pain procedures - local only vs sedation

[drpainfree]

Board certified anesthesiologist here, practice with two other board certified anesthesiologists and all three are boarded in pain. As a group we do 800 injections a month or so. We don’t offer sedation. We also have the best online ratings in our market. We also surveyed patients and asked what hurt worse, IV sticks they’ve gotten in the past vs the injection they just had and the IV was more painful or about the same in the overwhelming majority. I truly feel if you find patients needing or wanting sedation for procedures then you need to see what you’re doing in procedures that are different from some of the rest of us that make them hurt or take a hard look at your bedside manner. Also, I would welcome anyone who would like to come see if in action, maybe you can pick up some tricks.

In the old days, an ob who refused to offer labor epidural would have said pretty much the same thing. However, nowaday labor epidural is offered as a standard unless 1) contraindication 2) patient refusal

My question is, do you make an informed consent that patients have the OPTION to get conscious sedation with you if they prefer? For example, they had prior incidence of vasovagal response? Or they just simply tell you she/he is too anxious to do the procedures?

I'm not talking about the procedures that do not need sedation as recommended by ASA position statement. I am talking about the ones ASA says conscious sedation should be AVAILABLE to patients who have significant anxiety or are prone to complications from anxiety, such as vasovagal, can't lay still, etc.

As I said, however you practice in your PP is up to you. However, do you make the effort to inform your patient the option exists?

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[NOSfan]

n.b. Not an attorney, but it seems like 'Standard of Care' is being thrown out here so..........

West J Emerg Med. 2011 Feb; 12(1): 109–112.

PMCID: PMC3088386
PMID: 21691483
The Standard of Care: Legal History and Definitions: the Bad and Good News
Peter Moffett, MD and Gregory Moore, MD, JD

Go to:
Abstract
The true meaning of the term “the standard of care” is a frequent topic of discussion among emergency physicians as they evaluate and perform care on patients. This article, using legal cases and dictums, reviews the legal history and definitions of the standard of care. The goal is to provide the working physician with a practical and useful model of the standard of care to help guide daily practice.

SUMMARY AND RECOMMENDATIONS
In conclusion, the concept of the standard of care has evolved over the years and will continue to change as legal theory in this area develops. Hopefully this will allow for increased certainty and clarity, which is the stated goal of all laws. The bad news is that there are several important cases where the suggestion is that even if a practice is not the standard, if it is reasonable, a physician can be found culpable for not pursuing that course of action. The good news for physicians is that in more recent cases the courts have frequently upheld that the standard of care is what a minimally competent physician in the same field would do in the same situation, with the same resources. These recent cases also note that bad outcomes are to be expected, and all entities can not be expected to be diagnosed. Finally, clinical practice guidelines are being used more frequently in court cases as support for the standard of care; however, their acceptance and uses are continually changing and decided on a case-by-case basis (Table 2).

Table 2.
Historical development of the Standard of Care

Initial Definition
  Based on custom
  That which is typically done is what is considered standard
The 20th Century Definition (Helling v. Carey; The TJ Hooper)
  That which is customarily done plus anything that seems reasonable even if not typically done
The Modern Definition (Hall v. Hilburn; McCourt v. Abernathy; Johnston v. St. Francis Medical Center)
  That which a minimally competent physician in the same field would do under similar circumstances​

Remainder of article here: The Standard of Care: Legal History and Definitions: the Bad and Good News

 

[SommeRiver]

Did you honestly ask a pt to stop talking so you could "concentrate on the procedure?" Me and my pts get to know each other during procedures. We talk about life and discuss movies, books, the news, etc.

What are you talking about?

 

[paindoc007]

Did you honestly ask a pt to stop talking so you could "concentrate on the procedure?" Me and my pts get to know each other during procedures. We talk about life and discuss movies, books, the news, etc.

What are you talking about?

This.

Drpainfree - I think you think you’re more altruistic then you really are. Consensus, guidelines, and standard of care is clear here. It’s ok to admit to being wrong man.

I got trained to use particulates in my tfesi for instance. Started that way when I got in practice. Soon I figured out i was wrong, and doing so not best interest of the patient, not as safe, and not backed in the guidlines... So I changed. You can too.

 

[SSdoc33]

spinal

Did you honestly ask a pt to stop talking so you could "concentrate on the procedure?" Me and my pts get to know each other during procedures. We talk about life and discuss movies, books, the news, etc.

What are you talking about?

i ask them to stop talking during cervical epidurals.

other times i ask them to stop talking because i genuinely dislike them. usually, it not an issue

 

[drpainfree]

This.

Drpainfree - I think you think you’re more altruistic then you really are. Consensus, guidelines, and standard of care is clear here. It’s ok to admit to being wrong man.

I got trained to use particulates in my tfesi for instance. Started that way when I got in practice. Soon I figured out i was wrong, and doing so not best interest of the patient, not as safe, and not backed in the guidlines... So I changed. You can too.

Consensus, guideline and standard of care in local community had been presented and discussed above. If you cannot read, I cannot help you.

I am not sure what your point is about particulate. I changed my practice of using depomedrol to dex when I practiced in PP for a few years. What does it have anything to do with providing good medicine to your patients, or at least let your patients make informed consent about availability of conscious sedation.

I am talking about this as a 1) fellowship-trained, board-certified pain physician, 2) as an anesthesiologist who have been giving sedation for various types of spinal injections requested by various pain physicians, 3) as a patient who had received multiple spinal injections myself.

 

[SommeRiver]

i ask them to stop talking during cervical epidurals.

other times i ask them to stop talking because i genuinely dislike them. usually, it not an issue

Hahahaha...Touche.

