pain procedures - local only vs sedation

[lobelsteve]

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'"

Thanks for the correct and useful information.

My guess is the blowhard is so bad at his job, he increases vv events. Also, all his procedures must be painful.

30000+ procedures and 1 vv event. Turfed from ortho for 3rd synvisc due to passing out with first two. Had my fellow inject his knee. No IV. Done in exam room. Seated. I had ammonia in hand. Guy rolled eyes back, fell forward. Fellow caught him and he woke up. Done.

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[SommeRiver]

Getting stuck with an IV, having a doctor tell you to stop talking, NPO the night prior...all of these things are what make ppl faint. Low blood sugar possibly, IV stick failure x 5, and "Mr Smith I need you to stop talking so I can concentrate" are the problem.

I haven't had anyone faint from a routine spine procedure. Not once.

During fellowship I was placing a thoracic epidural catheter prior to CT surgery and had a dude faint. Luckily for him I had gone to medical school AND he had two available legs, so we just raised them up and he laid down. My mother could have dealt with that and she never spent $200k going to med school.

Edit - I just have to seriously laugh that someone has a pt that says he deals with procedural anxiety by talking, the doctor tells him to stop talking so he can "concentrate on the procedure," and that same doctor comes on this forum to argue with multiple other doctors who perform the SAME PROCEDURES, and the central theme of the argument is anxiolysis. You told the guy to stop doing what he does to control his anxiety bc you couldn't concentrate. Cervical ESI STFU so your jaw doesn't move my target, but otherwise a routine spine injxn I am going to use that time to talk about the last book I read, etc. LOL at this guy. You must suck at your job. I bet you never beat Double Dragon on Nintendo did you?

 

[Ducttape]

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.
.....

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".

and you made the conclusion that this study suggested that moderate/conscious sedation was appropriate for procedural intervention. I do not see that, my take away is not that at all - that moderate sedation is where there is drug induced depression of consciousness. this is loss of some degree of self-awareness and interestly rathmell specifically grouped these 2 groups (mostly because the GA group was a whopping total of what 1 patient).

my study that I posted suggested that the incidence rate of vasovagal reactions was 0.4%.

this study - 1.1%: Immediate Adverse Events in Interventional Pain Procedures: A Multi-Institutional Study. - PubMed - NCBI (retrospective)

this one - 4.2%: Adverse events associated with fluoroscopically guided lumbosacral transforaminal epidural steroid injections. - PubMed - NCBI


I highly doubt that one would win a lawsuit stating that one was going to use conscious sedation to prevent an unlikely complication with incidence rates of <5%.




as another way of looking at it, this study Adverse events of conscious sedation in ambulatory spine procedures. - PubMed - NCBI suggests that there is no difference in adverse events (what they are is unspecified) is no different between using conscious sedation and not using conscious sedation.


so.... why do something that will not change the likelihood of an adverse event from happening?




above all else, your stance that conscious sedation is something that we need to give informed consent on - that it is standard of care - is not at all a conclusion that I can agree with.

 

[Ferrismonk]

[QUOTE="You must suck at your job. I bet you never beat Double Dragon on Nintendo did you?[/QUOTE]

Now to be fair, double dragon was pretty hard...

 

[SommeRiver]

[QUOTE="You must suck at your job. I bet you never beat Double Dragon on Nintendo did you?

Now to be fair, double dragon was pretty hard...[/QUOTE]

Requires hand and eye coordination, concentration, and dedication to beat it. Those of us that beat it are in a separate category of human, and should be treated as such. Given that I beat the game, one should assume I can find the jxn of the TP and SAP with a 25 gauge 3.5 inch needle through a needle tract of 2cc lido.

 

[drpainfree]

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

it hasn't happened, doesn't mean it will not happen. when it does happen, let this be shown you've been warned.

 

[drpainfree]

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'"

You summed it well.

I agree titration of versed/fentanyl/propofol can take a patient from light sedation to deep sedation. It takes education, training and experience to get them done right.

