New Medicare LCD Guidelines: No Sedation for ESI/facets

[deleted875186]

My clinic gives a lot of sedation (despite my many arguments against). This is largely because I'm doc #6 and the other 5 have been doing everyone under sedation forever. There is definitely a culture I'm working against. That being said, I make it known I prefer no sedation for all my procedures and don't have an issue for those that buy in and try it.

Here's my 2cents on your situation.

1. The people who scream the most are Medicaid patients, smokers, and those on opioids. The less you have of each of these the less screaming you'll get.

2. I stopped using skin local except for needles bigger than a 22G. I found the local hurts a lot more than just the Quinke itself.

3. Wherever possible, convert to a 25G quinke with a bent tip instead of a 22G. It's a little more finesse to steer (more bevel control vs fulrum), but it hurts WAY less. Unless I need more than 3.5 inches to get to my target, I'm using a 25G for everything. I use 20G RF cannulas, so I'll use local first for those.

If you want to confirm, next time you do a bilateral SIJ or facet explain to the patient you're trying new techniques to make it hurt less and do one side one way and the other side a different way. Ask the patient which side hurt more.

I use 25G for everything that a 3.5 inch can reach as well, I think they’re more comfortable.

I’ve tried the “one side local, one side no local”, the first side always hurts more no matter what, psych I think is more important that needle gauge or skin local.

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[sloh]

How many butterballs don’t need a needle bigger than 25 gauge?

 

[xvaderx]

nobody NEEDS it

I think you missed the larger point.

But let's play devil's advocate:

Nobody NEEDS mbb or RF

 

[SSdoc33]

I think you missed the larger point.

But let's play devil's advocate:

Nobody NEEDS mbb or RF

i didnt miss the point.

the point is that sedation REALLY should not even be offered, except for SCS / kypho / etc. if your patients need sedation for ESI, MBB, or RF, then they really need psych, not a needle. if they say they wont get a shot without sedation, then they should find that elsewhere

 

[macman]

I would differ and say MAC is not reasonable for anything we do other than implants.

It sounds like you prefer not to use sedation with RFA, which is fine. To say it is unreasonable is quite different. Are you saying the Mayo Clinic or every other major med center that does IV sedation for RFA is UNREASONABLE, or just that you disagree with their approach? On what basis is it unreasonable?

 

[Ronin1]

It sounds like you prefer not to use sedation with RFA, which is fine. To say it is unreasonable is quite different. Are you saying the Mayo Clinic or every other major med center that does IV sedation for RFA is UNREASONABLE, or just that you disagree with their approach? On what basis is it unreasonable?

I’m ok with minimal IV sedation if requested. I’m not Ok with MAC anesthesia as it is excessive for the level of these procedures. Often in my experience the anesthesiologist/AA/CRNA obtunds these patients. In many instances the addition of MAC adds significant cost to the patient as well.

 

[nvrsumr]

I stopped using local(except rf and scs) based on Recs from this forum. Speeds up the process and my patients never noticed the change. Never 22g unless I need an 8 in which is pretty rare.

 

[bedrock]

Appreciate the tips, but I've tried most of them.

I don't do med mx anymore, so most of my pts are chronic opioid naive. I was actually thinking that having to tolerate chronic pain and having opioids in their system increases procedure tolerance.

The typical screamers are already anxious and the psychological effect of not using local makes it hurt worse it seems.

Did 25s for a year or two. Requires more adjustments, which makes procedure take longer, more fluoro, at least for me. I also like the lower level of resistance injecting though 22s.

Like the bigger burn of 18s.

Agree with this. I found that 25G take more adjustments, more time, more radiation. Other than MBB (still 25G), I do all my procedures with a 23G, which performs like a 22G, IMO, but is still a bit more gentle. Larger patients still need a 22G, 5-7in. I don't use local for 25G, but I do for 23-22G quincke/18G touhy.

Also agree with the bigger burn of the 18G, I used those for all my spine RFA, and I use 16G for peripheral joint RFA.

 

[PinchandBurn]

It sounds like you prefer not to use sedation with RFA, which is fine. To say it is unreasonable is quite different. Are you saying the Mayo Clinic or every other major med center that does IV sedation for RFA is UNREASONABLE, or just that you disagree with their approach? On what basis is it unreasonable?

I think this is well stated.

MAC is likely overkill for a RFA, esi,mbb.

An RFA can really hurt. I have rarely sedated for ESI, never for a MBB. That stated, many of these patients are coming to you because they are in a hyperalgesic state. To not give sedation to an already rev'd up nervous patient and nervous system doesnt make sense. I think people have their opinions as MACMAN stated, but I dont think it's inherently wrong.

 

[deleted875186]

I personally think the true value of oral Ativan or Valium is underestimated. If they take it before coming to the clinic it really does work pretty well.

 

[Laryngospasm]

I have done thousands of rfas with and without sedation.. I very rarely have anyone complain without sedation and they are not obtunded and can answer questions, go home quicker, less cost , less turn over. Valium or Ativan is great. Sedation is simply not needed for most rfas.

 

[TIVAndy]

I personally think the true value of oral Ativan or Valium is underestimated. If they take it before coming to the clinic it really does work pretty well.

how do u consent for procedure if they took ativan or valium before coming in clinic?