 

[drpainfree]

Did you honestly ask a pt to stop talking so you could "concentrate on the procedure?" Me and my pts get to know each other during procedures. We talk about life and discuss movies, books, the news, etc.

What are you talking about?

yes, I do. when the patient's talking so loud and non-stop and become disruptive to my instruction to c-arm operator.

but not a problem when I started offering conscious sedation to them.

 

[SommeRiver]

Consensus, guideline and standard of care in local community had been presented and discussed above. If you cannot read, I cannot help you.

I am not sure what your point is about particulate. I changed my practice of using depomedrol to dex when I practiced in PP for a few years. What does it have anything to do with providing good medicine to your patients, or at least let your patients make informed consent about availability of conscious sedation.

I am talking about this as a 1) fellowship-trained, board-certified pain physician, 2) as an anesthesiologist who have been giving sedation for various types of spinal injections requested by various pain physicians, 3) as a patient who had received multiple spinal injections myself.

I think there are plenty of ppl here who have enough experience that your credentials don't really matter.

 

[drpainfree]

I think there are plenty of ppl here who have enough experience that your credentials don't really matter.

actually, if you have been working as an anesthesiologist providing sedation under the request of non-fellowship trained pain management physician to give propofol for deep sedation, you'd know credentials matter.

Regardless, I have been trained to use conscious sedation for most if not all spinal procedures. I am not deviating from my fellowship training.

On the other hand, if you have been trained to provide conscious sedation for spinal procedures in your training, yet deviate your practice later in your PP by not obtaining informed consent from your patients that they do NOT wish to receive conscious sedation, you have one more issue to defend yourself when an anxiety-related complication happens in your practice.

"I just think they don't need conscious sedation" is not going to fly.

 

[drpainfree]

for guys quoting SIS statement conscious sedation with midazolam/fentanyl might affect diagnostic values of MNBB either cervical or lumbar, here's another study refuting the SIS claim published by ASIPP.

Systematic Review of the Role of Sedation in Diagnostic Spinal Interventional Techniques
Howard S. Smith, MD1, Pradeep Chopra, MD2, Vikram B. Patel, MD3, Michael E. Frey, MD4, and Rahul Rastogi, MD5

Conclusion: This systematic review provides no significant evidence of the influence of se-dation either with midazolam or fentanyl in the evaluation of cervical and lumbar facet joint pain with controlled cervical and lumbar facet joint nerve blocks with an indicated evidence of Level II-1, with application of stringent criteria of at least 80% pain relief and the ability to perform previously painful movements after the diagnostic blocks.

See article attached.

I personally stay away from fentanyl for most situations, including MNBB. Again as I said above, I do not make the diagnostic determination until 1 to 7 days after the MNBB.

Midazolam has onset of 2 minutes, peak in about 5 minutes, and wears off in 1-2 hours.

You can't beat it with any oral benzo. It's the perfect agent of choice for conscious sedation for spinal procedures.

 

[Ducttape]

please stop using labor epidurals as an example. the problem with this example is that labor is painful and long lasting, unlike our procedures. the time frame of labor is hours. the time frame for an interventional spine procedure is minutes, or 25 seconds in lobelsteves hands.

your own phrases suggest that you are not, well, thinking completely straight:

"You owe it to your patient to give them the option for the reasons of benefit, risk, alternative and cost."
""I just think they don't need conscious sedation" is not going to fly."
"What does it have anything to do with providing good medicine to your patients, or at least let your patients make informed consent about availability of conscious sedation."
"My question is, do you make an informed consent that patients have the OPTION to get conscious sedation with you if they prefer? For example, they had prior incidence of vasovagal response? Or they just simply tell you she/he is too anxious to do the procedures?

I'm not talking about the procedures that do not need sedation as recommended by ASA position statement. I am talking about the ones ASA says conscious sedation should be AVAILABLE to patients who have significant anxiety or are prone to complications from anxiety, such as vasovagal, can't lay still, etc.

As I said, however you practice in your PP is up to you. However, do you make the effort to inform your patient the option exists?"

the highlighted comments contradict some of the others.

we do a lot of things and do not offer patients alternatives. case in point, opioid medication. if you use your above comments and apply them across the board, we need to be offering opioid medications to all patients, because we need to give them options of how to manage their pain. yet we do not. and we do not offer procedures that we are sure will not work.

yes, your second to last point is germane, but then you counter it with the last statement. if how I practice is up to you, why do I have to make the effort to inform the patient that the option exists for my practice?

 

[Dr. Ice]

actually, if you have been working as an anesthesiologist providing sedation under the request of non-fellowship trained pain management physician to give propofol for deep sedation, you'd know credentials matter.

Regardless, I have been trained to use conscious sedation for most if not all spinal procedures. I am not deviating from my fellowship training.

On the other hand, if you have been trained to provide conscious sedation for spinal procedures in your training, yet deviate your practice later in your PP by not obtaining informed consent from your patients that they do NOT wish to receive conscious sedation, you have one more issue to defend yourself when an anxiety-related complication happens in your practice.

"I just think they don't need conscious sedation" is not going to fly.

Maybe your concern about the vasovagal reactions comes from you bagging their nerves during transforaminals...

 

[SommeRiver]

actually, if you have been working as an anesthesiologist providing sedation under the request of non-fellowship trained pain management physician to give propofol for deep sedation, you'd know credentials matter.

Regardless, I have been trained to use conscious sedation for most if not all spinal procedures. I am not deviating from my fellowship training.

On the other hand, if you have been trained to provide conscious sedation for spinal procedures in your training, yet deviate your practice later in your PP by not obtaining informed consent from your patients that they do NOT wish to receive conscious sedation, you have one more issue to defend yourself when an anxiety-related complication happens in your practice.