This is why PMR guys are so hard against using conscious sedation for spinal procedures because it would either force them to take procedures to ASC or stop doing them in office.

Instead, they just simply argue it is not necessary.

 

[drpainfree]

Thanks for the correct and useful information.

My guess is the blowhard is so bad at his job, he increases vv events. Also, all his procedures must be painful.

30000+ procedures and 1 vv event. Turfed from ortho for 3rd synvisc due to passing out with first two. Had my fellow inject his knee. No IV. Done in exam room. Seated. I had ammonia in hand. Guy rolled eyes back, fell forward. Fellow caught him and he woke up. Done.

I'm going to ignore your posts not because of your inflammatory personality, but you actually don't have anything educational to substantiate your point but your personal experience.

 

[SommeRiver]

You summed it well.

I agree titration of versed/fentanyl/propofol can take a patient from light sedation to deep sedation. It takes education, training and experience to get them done right.

This is why PMR guys are so hard against using conscious sedation for spinal procedures because it would either force them to take procedures to ASC or stop doing them in office.

Instead, they just simply argue it is not necessary.

I have my own ASC. Two actually, and I do procedures there. I don't use sedation.

 

[drpainfree]

Getting stuck with an IV, having a doctor tell you to stop talking, NPO the night prior...all of these things are what make ppl faint. Low blood sugar possibly, IV stick failure x 5, and "Mr Smith I need you to stop talking so I can concentrate" are the problem.

I haven't had anyone faint from a routine spine procedure. Not once.

During fellowship I was placing a thoracic epidural catheter prior to CT surgery and had a dude faint. Luckily for him I had gone to medical school AND he had two available legs, so we just raised them up and he laid down. My mother could have dealt with that and she never spent $200k going to med school.

Edit - I just have to seriously laugh that someone has a pt that says he deals with procedural anxiety by talking, the doctor tells him to stop talking so he can "concentrate on the procedure," and that same doctor comes on this forum to argue with multiple other doctors who perform the SAME PROCEDURES, and the central theme of the argument is anxiolysis. You told the guy to stop doing what he does to control his anxiety bc you couldn't concentrate. Cervical ESI STFU so your jaw doesn't move my target, but otherwise a routine spine injxn I am going to use that time to talk about the last book I read, etc. LOL at this guy. You must suck at your job. I bet you never beat Double Dragon on Nintendo did you?

I bet when you placed your thoracic epidural you had IV placed and tons of resuscitation meds right there next to you in OR.

Holy smoke, it take you to IV stick 5 times to get an IV, you should stop medicine all together or go back to internship.

Yes, I will tell the patient to lay still, and stop talking if it becomes disruptive. Obviously, you don't understand the safety of procedure takes priority over your carelessness.

 

[drpainfree]

and you made the conclusion that this study suggested that moderate/conscious sedation was appropriate for procedural intervention. I do not see that, my take away is not that at all - that moderate sedation is where there is drug induced depression of consciousness. this is loss of some degree of self-awareness and interestly rathmell specifically grouped these 2 groups (mostly because the GA group was a whopping total of what 1 patient).

my study that I posted suggested that the incidence rate of vasovagal reactions was 0.4%.

this study - 1.1%: Immediate Adverse Events in Interventional Pain Procedures: A Multi-Institutional Study. - PubMed - NCBI (retrospective)

this one - 4.2%: Adverse events associated with fluoroscopically guided lumbosacral transforaminal epidural steroid injections. - PubMed - NCBI


I highly doubt that one would win a lawsuit stating that one was going to use conscious sedation to prevent an unlikely complication with incidence rates of <5%.




as another way of looking at it, this study Adverse events of conscious sedation in ambulatory spine procedures. - PubMed - NCBI suggests that there is no difference in adverse events (what they are is unspecified) is no different between using conscious sedation and not using conscious sedation.


so.... why do something that will not change the likelihood of an adverse event from happening?




above all else, your stance that conscious sedation is something that we need to give informed consent on - that it is standard of care - is not at all a conclusion that I can agree with.

rathmell study says any sedation/anesthesia that makes patients unresponsive is risky.

conscious sedation by definition has the patient sedated in a moderate level, so they are still responsive.

are you arguing here as an anesthesiologist, you can knock patients out with 2-4mg of versed into deep sedation? If you are, I rest my case with you and suggest you redo you anesthesia residency.

