, intoxicated. I can see why we think differently.
 
algosdoc said:
SIS is developing "Standards" for every procedure now with extensive descriptions. It will probably be published after late in 2018
Click to expand...

Can these busy body academics develop new treatments or interventional techniques proven to be better than what we currently have rather than pontificate and self aggrandize with their "expert" consensus statements. I know it's actually hard to do real research rather than endless literature reviews to make associate prof.

They never get tired of the circle jerk.
 
drpainfree said:
The reason I give sedation pre-operatively is to PREVENT vasovagal, not to treat.

We all know how to conservatively treat a vasovagal response (if you read my post carefully). Yes, I would laugh at you if you give versed to treat vasovagal.

My goal is to AVOID vasovagal response in the middle of my procedure which can lead to mid-procedure abort, not what I am looking for.

Besides, vasovagal in most people is not a life-threatening condition. In some young male patients who might have occult cardiac issues (Brugada syndrome, for example), vasovagal reaction can be a major event.

In OR we pre-sedate before we intube. In ER, half of patients who need to be intubated are already AMS, intoxicated. I can see why we think differently.
Click to expand...
I could be wrong, but it seems to me Brugada syndrome is not common (1 in 5,000 or so). Second, if worried about people with pre-existing heart conditions such as Brugada syndrome, it seems like a screening EKG might be a good idea. But, "versed for everyone" as a guard against heart arrhythmias?

I don't know.

Again, I could be wrong, but lets do the math: If 1 in 100 patients vagal (it may not even be that often) with a pain procedure, and 1 in 5,000 of them have Brugada syndrome, then approximately 1 in 500,000 patients that will vagal and also turn out to have Brugada syndrome. Then, only a fraction of those Brugada patients who vagal will have an arrhythmia, so divide that number in half. Therefore, about 1 in 1,000,000 of your patients will turn out to have Brugada syndrome, then vagal, then have an arrhythmia. That's a lot of versed to maybe prevent a rare Brugada syndrome patient from vagaling, who might now even have a vagal episode, and if they did, might not even have a significant arrhythmia other than self-limited, self-treating, bradycardia.

Also, is there a dire need to "avoid vasovagal response" to prevent a mid-procedure? The treatment for vasovagal syncope is to lay the patient down. Pain patients are already laying down during pain procedures. I'm not so sure one needs to necessarily abort a procedure because a patient starts to feel funny and might be feeling vagal. You just let them lay there until they feel better and check a blood pressure. That is how neurocardiogenic syncopal (vagal) episodes end. The patient faints, falls, ends up in a laying position, which causes increased cerebral perfusion pressure, and they wake up. But if they're already laying down, as they are during a pain procedure, they're already fixed. Am I wrong?

Maybe.

If a patient has a history of prolonged vagal episodes, I suppose that's one situation. And people who are prone to vagal episodes generally know that, by adulthood. But otherwise, does routinely sedating people to prevent vagal episodes make sense? Or, is it more like giving a fish a bicycle and telling him he'd really need it if he grows legs?

I don't know.

Maybe.
 
emd123 said:
I could be wrong, but it seems to me Brugada syndrome is not common (1 in 5,000 or so). Second, if worried about people with pre-existing heart conditions such as Brugada syndrome, it seems like a screening EKG might be a good idea. But, "versed for everyone" as a guard against heart arrhythmias?

I don't know.

Again, I could be wrong, but lets do the math: If 1 in 100 patients vagal (it may not even be that often) with a pain procedure, and 1 in 5,000 of them have Brugada syndrome, then approximately 1 in 500,000 patients that will vagal and also turn out to have Brugada syndrome. Then, only a fraction of those Brugada patients who vagal will have an arrhythmia, so divide that number in half. Therefore, about 1 in 1,000,000 of your patients will turn out to have Brugada syndrome, then vagal, then have an arrhythmia. That's a lot of versed to maybe prevent a rare Brugada syndrome patient from vagaling, who might now even have a vagal episode, and if they did, might not even have a significant arrhythmia other than self-limited, self-treating, bradycardia.

Also, is there a dire need to "avoid vasovagal response" to prevent a mid-procedure? The treatment for vasovagal syncope is to lay the patient down. Pain patients are already laying down during pain procedures. I'm not so sure one needs to necessarily abort a procedure because a patient starts to feel funny and might be feeling vagal. You just let them lay there until they feel better and check a blood pressure. That is how neurocardiogenic syncopal (vagal) episodes end. The patient faints, falls, ends up in a laying position, which causes increased cerebral perfusion pressure, and they wake up. But if they're already laying down, as they are during a pain procedure, they're already fixed. Am I wrong?

Maybe.

If a patient has a history of prolonged vagal episodes, I suppose that's one situation. And people who are prone to vagal episodes generally know that, by adulthood. But otherwise, does routinely sedating people to prevent vagal episodes make sense? Or, is it more like giving a fish a bicycle and telling him he'd really need it if he grows legs?

I don't know.

Maybe.
Click to expand...


Have a vasovagal response on the table is not fun. In an healthy patient, you can "wait" it out. I typically stimulate them to increase their sympathetic tone. I find ammonia salt works pretty well. My MA who also operates fluoro knows the routine well now since she got used to deal with the situation. Still it's not a situation I'm happy to deal with because I'm focusing on getting the case done and room turned over.

On the other hand if you have a patient with pre-existing cardiac neurological conditions, whether it's cardiac arrhythmia, CAD, history of TIA, or Brugada or whatever random rare condition you have, a vasovagal hypotension/bradycardia can precipitously trigger serious cardiac conditions.