Hands down your craziest post yet. This is an absurd statement on several levels.

I was trained with sedation too, and I'm not doing it bc it is stupid and entirely unnecessary. I guess if "they" find out I'm not doing things how I was trained I get in trouble for not using sedation? Did you really make that statement?

Your first paragraph means nothing. You said credentials matter when you do propofol for sedation at the request of non fellowship trained pain MDs? What does that even mean? I'm fellowship trained and so are most of the ppl in this thread if I had to guess. What if I didn't do a fellowship? Would that make you more correct than me? Would your opinion matter more? I would bet 90% of residents from my residency would pass the pain boards on the first attempt, so board certification doesn't always imply knowledge...I mean, look at this thread...

 

[lobelsteve]

actually, if you have been working as an anesthesiologist providing sedation under the request of non-fellowship trained pain management physician to give propofol for deep sedation, you'd know credentials matter.

Regardless, I have been trained to use conscious sedation for most if not all spinal procedures. I am not deviating from my fellowship training.

On the other hand, if you have been trained to provide conscious sedation for spinal procedures in your training, yet deviate your practice later in your PP by not obtaining informed consent from your patients that they do NOT wish to receive conscious sedation, you have one more issue to defend yourself when an anxiety-related complication happens in your practice.

"I just think they don't need conscious sedation" is not going to fly.

Anxiety related complications. You are so FOS it is laughable.

 

[NJPAIN]

I absolutely prefer to use straight local vs IV sedation for a multitude of factors. As crazy as it may sound the “culture” of pain medicine in the area becomes a factor. I believe that more practices in my area offer sedation than do not. Consequently, patients believe ( not based upon personal experience) that having a procedure without IV sedation is barbaric. If the cost of sedation is not out of pocket there is no convincing them not to go wherever they can have sedation. Rarely does “ trust me, you will do fine without sedation” fly.


Sent from my iPhone using Tapatalk

 

[drpainfree]

I absolutely prefer to use straight local vs IV sedation for a multitude of factors. As crazy as it may sound the “culture” of pain medicine in the area becomes a factor. I believe that more practices in my area offer sedation than do not. Consequently, patients believe ( not based upon personal experience) that having a procedure without IV sedation is barbaric. If the cost of sedation is not out of pocket there is no convincing them not to go wherever they can have sedation. Rarely does “ trust me, you will do fine without sedation” fly.


Sent from my iPhone using Tapatalk

I agree. "trust me you will do fine without sedation" is not convincing for most of my patients.

at the end of the day, it's not what we prefer as physicians, it's what's best for patients and let them make the informed consent, whether you think you should provide conscious sedation, or you do not think you should.

You let them know your rationale, you let them decide, and you let them walk away if they prefer sedation yet you do not feel comfortable or medically necessary.

Short of that, when you do have an anxiety-related complication that could be prevented by providing conscious sedation during the procedure, I guaranteed you will be held accountable for NOT making an informed consent with your patient.

 

[drpainfree]

Anxiety related complications. You are so FOS it is laughable.

obviously you do not understand anxiety can cause complication.

heck, you don't even think doing spinal procedures in your procedure suite is no different than doing them in an operating room, and you will be held to the same standard if a complication occurs.

but what do I expect you to know? you have zero experience providing sedation or anesthesia.

You have probably never in your life pushed versed/fentanyl/propofol/suc to any patients. You probably haven't run a code in your life time.

What do I expect?

It's like trying to teach a horse to sing, you are just not going to get it.

 

[244913]

I agree. "trust me you will do fine without sedation" is not convincing for most of my patients.

at the end of the day, it's not what we prefer as physicians, it's what's best for patients and let them make the informed consent, whether you think you should provide conscious sedation, or you do not think you should.

Do you do this sedation for free? Do you ever do it at OON ASC's?

 

[drusso]

I recently looked at my data: Full-spectrum pain/office procedure suite. I sedate 5% of my procedure patients...Median dose: 62.5 mcg FNT; 2.3 mg Versed.

 

[drpainfree]

Do you do this sedation for free? Do you ever do it at OON ASC's?

when I was doing procedures at OON ASC before, I did not get into their business aspect. I did specifically request the anesthesia to NOT use propofol.

I do bill for conscious sedation when I am providing it in office, half of time it doesn't get reimbursed by commercial payers.

 

[Dr. Ice]

obviously you do not understand anxiety can cause complication.

heck, you don't even think doing spinal procedures in your procedure suite is no different than doing them in an operating room, and you will be hold to the same standard if a complication occurs.

but what do I expect you to know? you have zero experience providing sedation or anesthesia.

You have probably never in your life pushed versed/fentanyl/propofol/suc to any patients. You probably haven't run a code in your life time.

What do I expect?

It's like trying to teach a horse to sing, you are just not going to get it.

That’s rich. That’s like saying you are ordering all the wrong procedures on patients because you’ve never been trained to do a REAL physical exam. The holier than thou argument of anesthesia docs pushing anesthesia doesn’t hold a lot of water. Just because x number of docs with poor technical skill and bad hands do shots with sedation be it minimal or whatever doesn’t mean that it should be considered any type of standard of care. FYI..there’s a lot of discussion about pain procedures not being paid for in any surgical center or hospital due to SOS.

 

[SommeRiver]

"Trust me you will be fine without sedation" is a statement...

 

[drpainfree]

Hands down your craziest post yet. This is an absurd statement on several levels.

I was trained with sedation too, and I'm not doing it bc it is stupid and entirely unnecessary. I guess if "they" find out I'm not doing things how I was trained I get in trouble for not using sedation? Did you really make that statement?