I'm going to attach kennedy study here. you can read it yourself so you can understand the incidence rate of recurrent vasovagal is not 3-4%, it's 25%, but reduced to 0% with conscious sedation. BTW, kennedy study done by PMR physicians

 

[drpainfree]

I have my own ASC. Two actually, and I do procedures there. I don't use sedation.

taking cases to ASC meaning you will hire someone else trained in anesthesia to provide conscious sedation correctly.

 

[SSdoc33]

it hasn't happened, doesn't mean it will not happen. when it does happen, let this be shown you've been warned.

so, just to make sure i understand you correctly, i am MORE likely to have a complication if i don't use sedation? that is the hill you want to die on?

 

[drpainfree]

so, just to make sure i understand you correctly, i am MORE likely to have a complication if i don't use sedation? that is the hill you want to die on?

this is the same ignorance ob used to have, labor epidural causes more complications. of course, the misconception has been proven WRONG long ago.

anesthesia service is protective if for right indication, provided by people with right training.

I am not arguing you have to provide conscious sedation for every case. I am saying for the right patient there is role for conscious sedation to reduce risks associated with spinal procedures.

what you guys are saying here is, no, ABSOLUTELY no need for sedation of any type, because of your personal experience.

That does not cut it for me.

 

[SommeRiver]

taking cases to ASC meaning you will hire someone else trained in anesthesia to provide conscious sedation correctly.

We have 20 ortho surgeons in my group and we have anesthesia in house and available. You're so ridiculous dude.

 

[Ducttape]

rathmell study says any sedation/anesthesia that makes patients unresponsive is risky.

conscious sedation by definition has the patient sedated in a moderate level, so they are still responsive.

are you arguing here as an anesthesiologist, you can knock patients out with 2-4mg of versed into deep sedation? If you are, I rest my case with you and suggest you redo you anesthesia residency.

I'm going to attach kennedy study here. you can read it yourself so you can understand the incidence rate of recurrent vasovagal is not 3-4%, it's 25%, but reduced to 0% with conscious sedation. BTW, kennedy study done by PMR physicians

do not try to change the topic midway through. changing the argument to discuss recurrent vasovagal reaction weakens your stance because it is clearly a diversionary tactic.

i see that you are making several different arguments, in a vast attempt to cover your claim. your wholesale "we need to let patients decide on conscious sedation" is just wrong.




let me summarize what i see is consensus - of rathmell, ASA, SIS, etc. and emphasize this is my personal opinion, so someone from an alternate universe doesnt complain:
- conscious sedation is not standard of care for run of the mill interventional injections.

- conscious sedation is not standard of care to preventing patients from having vasovagal events.

- conscious sedation can be considered and may be offered to those who have significant anxiety, are undergoing a not-run of the mill procedure that requires near immobility, or are at risk for recurrent vasovagal reaction

- there is no medical or legal requirement that an interventional spine physician has to offer conscious sedation and "let the patient decide".


fwiw, there is a hypothesis out there that part of our "opioid epidemic" may be due to the fact that we are using opioids for labor epidurals, and essentially priming the pump in utero. more research needs to be done.

 

[drpainfree]

do not try to change the topic midway through. changing the argument to discuss recurrent vasovagal reaction weakens your stance because it is clearly a diversionary tactic.

i see that you are making several different arguments, in a vast attempt to cover your claim. your wholesale "we need to let patients decide on conscious sedation" is just wrong.

I have not changed the topic midway. How do you know if your patient will have a RECURRENT vasovagal if you never inquired the history of vasovagal before you give him/her a procedure?