Remember, a patient can vasovagal AFTER they get up from the table after the procedure is done. I have seen this happened.

My point is, if I suspect someone who might be prone to vasovagal reaction or if vasovagal reaction during my procedure can trigger dire consequence, I will try my best to prevent it.

My threshold is low. So I do give IV sedation with anxiolytics, which takes me and my staff a little more time to prepare IV and remove IV.

I have seen zero vasovagal with IV anxiolytics on patients who previously had vasovagal without sedation. The procedure proceeded much smoother and it is a better and safer experience for my patients.
 
But why mbb if it’s meant to be purely diagnostic would you sedate them? Couldn’t that skew the response. There’s an anesthesia doc who sedated everyone at my asc. Needless to say her rf/mbb ratio is a lot higher than mine
 
drpainfree said:
Have a vasovagal response on the table is not fun. In an healthy patient, you can "wait" it out. I typically stimulate them to increase their sympathetic tone. I find ammonia salt works pretty well. My MA who also operates fluoro knows the routine well now since she got used to deal with the situation. Still it's not a situation I'm happy to deal with because I'm focusing on getting the case done and room turned over.

On the other hand if you have a patient with pre-existing cardiac neurological conditions, whether it's cardiac arrhythmia, CAD, history of TIA, or Brugada or whatever random rare condition you have, a vasovagal hypotension/bradycardia can precipitously trigger serious cardiac conditions.

Remember, a patient can vasovagal AFTER they get up from the table after the procedure is done. I have seen this happened.

My point is, if I suspect someone who might be prone to vasovagal reaction or if vasovagal reaction during my procedure can trigger dire consequence, I will try my best to prevent it.

My threshold is low. So I do give IV sedation with anxiolytics, which takes me and my staff a little more time to prepare IV and remove IV.

I have seen zero vasovagal with IV anxiolytics on patients who previously had vasovagal without sedation. The procedure proceeded much smoother and it is a better and safer experience for my patients.
Click to expand...

Username appropriate. Care substandard.
 
Dr. Ice said:
But why mbb if it’s meant to be purely diagnostic would you sedate them? Couldn’t that skew the response. There’s an anesthesia doc who sedated everyone at my asc. Needless to say her rf/mbb ratio is a lot higher than mine
Click to expand...


Midazolam: quick onset, short half-life, typically when my patients get up from table, 2-4mg of midazolam is no longer affecting their mentation. By the time they are discharged approximately 40 minutes from receiving midazolam IV, they are ambulating, wide-wake...they can tell me how they feel at the time...but really I'm looking for 4-8 hours of relief for diagnostic accuracy if I'm doing pure diagnostic block.

Have you ever given versed or received via IV before? It does NOT SEDATE you at low dose. It eases you off.

When we do anesthesia, pre-intubating cocktail is typically versed/fentanyl/propofol. Give 2mg of versed in pre-op really just relax patients, no sedative effect. Propofol is the one that knock out consciousness.
 
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if you are so worried about vasovagal, why not just give an oral dose of ativan and not cause bradycardia from the IV attempts, or introduce the risk of infection from that IV? possibly 0.1% of all IV catheters lead to staph aureus bacteremia. (Maki DG, Kluger DM, Crnich CJ. The risk of bloodstream infection in adults with different intravascular devices: a systematic review of 200 published prospective studies. Mayo Clin Proc 2006; 81: 1159-1171.)


fyi, elimination half life of iv midazolam is 1.5-2.5 hours. the elimination half life of one of the active metabolites, 1-hydroxymidazolam, is 12 hours.

additionally, there is a subset - possibly as high as 6% - that might have a prolonged elimination half life of midazolam of 8 hours. Prolonged midazolam elimination half-life.

you are making a semantic point about "relax" vs "sedate". it is a benzodiazepine that affects cognition. you may call it "relaxation" but it is still a benzodiazepine related effect. do you tell your patients to drive after giving a dose of versed?

oh gosh, please don't answer that, cause im afraid of the answer...
 
Ducttape said:
if you are so worried about vasovagal, why not just give an oral dose of ativan and not cause bradycardia from the IV attempts, or introduce the risk of infection from that IV? possibly 0.1% of all IV catheters lead to staph aureus bacteremia. (Maki DG, Kluger DM, Crnich CJ. The risk of bloodstream infection in adults with different intravascular devices: a systematic review of 200 published prospective studies. Mayo Clin Proc 2006; 81: 1159-1171.)


fyi, elimination half life of iv midazolam is 1.5-2.5 hours. the elimination half life of one of the active metabolites, 1-hydroxymidazolam, is 12 hours.

additionally, there is a subset - possibly as high as 6% - that might have a prolonged elimination half life of midazolam of 8 hours. Prolonged midazolam elimination half-life.

you are making a semantic point about "relax" vs "sedate". it is a benzodiazepine that affects cognition. you may call it "relaxation" but it is still a benzodiazepine related effect. do you tell your patients to drive after giving a dose of versed?

oh gosh, please don't answer that, cause im afraid of the answer...
Click to expand...


if you are comparing oral ativan to iv versed in terms of onset, half life, you obviously haven't done enough anesthesia or at least used versed via IV enough...
 
I give ZERO sedation.

Versed for medial branch blocks is madness.

You're talking about vagal episodes like it is akin to a STEMI. You want to freak someone out, give them all this medical attention and stick an IV in them...I know many of those pts get stuck 5x before proper IV placement occurs.
 
What brand of monitor are you using for vitals during a procedure?

There are cheap ones for around 350. But is that tooo cheap?

Also, anyone using PO versed for procedures?



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