Your first paragraph means nothing. You said credentials matter when you do propofol for sedation at the request of non fellowship trained pain MDs? What does that even mean? I'm fellowship trained and so are most of the ppl in this thread if I had to guess. What if I didn't do a fellowship? Would that make you more correct than me? Would your opinion matter more? I would bet 90% of residents from my residency would pass the pain boards on the first attempt, so board certification doesn't always imply knowledge...I mean, look at this thread...

don't you realize that you are able to do what you do, all because how you were trained?

it will matter when it comes to court testimony how you were trained and how you deviate from your training when a complication occurs.

just simply saying "how I trained was stupid" will not cut it.

as for my first paragraph, you obviously don't get what I was saying. if you have done anesthesia in local communities providing anesthesia for non-fellowship trained pain physicians, you will know almost everyone of them require anesthesiologists to knock the patient out. My point was, being fellowship-trained and educated should make you understand the appropriate type of sedation to administer to your patients. It does not, however, give you the arrogance to believe you can somewhat deviate from the standard by simply calling your training as "stupid".

In fact, I would caution for saying something like that as this is public forum. Anything we're saying here is achieved permanently by services like google. In another words, what we are saying here is searchable by attorneys when really complication happens. You better have a strong defense when they find you to call your training "stupid".

 

[drpainfree]

That’s rich. That’s like saying you are ordering all the wrong procedures on patients because you’ve never been trained to do a REAL physical exam. The holier than thou argument of anesthesia docs pushing anesthesia doesn’t hold a lot of water. Just because x number of docs with poor technical skill and bad hands do shots with sedation be it minimal or whatever doesn’t mean that it should be considered any type of standard of care. FYI..there’s a lot of discussion about pain procedures not being paid for in any surgical center or hospital due to SOS.

why? you think anesthesia-trained pain physicians who had gone through formal fellowship-training don't do physical exams before ordering a procedure?

That's interesting.

My initial consultation is 45 to 60 minutes long. How long is yours?

You want to start the pissing contest to diminish the discussion to who a better doctor is?

If you are going to make an inflammatory post, at least use something like EMG/NCS. I would agree with you that as anesthesia-trained pain physician, I will take the input of PMR-trained pain physician on the necessity of EMG/NCS any time of day.

Despite the fact EMG/NCS hurts, detested by every patient who gets it.

On the other hand, PMR-trained pain guys somehow think they have full understanding of sedation and anesthesia and qualified to talk about medical necessity of it, despite the recommendation from ASA saying otherwise.

 

[SommeRiver]

don't you realize that you are able to do what you do, all because how you were trained?

it will matter when it comes to court testimony how you were trained and how you deviate from your training when a complication occurs.

just simply saying "how I trained was stupid" will not cut it.

as for my first paragraph, you obviously don't get what I was saying. if you have done anesthesia in local communities providing anesthesia for non-fellowship trained pain physicians, you will know almost everyone of them require anesthesiologists to knock the patient out. My point was, being fellowship-trained and educated should make you understand the appropriate type of sedation to administer to your patients. It does not, however, give you the arrogance to believe you can somewhat deviate from the standard by simply calling your training as "stupid".

In fact, I would caution for saying something like that as this is public forum. Anything we're saying here is achieved permanently by services like google. In another words, what we are saying here is searchable by attorneys when really complication happens. You better have a strong defense when they find you to call your training "stupid".

I don't have time for this.

 

[Dr. Ice]

why? you think anesthesia-trained pain physicians who had gone through formal fellowship-training don't do physical exams before ordering a procedure?

That's interesting.

My initial consultation is 45 to 60 minutes long. How long is yours?

You want to start the pissing contest to diminish the discussion to who a better doctor is?

If you are going to make an inflammatory post, at least use something like EMG/NCS. I would agree with you that as anesthesia-trained pain physician, I will take the input of PMR-trained pain physician on the necessity of EMG/NCS any time of day.

Despite the fact EMG/NCS hurts, detested by every patient who gets it.

On the other hand, PMR-trained pain guys somehow think they have full understanding of sedation and anesthesia and qualified to talk about medical necessity of it, despite the recommendation from ASA saying otherwise.

We might not have a full understanding of anesthesia but we have a full understanding that 90% of spine procedures which includes 90% of “interventional” whatever you wanna call it doesn’t require any sedation.

Btw emgs are longer “procedurally” and no one sedates anyone for that

 

[drpainfree]

We might not have a full understanding of anesthesia but we have a full understanding that 90% of spine procedures which includes 90% of “interventional” whatever you wanna call it doesn’t require any sedation.

- "Doc, in front of this jury, please substantiate your claim that you have FULL understanding that 90% of spine procedures does NOT require any sedation?"
- "Doc, please tell me where you obtained your FULL understanding from?"
- "Doc, who do you think have more education, training and experience on the necessity of conscious sedation, you or ASA?"
- "Doc, please read it out for me what ASA says about the necessity of conscious sedation for spinal injections?"

Btw emgs are longer “procedurally” and no one sedates anyone for that

- see, as an anesthesia-trained pain physician, I would respond your statement by saying, "thanks, Dr. Ice for your information".
Why? Because I don't pretend I have FULL understanding of how much EMG/NCS hurts and whether or not sedation is necessary.

 

[Dr. Ice]

- "Doc, in front of this jury, please substantiate your claim that you have FULL understanding that 90% of spine procedures does NOT require any sedation?"
- "Doc, please tell me where you obtained your FULL understanding from?"
- "Doc, who do you think have more education, training and experience on the necessity of conscious sedation, you or ASA?"
- "Doc, please read it out for me what ASA says about the necessity of conscious sedation for spinal injections?"