Do you routinely ask your patients if they had spinal injections done prior without sedation and became "vasovagal"? I doubt it.

and how often can a patient reliably tell you he had "vasovagal reaction"? Not often.

So what you end up in reality is, you would never have a RECURRENT vasovagal reaction. When a high risk patient has recurrent vasovagal reaction on your table while you are doing injection, you would think it as the first time a vasovagal reaction happens with this patient.

The point is, the rate of vasovagal reaction undergoing spinal injection is at least 3-4% in general population, can be as high as 25% for patients who already had it. Since it's unreliable to determine which one of your patients actually had prior vasovagal reaction, you would have to consider any of your new patients who are high risk for getting vasovagal reaction (young, male, stocky, for example) to be at the higher end of this probability.
Whether it is 3-4% or 25%, or somewhere betwee, it's not a rare event as you are saying based on your personal experience. In fact, you still don't believe it when I showed you kennedy's study where the sample size was over 6000 patients. The study was actually done by PMR physicians at Stanford with the conclusion.

If you are so confident with your "personal experience", I invite you all compile your data and publish a study to show much lower vasovagal rate in average patient population and high-risk population.

Until you have a study to back you up, you should stop talking about how rare these complications occur based on your "personal" experience

It doesn't look good when a complication happens and you are being put in shame by plaintiff attorney in front of a jury because your personal experience is actually what's going to be held against you.

let me summarize what i see is consensus - of rathmell, ASA, SIS, etc. and emphasize this is my personal opinion, so someone from an alternate universe doesnt complain:
- conscious sedation is not standard of care for run of the mill interventional injections.

- conscious sedation is not standard of care to preventing patients from having vasovagal events.

- conscious sedation can be considered and may be offered to those who have significant anxiety, are undergoing a not-run of the mill procedure that requires near immobility, or are at risk for recurrent vasovagal reaction

- there is no medical or legal requirement that an interventional spine physician has to offer conscious sedation and "let the patient decide".

Since you are using the phrase of "standard of care", I suggest you to do a survey in your local ASIPP chapter, or something similar to get an idea of what percentage of spinal procedures are done with some type of sedation. It will determine what the standard of care is for your locality.

I know in my area majority of spinal procedures are done in ASC with anesthesia service present.

While I agree with you conscious sedation is not indicated for ALL interventional injections, I absolutely disagree with you and willing to go on record to say this: as an interventional pain physician, you absolutely need to obtain an informed consent from patient regarding the availability of conscious sedation, the risk, benefit and alternatives of consicious sedation.

Why? Just as you stated above, "conscious sedation can be considered and may be offered to those who have significant anxiety". This is the position from ASA, SIS, and etc.

So doc, let me ask you a basic question, if you do NOT spend time to consult and explain the indication and benefit of sedation, how do you assess if the patient has "significant anxiety"? Do you bother to ask the patient "how do you feel about the procedure"? Do you feel "anxious about the procedure"?

If you do, great, you better document it and let the patient consent on it.

If you never discuss/inquire about their anxiety towards spinal injection, and you just simply assume the conscious sedation is NOT needed, you would have just breached the ASA/SIS guideline, because you just simply ASSUMED the patient has no "significant anxiety".

In my patient population, more than 60% of my patients have some degree of anxiety, depression, even bipolar or some combination/mix of all. But again, it's my personal experience. I'm NOT going to use it to prove a point.

fwiw, there is a hypothesis out there that part of our "opioid epidemic" may be due to the fact that we are using opioids for labor epidurals, and essentially priming the pump in utero. more research needs to be done.

Fine, if you believe opioid in labor epidural causes opioid epidemic, and it's indeed been proven so, then draft a guideline to recommend against using opioids in labor epidural.

Isn't it what ASA did with spinal injection guideline, recommending against anything beyond conscious sedation?

Frankly, in the years I was doing ob anesthesia, I had never put fentanyl in my ropivacaine/bupivacaine drip. patient did great.

If it was your wife laying there, suffering, you would let her HAVE the option of getting a labor epidural, right?