 

[powermd]

I've done kyphoplasty without sedation, never sedate for SCS, and do 99% of RF without sedation. The nervous folks get 5-10 mg Valium. Aside from an occasional freak out, most patients do just fine without sedation if you use adequate local and good technique. Most of my spinal procedures are with 25g needles, not 22. There's a world of difference between the two.

 

[gator2886]

We contract with an anesthesiology group at our asc. For years they have been telling us that private insurance companies (and definitely Medicare) do not pay them for conscious sedation for pain management procedures. In light of that, I either don’t use it or tell the patients it will cost them $250 if they want it. Some of them opt to pay it. I will give the real anxious people a little po Xanax or Ativan prior to the procedure to get them through it. Most patients wind up telling me that the procedure was fine and that they can’t believe their friend or relative “needed to be sedated for it”

Dr. Ice, We provide IV sedation for our patients in our ASC. We do NOT charge for it. I was told it was "bundled" into the bill for the facility fee....Our billing office was "nervous" to charge for it..Thougts?

 

[deleted875186]

how do u consent for procedure if they took ativan or valium before coming in clinic?

I just have them consent when they get there. I’ve already talked about the procedure in the clinic on the last visit anyway.

 

[deleted875186]

how do u consent for procedure if they took ativan or valium before coming in clinic?

I personally don’t think an oral benzo makes someone non consentable. The clinic im at is generally fine with it, I would be interested if other people have the patient wait till they come to the clinic tk take an oral benzo? To me there no way it’ll work unless they sit there for 30 mins to wait after they take it.

 

[Dr. Ice]

Dr. Ice, We provide IV sedation for our patients in our ASC. We do NOT charge for it. I was told it was "bundled" into the bill for the facility fee....Our billing office was "nervous" to charge for it..Thougts?

Not sure if this a geographic thing or not, but one my colleagues in north jersey told me that bcbs and Aetna absolutely don’t cover conscious sedation for any pain management procedure. I have no idea, and I’m not an anesthesiologist. Maybe they are ripping everyone off. For what it’s worth, not offering sedation has made me a better “technician” over the last few years

 

[deleted131481]

I personally don’t think an oral benzo makes someone non consentable. The clinic im at is generally fine with it, I would be interested if other people have the patient wait till they come to the clinic tk take an oral benzo? To me there no way it’ll work unless they sit there for 30 mins to wait after they take it.

I personally agree with you. I'm not sure about the implications of a consent issue coming up and patient claiming they signed it after taking a sedative.

I try to get consent signed at the clinic visit, or tell them to wait to take the valium after signing consent and there's usually 20+ minutes to go. For various reasons our clinic flow is fairly inefficient so this doesn't tend to get in the way of a relatively slow pace.

 

[DrMDAware]

I have done thousands of rfas with and without sedation.. I very rarely have anyone complain without sedation and they are not obtunded and can answer questions, go home quicker, less cost , less turn over. Valium or Ativan is great. Sedation is simply not needed for most rfas.

Good to know.

When they take PO benzos the night before or day of the procedure can they still drive themselves back or do you have them use a driver?

 

[deleted875186]

Good to know.

When they take PO benzos the night before or day of the procedure can they still drive themselves back or do you have them use a driver?

Don’t you have them arrange for a ride home anyway with an injection?

 

[callmeanesthesia]

Good to know.

When they take PO benzos the night before or day of the procedure can they still drive themselves back or do you have them use a driver?

Driver required for all spine injections anyway, in my practice. Yes, it’s overkill for some injections, but otherwise it creates confusion for patients. Also, even for things you would t expect like SI joints I’ve had one or two get leg weakness after.

Under age 65: Xanax 0.5 mg tab #2. Take one tab 2 hours prior to procedure, repeat in 1 hour if needed. DO NOT DRIVE AFTER TAKING
Over age 65, same except 0.25 mg tabs.
For patients who had a hard time with the branch blocks I will also prescribe one 5 mg Norco. A few (less than 5%, probably) choose to have the RF done at the ASC with IV sedation.

 

[RoloTomassi]

Driver only if sedation (all types, including PO). If any weakness, must hang out for a bit or call driver.

I don't have a problem with getting consent after PO.

Xanax 1 mg + two Tylenol 3s, 1 hour before. I use this regimen because scheduler can call in. If I think that won't cut it, I'll write Xanax 2 mg or Valium 5-10 mg + hydro/oxy 5-10 mg.

 

[DrMDAware]

Don’t you have them arrange for a ride home anyway with an injection?

If local then no.

 

[Laryngospasm]

It’s hospital policy for them to have a driver after spine procedures. At my old practice I would watch them for 30 minutes as long as there were. O issues they could drive. Having a driver is most likely overkill but it doesn’t hurt although sometimes people struggle to find someone.

 

[bedrock]

no sedation- may drive themselves
PO or IV sedation- must have driver, IV sedation must fast after midnight.

I do 99.9% of epidurals without local in the primary injectate. Medically, I think it's reasonable to drive home after a procedure done under local only and I find that this policy helps motivate patients to have their procedures with local only, particularly since we have to eat the cost of IV sedation from BCBS.