- see, as an anesthesia-trained pain physician, I would respond your statement by saying, "thanks, Dr. Ice for your information".
Why? Because I don't pretend I have FULL understanding of how much EMG/NCS hurts and whether or not sedation is necessary.

This is absurd. Your fellow anesthesia colleagues on here have called you out on your ludicrous statements.

I can tell you as a pmr trained doc who does emgs and what you do...90% and probably over of patients are not sedated for any of it

 

[drpainfree]

I recently looked at my data: Full-spectrum pain/office procedure suite. I sedate 5% of my procedure patients...Median dose: 62.5 mcg FNT; 2.3 mg Versed.

The option of receiving conscious sedation is determined on a case-by-case basis. Whether it's 5%, or 90% is not set in stone by ASA. However, do understand it's part of informed consent that the patient should be told that conscious sedation is available if they feel they are too nervous or anxious to undergo the procedure without it.

I can't emphasize enough this point.

This is like GI guy did an upper GI without any sedation and the patient stroke out due to anxiety/stimulation. It turns out he/she never even inform the patient the option of conscious sedation is available.

 

[drpainfree]

This is absurd. Your fellow anesthesia colleagues on here have called you out on your ludicrous statements.

I can tell you as a pmr trained doc who does emgs and what you do...90% and probably over of patients are not sedated for any of it

Ludicrous statement? You are calling ASA position statement ludicrous?

Just because you do not sedate, does not mean they should not be sedated, or at least be offered the option as the part of informed consent?

 

[drpainfree]

Ludicrous statement? You are calling ASA position statement ludicrous?

Just because you do not sedate, does not mean they should not be sedated, or at least be offered the option as the part of informed consent?

n.b. Not an attorney, but it seems like 'Standard of Care' is being thrown out here so..........

West J Emerg Med. 2011 Feb; 12(1): 109–112.

PMCID: PMC3088386
PMID: 21691483
The Standard of Care: Legal History and Definitions: the Bad and Good News
Peter Moffett, MD and Gregory Moore, MD, JD

Go to:
Abstract
The true meaning of the term “the standard of care” is a frequent topic of discussion among emergency physicians as they evaluate and perform care on patients. This article, using legal cases and dictums, reviews the legal history and definitions of the standard of care. The goal is to provide the working physician with a practical and useful model of the standard of care to help guide daily practice.

SUMMARY AND RECOMMENDATIONS
In conclusion, the concept of the standard of care has evolved over the years and will continue to change as legal theory in this area develops. Hopefully this will allow for increased certainty and clarity, which is the stated goal of all laws. The bad news is that there are several important cases where the suggestion is that even if a practice is not the standard, if it is reasonable, a physician can be found culpable for not pursuing that course of action. The good news for physicians is that in more recent cases the courts have frequently upheld that the standard of care is what a minimally competent physician in the same field would do in the same situation, with the same resources. These recent cases also note that bad outcomes are to be expected, and all entities can not be expected to be diagnosed. Finally, clinical practice guidelines are being used more frequently in court cases as support for the standard of care; however, their acceptance and uses are continually changing and decided on a case-by-case basis (Table 2).

Table 2.
Historical development of the Standard of Care

Initial Definition
  Based on custom
  That which is typically done is what is considered standard
The 20th Century Definition (Helling v. Carey; The TJ Hooper)
  That which is customarily done plus anything that seems reasonable even if not typically done
The Modern Definition (Hall v. Hilburn; McCourt v. Abernathy; Johnston v. St. Francis Medical Center)
  That which a minimally competent physician in the same field would do under similar circumstances​

Remainder of article here: The Standard of Care: Legal History and Definitions: the Bad and Good News

Thank you for the citation. Interesting read.

The Modern Definition of Standard of Care
(Hall v. Hilburn; McCourt v. Abernathy; Johnston v. St. Francis Medical Center)  
That which a minimally competent physician in the same field would do under similar circumstances

I would say, the minimally competent physician in the same field would do in the case of spinal injection with regard to conscious sedation is making informed consent on the risk, benefit and alternative of conscious sedation and let patient sign off on the dotted line. Without this informed consent, if an anxiety-related complication that could have been prevented by proper sedation and monitoring occurs, you would have not met the "minimum competency" requirement.

 

[nvrsumr]

I am going to to do a little poll at my next state pain society meeting regarding conscious sedation in my community. This a a good discussion and based on the board the standard has swung strongly to never sedate. Part of reason I spend time on here.

The collollary of never sedation is these procedures never need or considering cost should be done in an asc or hospital. Will we get a SIS position statement affirming this soon as well?

 

[drpainfree]

I am going to to do a little poll at my next state pain society meeting regarding conscious sedation in my community. This a a good discussion and based on the board the standard has swung strongly to never sedate. Part of reason I spend time on here.

The collollary of never sedation is these procedures never need or considering cost should be done in an asc or hospital. Will we get a SIS position statement affirming this soon as well?

I tried to search on ASIPP. It seems they don't have a guideline on conscious sedation on spinal procedures.

ASA position statement is pretty clear: conscious sedation is indicated for right patients.

SIS says sedation is not routinely needed. Yet it does not define the type of sedation. In Factfinder, it actually lumped deep sedation with conscious sedation into one encompassing term of "sedation". From anesthesiology's perspective, this diminish the credibility of SIS guideline.

I agree. This "never sedation" has far-reaching consequence. Meaning, it would open the flood gate of denying procedures to be done at ASC (btw, it won't happen). I am sure most guys on this forum would have no problem with that since we don't do procedures at ASC. However, it's not the norm as of now. This is why I said standard of care in local communities at present is provision of sedation of various depth, with majority of procedures done at ASC.