So please do not take away the option of receiving labor epidural from your patients, just like you wouldn't take it away from your wife.

Why is it so hard for some of you to see the point when it comes to spinal injection?

 

[drpainfree]

We have 20 ortho surgeons in my group and we have anesthesia in house and available. You're so ridiculous dude.

so you worked for 20 orthopods and now you think you HAVE not one, but two ASCs.

I typically try to stay on the discussion, but man, you have the conflict of interest up the wazoo.

For guys doing procedures in office and don't offer conscious sedation, I can at least understand they just want simplify the logistic.

But what the hell is your reason doing injections in ASC, not one, but two ASC (probably OON)? just so that you and your orthopods can rip the system off for SOS differentials?

Yet, you think you are such a hot shot, know it all...

Here's a thought, why not get a real job, where you are not bottle-fed with procedures? Where you can actually do some ethical works independently from the direction of 20 orthopods?

 

[SommeRiver]

so you worked for 20 orthopods and now you think you HAVE not one, but two ASCs.

I typically try to stay on the discussion, but man, you have the conflict of interest up the wazoo.

For guys doing procedures in office and don't offer conscious sedation, I can at least understand they just want simplify the logistic.

But what the hell is your reason doing injections in ASC, not one, but two ASC (probably OON)? just so that you and your orthopods can rip the system off for SOS differentials?

Yet, you think you are such a hot shot, know it all...

Here's a thought, why not get a real job, where you are not bottle-fed with procedures? Where you can actually do some ethical works independently from the direction of 20 orthopods?

OMG dude. You're a clueless idiot and I just can't do this anymore. I have access to anesthesia if I want it, but I don't want it so I don't use it for anything other than SCS...because I'm not a jackass...I'm out. This is a massive waste of my time.

 

[lobelsteve]

The sky is blue.

 

[Painted]

:troll:

 

[paindoc007]

Most entertaining thread ever

 

[lonelobo]

Where are all these vasovagal events coming from? I just don't see anywhere near the rate mentioned in Kennedy paper(5% of all MBB?)

Think I have seen more VV with placement of IV than actual spine procedures

 

[DOctorJay]

are the vasovagal events related to trainees doing the procedures?

 

[Dr. Ice]

I don’t think this guy is gonna stop until someone concedes that it’s necessary to have all patients sign consent that he discussed (and probaly coerced) them into getting sedation for the procedure. He’s trying to justify his practice and if everyone on here disagrees with him he’s going to have to give his practice some serious thought. Well just to stop the madness..I will say it.

I hereby consider myself “warned” of the risks of not mandatorily discussing sedation with all my patients. There...now we can end this ridiculous conversation.

 

[Orin]

My fav way to do genics is with a propofol bolus.

 

[Ducttape]

You make so many assumptions about other people’s practices that your arguments become , um nonsequitor.

In addition, you now state that instead of “inform patient”, that essentially sedation is mandatory to avoid the possibility of a non lethal complication that is, even by best accounts, 7% of the time. (Recurrent vagal reactions were never part of our initial first 2 pages of this thread and are not part of this convo. Don’t bother)

By your logic... 95% of patients have pain from initial iv insertion. Do you require that they pretreat with TAC for 15 min in prean prior to attempt to start iv? The incidence rate of phlebitis from Peripheral IVs is 30%. Do you prophylax against this or provide informed consent for this “serious” complication with a mortality rate probably equal to vasovagal reaction? Do you inform patients of the risk of respiratory depression, cardiovascular depression, even addiction from sedation?


FYI your statement goes beyond what ASA says when you state that we have to give them informed consent. I will continue to follow their expert opinion and CONSIDER offering sedation. Because your opinions are not representative of standard of care regardless of your selfopinion - their opinion are.

Also, How I practice does not enter this discussion - because I have not revealed what I do do. You made assumptions about that too....

 

[drpainfree]

You make so many assumptions about other people’s practices that your arguments become , um nonsequitor.