 

[lobelsteve]

https://www.google.com/url?sa=t&sou...FjAJegQIBhAB&usg=AOvVaw10avjehTduL7_r8rZK7uhu

 

[drusso]

dirtbag

I'd expect nothing less from you....

 

[drpainfree]

https://www.google.com/url?sa=t&source=web&rct=j&url=https://depts.washington.edu/asaccp/sites/default/files/pdf/Click%20here%20for%20_32.pdf&ved=2ahUKEwiqu-vZ7_zcAhVDNX0KHZjMBQcQFjAJegQIBhAB&usg=AOvVaw10avjehTduL7_r8rZK7uhu

if you were going to quote a study, at least provide the full article for everyone to read and digest.

See article attached.

Conclusion
"Traumatic spinal cord injury was more common in patients who received sedation or general anesthesia and in those who were unresponsive during the procedure."

Conscious sedation is defined as "responsive" to verbal command.

ASA positional statement is clear on the medical necessity of "conscious sedation", recommends against deep sedation or general anesthesia.

But then again, to understand the difference of all these, you have to understand different depth of sedation. I attached here an article in my post yesterday from ASA explaining different depth of sedation. Please read it so you can make an educated and intelligent discussion on this topic.

 

[nvrsumr]

I assumed that comment was -magenta-with a 5% sedation rate?

 

[drpainfree]

if you were going to quote a study, at least provide the full article for everyone to read and digest.

See article attached.

Conclusion
"Traumatic spinal cord injury was more common in patients who received sedation or general anesthesia and in those who were unresponsive during the procedure."

Conscious sedation is defined as "responsive" to verbal command.

ASA positional statement is clear on the medical necessity of "conscious sedation", recommends against deep sedation or general anesthesia.

But then again, to understand the difference of all these, you have to understand different depth of sedation. I attached here an article in my post yesterday from ASA explaining different depth of sedation. Please read it so you can make an educated and intelligent discussion on this topic.

Here I am attaching it again.

 

[drpainfree]

btw, ASA position statement came out/amended in 2016, 5 years after rathmell study in 2011.

You don't think they have taken into the consideration of their own closed claim study when issuing guideline?

 

[drusso]

I assumed that comment was -magenta-with a 5% sedation rate?

No...really 5%...

 

[nvrsumr]

I meant the dirtbag comment was magenta...

 

[Ducttape]

you keep emphasizing the point of depth of anesthesia.


if you delve deeply into the data, fully 75% of those with spinal cord injury were responsive during the procedure, and 64% got sedation only (only ONE patient got general anesthesia in this study).

and to finish your comments, which you reread what you posted and emphasize a different phrase...

Advocates state that sedation allays anxiety, allowing treatment in a population that could not otherwise receive treatment; and renders patients temporarily immobile during these procedures and reduces the risk of sudden movement, thereby
potentially decreasing the risk of neural injury.10,24–26 Opponents cite ample anecdotes in the form of case reports, in which a responsive patient reported symptoms as a needle contacted a peripheral nerve or the spinal cord itself, allowing the procedure to be discontinued and causing no permanent neural injury.10,24,25,27,28 Indeed, a recent consensus group concluded that warning signs, such as paresthesia or pain on injection of a local anesthetic, inconsistently herald needle contact with the spinal cord; however, some patients do report warning signs of needle-to neuraxis proximity. The group warned that general anesthesia or heavy sedation removes any ability for the patient to recognize and report warning signs; they recommended that neuraxial regional anesthesia should rarely be performed in adult patients whose sensorium is compromised by general anesthesia or heavy sedation.10 Although imperfect, the current analysis supports the notion that use of sedation or general anesthesia and conduct of cervical procedures in unresponsive patients are associated with a significant increase in the likelihood of permanent spinal cord injury.

 

[paindoc007]

the dirtbag comment was wrg to your Trotskyite facial hair, drusso. I thought you loved the free market..this is a free market of ideas and verbal badinage. This forum is the Koch brothers' PDE2 inhibitor enabled wet dream

Confusing insult

 

[Dr. Ice]

- "Doc, in front of this jury, please substantiate your claim that you have FULL understanding that 90% of spine procedures does NOT require any sedation?"
- "Doc, please tell me where you obtained your FULL understanding from?"
- "Doc, who do you think have more education, training and experience on the necessity of conscious sedation, you or ASA?"
- "Doc, please read it out for me what ASA says about the necessity of conscious sedation for spinal injections?"


- see, as an anesthesia-trained pain physician, I would respond your statement by saying, "thanks, Dr. Ice for your information".
Why? Because I don't pretend I have FULL understanding of how much EMG/NCS hurts and whether or not sedation is necessary.

Yeah you’re right..I should be very concerned that because I don’t sedate patients most of the time that I will have to defend myself in a court of law that by some freak accident, some overly anxious person had an anxiety attack or a vasovagal episode that somehow led to a catastrophic outcome from their medical branch block. That makes a lot of sense. You must have a way more wacked our patient population than me...and I thought I saw some nut jobs.

I think I’m done with this convsersation.

 

[drpainfree]

you keep emphasizing the point of depth of anesthesia.


if you delve deeply into the data, fully 75% of those with spinal cord injury were responsive during the procedure, and 64% got sedation only (only ONE patient got general anesthesia in this study).

and to finish your comments, which you reread what you posted and emphasize a different phrase...