I'm not making assumption. It was clear from posts above, majority of you use own experience to refute the medical necessity of conscious sedation.

You personally may have not brag about how many procedures you have done without sedation, but never had any complications.

Other guys in your camp have, just read through posts above.

In addition, you now state that instead of “inform patient”, that essentially sedation is mandatory to avoid the possibility of a non lethal complication that is, even by best accounts, 7% of the time. (Recurrent vagal reactions were never part of our initial first 2 pages of this thread and are not part of this convo. Don’t bother)

I'm not sure where you get 7% from. Kennedy study shows it's 3-4% among general population and 25% among patients who previously had vasovagal reaction, which I am equating to high risk patients group. Anywhere betwween 3-4% and 25%, fine, you want to pick a random number, 7%, one out of 14 cases where you haven't injection before. It's NOT a rare event by any stretch of imagination.

I never said "sedation is mandatory to avoid possibility of a non lethal complication", I said it's essential to obtain INFORMED CONSENT whether the patient receives conscious sedation or not. You owe to EACH ONE of your patients to 1) evaluate the anxiety level with regard to a particular procedure 2) explain risk, benefit and alternative of conscious sedation with regard to the particular procedure for the particular patient 3) provide your opinion of why conscious sedation is medically necessary or not for a particular patient undergoing a particular procedure. At the end of the day before you poke a set of needles into your patient' spine, you have the duty to follow ASA guideline on providing conscious sedation to patients who have significant anxiety. Only you can defend yourself when an anxiety-related complication occurs is to obtain informed consent where the patient had refused conscious sedation after your consultation.

By your logic... 95% of patients have pain from initial iv insertion. Do you require that they pretreat with TAC for 15 min in prean prior to attempt to start iv? The incidence rate of phlebitis from Peripheral IVs is 30%. Do you prophylax against this or provide informed consent for this “serious” complication with a mortality rate probably equal to vasovagal reaction? Do you inform patients of the risk of respiratory depression, cardiovascular depression, even addiction from sedation?

You are putting words in my mouth...don't quote my "logic", which I have not use it to prove my point. While I have said we as physicians need to consider patient's comfort level and be willing to meet their wish whenever possible without violating our ethic standard (relevant in the case of opioid prescripiton as such an exception), I have always emphasized this is NOT about my personal experience, my wish or my logic.

ASA guideline states clearly conscious sedation is indicated for significant anxiety, period.

Poor analogy of IV insertion pain. Put aside IV insertion takes no more than 2 seconds in experienced hands, the complication caused by IV insertion pain is exceedingly rare. I have not heard phlebotomy or IV insertion causes 4% to 25% of vasovagal reaction. Have you? If you have, please pull our the study and let's review them.

Furthermore, if you think 95% of patients who receive IV will have pain on insertion, therefore something needs to be done to prevent some type of complication from IV insertion pain, fine, then tell me what's the rate of this/these complications (such as 7% as you quoted above for vasovagal reaction in the case of spinal injection, yes, quote me a study that shows IV insertion pain is associated with vasovagal reaction rate of significant %, for example), and show me a guideline that has been put out by ASA or peri-operative nursing, or whatever authority out there that has made positional statement about pretreatment prior to starting IV. Sure if these studies exist, your analogy would be a reasonable comparison and I would then agree something needs to be done about pre-treatment.

Until you have these studies/guidelines to back you up, your poor analogy of IV insertion to spinal injection proves nothing.

FYI your statement goes beyond what ASA says when you state that we have to give them informed consent. I will continue to follow their expert opinion and CONSIDER offering sedation. Because your opinions are not representative of standard of care regardless of your selfopinion - their opinion are.

My statement does NOT go beyond what ASA position statement. It is exactly what will satisfy ASA requirement on their guideline, by appropriately assessing a patient's anxiety level (whether it's significant) for a particular spinal procedure to determine if it's medically necessary to for the patient to receive conscious sedation.