I'm glad we're discussing the actual science and data. Let's take a closer look at the rathmell study.

table 5 on page 923,

Out of 54 patients where "responsiveness" during the procedure was determined, 32 had spinal cord injury, and 22 had no spinal cord injury. Out of 45 patients who were responsive during the procedure, 24 had SCI and 21 had no SCI. There is a small difference, but not really significant.

On the other hand, for patients who were NOT responsive, 8 out of 9 had SCI and 1 out 9 had no SCI. The odds ratio is 8 to 1.

The same pattern is seen above. 24 out 58 patients who received "sedation" and "general anesthesia" had SCI, vs. 4 patients who did NOT have SCI. Again the odd ratio is 6 to 1.

Now let's look how sedation and "responsiveness" are defined in the study.

Paragraph 2, Page 920,

"Patients were considered responsive during the procedure if no sedation or only light sedation was used. If moderate or deep sedation or general anesthesia was used during the procedure, the patient was considered not responsive".

There's fatal flaw here that caused the confusion and mix-up of moderate sedation and deep sedation.

Again ASA definition,

"Minimal Sedation (Anxiolysis) is a drug-induced state during which patients respond normally to verbal commands. Although cognitive function and physical coordination may be impaired, airway reflexes, and ventilatory and cardiovascular functions are unaffected.

Moderate Sedation/Analgesia (“Conscious Sedation”) is a drug-induced depression of consciousness during which patients respond purposefully** to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained."

Deep Sedation/Analgesia is a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully** following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.

General Anesthesia is a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired."

The anesthesiologists here should all agree what separates moderate/conscious sedation (with 2-4 mg of midazolam plus/minus 25mcg of fentany for example) from deep sedation (with 100mg of propofol for example) is 1) responsiveness to verbal command easily or light tactile stimulation vs. repeated/painful stimulation 2) patient in conscious sedation does not lose airway, vs. easily impaired in deep sedation.

Rathmell study suggests that if patient remains responsive, the risks of SCI is significantly less (about 1/8 to 1/6 of probability) than someone else who were unresponsive during a CESI procedure.

The clarification here is, moderate/conscious sedation is by definition the provision of sedation depth for patients to be easily responsive. Rathmell grouped patients who received moderate/conscious sedation with patients who received deep sedation and general anesthesia into one category of "unresponsive patients".

 

[drpainfree]

Yeah you’re right..I should be very concerned that because I don’t sedate patients most of the time that I will have to defend myself in a court of law that by some freak accident, some overly anxious person had an anxiety attack or a vasovagal episode that somehow led to a catastrophic outcome from their medical branch block. That makes a lot of sense. You must have a way more wacked our patient population than me...and I thought I saw some nut jobs.

I think I’m done with this convsersation.

Yes. It's basically what's going to happen.

You will have to defend yourself on the "freakish" nature of anxiety-related complications, such as vasovagal rxn, hypertensive crisis, inability to remain still resulting inadvertent needle trauma, etc.

Kennedy study I quoted above shows the incidence rate of vasovagal reaction in spinal procedure is 3.3% with 95 CI of 2.9 to 3.8%. It is not huge, but not small either, 1 out 25, roughly.

However, in patients who had vasovagal reaction, the rate of recurrent vasovagal rxn is a whopping 25% if spinal procedures were done without conscious sedation! That's 1 out 4 of your high risk patients who are prone to vasovagal, young, healthy, male, mostly.

However, with moderate sedation, the rate of recurrent vasovagal rxn is significantly reduced, so much so to 0%.

chew on that for a moment:

Suppose you have a young, stocky male patient who never had spinal injections before, and you never bothered to inquire about his past vasovagal rxn of any type (in fact he felt nauseated with a blood draw 3 weeks ago, but didn't tell anyone voluntarily), and you never bother to offer him the option of sedation, and you never bother to monitor his vital signs during your procedure.

Statistically-speaking, you have 1 out of 4 probability during your spinal procedure he will faint, vomit, and even aspirate on your table. The best case scenario, you recognize the reaction quickly and put some ammonia salt on his nose, and he comes around. You try to proceed with VS monitoring and realize his BP/HR still sinking with your needle insertion, you reluctantly abort the procedure and repeat the procedure under sedation. Another possible scenario, he develops an aspiration pneumonitis because he is not NPO and vomits (by the way, would be completely avoided by requiring NPO for conscious sedation). Even more traumatically, he could develop bronchospasm from aspiration, desaturate (of course, you wouldn't know because you don't bother to monitor VS during spinal procedure), ends up in ICU for pulmonary edema (if you are able to recognize the emergency and call EMT immediately).

ALL of these could have been avoided based on statistics, by simply inserting an IV, and push a few mg of versed and provide appropriate level of VS monitoring.

Or you can at least defend yourself by telling plaintiff's attorney and jury that you had, at the minimum, obtained the informed consent from the patient for which the patient opted out of receiving conscious sedation for the procedure.

Yet, you didn't do any of these, simply because as you stated above vasovagal reaction is some sort of "freak accident".

Best luck, don't say you haven't been warned and educated.

 

[SSdoc33]

Yes. It's basically what's going to happen.

You will have to defend yourself on the "freakish" nature of anxiety-related complications, such as vasovagal rxn, hypertensive crisis, inability to remain still resulting inadvertent needle trauma, etc.

Kennedy study I quoted above shows the incidence rate of vasovagal reaction in spinal procedure is 3.3% with 95 CI of 2.9 to 3.8%. It is not huge, but not small either, 1 out 25, roughly.

However, in patients who had vasovagal reaction, the rate of recurrent vasovagal rxn is a whopping 25% if spinal procedures were done without conscious sedation! That's 1 out 4 of your high risk patients who are prone to vasovagal, young, healthy, male, mostly.

However, with moderate sedation, the rate of recurrent vasovagal rxn is significantly reduced, so much so to 0%.

chew on that for a moment:

Suppose you have a young, stocky male patient who never had spinal injections before, and you never bothered to inquire about his past vasovagal rxn of any type (in fact he felt nauseated with a blood draw 3 weeks ago, but didn't tell anyone voluntarily), and you never bother to offer him the option of sedation, and you never bother to monitor his vital signs during your procedure.

Statistically-speaking, you have 1 out of 4 probability during your spinal procedure he will faint, vomit, and even aspirate on your table. The best case scenario, you recognize the reaction quickly and put some ammonia salt on his nose, and he comes around. You try to proceed with VS monitoring and realize his BP/HR still sinking with your needle insertion, you reluctantly abort the procedure and repeat the procedure under sedation. Another possible scenario, he develops an aspiration pneumonitis because he is not NPO and vomits (by the way, would be completely avoided by requiring NPO for conscious sedation). Even more traumatically, he could develop bronchospasm from aspiration, desaturate (of course, you wouldn't know because you don't bother to monitor VS during spinal procedure), ends up in ICU for pulmonary edema (if you are able to recognize the emergency and call EMT immediately).

ALL of these could have been avoided based on statistics, by simply inserting an IV, and push a few mg of versed and provide appropriate level of VS monitoring.

Or you can at least defend yourself by telling plaintiff's attorney and jury that you had, at the minimum, obtained the informed consent from the patient for which the patient opted out of receiving conscious sedation for the procedure.

Yet, you didn't do any of these, simply because as you stated above vasovagal reaction is some sort of "freak accident".

Best luck, don't say you haven't been warned and educated.

ive had/caused, maybe 500 vasovagal episodes in my career. never had to use smelling salts, never had an aspiration, pneumonia, vomiting, desats, pulmonary edema, or ICU stay. the good old "elevate your legs" seems to do the trick.

-Like what? -Shouldn't he elevate his legs?

you are living in a fantasy world where you can justify your position wrt sedation

 

[Dr. Ice]

Yes. It's basically what's going to happen.

You will have to defend yourself on the "freakish" nature of anxiety-related complications, such as vasovagal rxn, hypertensive crisis, inability to remain still resulting inadvertent needle trauma, etc.

Kennedy study I quoted above shows the incidence rate of vasovagal reaction in spinal procedure is 3.3% with 95 CI of 2.9 to 3.8%. It is not huge, but not small either, 1 out 25, roughly.

However, in patients who had vasovagal reaction, the rate of recurrent vasovagal rxn is a whopping 25% if spinal procedures were done without conscious sedation! That's 1 out 4 of your high risk patients who are prone to vasovagal, young, healthy, male, mostly.

However, with moderate sedation, the rate of recurrent vasovagal rxn is significantly reduced, so much so to 0%.

chew on that for a moment:

Suppose you have a young, stocky male patient who never had spinal injections before, and you never bothered to inquire about his past vasovagal rxn of any type (in fact he felt nauseated with a blood draw 3 weeks ago, but didn't tell anyone voluntarily), and you never bother to offer him the option of sedation, and you never bother to monitor his vital signs during your procedure.

Statistically-speaking, you have 1 out of 4 probability during your spinal procedure he will faint, vomit, and even aspirate on your table. The best case scenario, you recognize the reaction quickly and put some ammonia salt on his nose, and he comes around. You try to proceed with VS monitoring and realize his BP/HR still sinking with your needle insertion, you reluctantly abort the procedure and repeat the procedure under sedation. Another possible scenario, he develops an aspiration pneumonitis because he is not NPO and vomits (by the way, would be completely avoided by requiring NPO for conscious sedation). Even more traumatically, he could develop bronchospasm from aspiration, desaturate (of course, you wouldn't know because you don't bother to monitor VS during spinal procedure), ends up in ICU for pulmonary edema (if you are able to recognize the emergency and call EMT immediately).

ALL of these could have been avoided based on statistics, by simply inserting an IV, and push a few mg of versed and provide appropriate level of VS monitoring.

Or you can at least defend yourself by telling plaintiff's attorney and jury that you had, at the minimum, obtained the informed consent from the patient for which the patient opted out of receiving conscious sedation for the procedure.

Yet, you didn't do any of these, simply because as you stated above vasovagal reaction is some sort of "freak accident".

Best luck, don't say you haven't been warned and educated.

10,000 procedures later and it’s never happened...but thanks for the “education.” You keep on sedating your patients for a 3 minute injection

 

[Ferrismonk]

Without getting into the whole local/sedation argument,I keep seeing terms passed around incorrectly and feel the need to clarify to make sure we're all talking about the same thing.

1. The type of sedation is has nothing to do with the medication used. Propofol, Versed, Fentanyl, etc all have different effects and titrate differently, but that does not equal the "type" of anesthesia.

The spectrum of sedation is anxiolysis -> moderate (conscious) sedation -> Deep sedation -> general anesthesia

2. MAC (Monitored Anesthesia Care) is NOT a type of sedation. MAC is defined as an independent anesthesia provider service that is less than deep sedation or general anesthesia. The point of MAC is that the anesthesia provider is present and can handle all the complications of sedation and can also transfer between sedation states easily if necessary.

3. While ROUTINE sedation for pain procedures is NOT considered standard-of-care, it isn't considered contraindicated.

SIS states "If 'significant anxiety' or vasovagal reaction is a concern for a particular patient, conscious sedation can be considered."

ASA states that in "Exceptional circumstances, wherein moderate sedation may be considered, include 'significant anxiety' and for 'procedures that are prolonged and/or painful'"