My statement recommends the most bullet-proof method to make this medical necessity determination for each patient is to obtain an informed consent regarding conscious sedation, again by 1) evaluating the anxiety level with regard to a particular procedure 2) explaining risk, benefit and alternative of conscious sedation with regard to the particular procedure for the particular patient 3) providing your opinion of why conscious sedation is medically necessary or not for a particular patient undergoing a particular procedure.

It is a recommendation I think a pain management physician absolutely should follow to be aligned with ASA guideline on this matter.

With regard to standard of care, I already explained to you standard of care is not determined by me, you or anyone of us here on this forum. It's determined by the cohort of pain physicians in your local community. That's the standard of care you will be measured against, in addition to the ASA guideline I have quoted above.

 

[drpainfree]

OMG dude. You're a clueless idiot and I just can't do this anymore. I have access to anesthesia if I want it, but I don't want it so I don't use it for anything other than SCS...because I'm not a jackass...I'm out. This is a massive waste of my time.

While I won't label you as a shameless *****, I won't waste my time to defend myself against your mindless insult.

In fact, I just wish one of these days when **** hits the fan and a preventable complication such as vasovagal reaction, hypertensive crisis, traumatic needle injury from inadvertent movement of a anxious patient, or any others anxiety-related complication or combination of these, happens to you in any one of 2 ASCs YOU HAVE, you'd still be able to keep your little job among 20 orthopods.

In my area, PMR guys got hired out of training to work for orthogroup can last no more than 3 years. So keep your arrogant and *****ic attitude up and see how long you will last until a complication happens. Or maybe you won't even get to stay long enough for the complication to happen, who knows.

 

[drpainfree]

I don’t think this guy is gonna stop until someone concedes that it’s necessary to have all patients sign consent that he discussed (and probaly coerced) them into getting sedation for the procedure. He’s trying to justify his practice and if everyone on here disagrees with him he’s going to have to give his practice some serious thought. Well just to stop the madness..I will say it.

I hereby consider myself “warned” of the risks of not mandatorily discussing sedation with all my patients. There...now we can end this ridiculous conversation.

You forget to mention (if you had read my posts above), I also consent my patients OUT OF deep sedation because it is risky in the setting of spinal procedures and discouraged by ASA.

I'm not trying to justify my practice because I know it is how a good medicine should be practiced, by following guidelines, by discussing with patients about r/b/a and providing the best option to patients with your ethical and professional opinion, and by letting patients choose what they prefer by knowing the risk, benefit ratio of consicious sedation vs. no conscious sedation, and even let them walk away when there's a mismatch.

It's simply a good medicine. Whether or not you want to follow, is your business.

 

[drpainfree]

Where are all these vasovagal events coming from? I just don't see anywhere near the rate mentioned in Kennedy paper(5% of all MBB?)

Kennedy Study:
"This study is a retrospective analysis of an existing pro-spectively collected dataset including 6,364 consecutive spine injections performed on 3,529 consecutive patients. The data were pulled from a larger cohort so that only spine injections were included which were defined as TFESIs, interlaminar epidural steroid injections, caudal epi-dural steroid injections, zygoepophyseal intraarticular joint injections, medial branch blocks, radiofrequency neuroto-mies, third occipital nerve blocks, intradiscal injections, and sacroiliac joint injections. All procedures were per-formed at a single academic medical center between 2004 and 2008. This study was institutional review board approved and HIPAA compliant."

Think I have seen more VV with placement of IV than actual spine procedures

I doubt it, otherwise we'd hear from pre-op nurses all the time when they insert IVs.

I have placed no less than 20,000 IVs in last 16 years, have not had one vasovagal reaction. The closest one was a young male who felt a little nauseated after a simple IV insertion with 22g angiocath.

Hey, but it's just what it is, my personal experience. I'm not trying to use personal experience to prove anything.

Instead, like I proposed to ducttape, if you really are concerned about the vasovagal rxn associated with IV insertion pain/anxiety, quote a good study to support your claim it has such a high incidence rate and cite a guideline or position statement that we should pre-treat IV insertion anxiety. I'd be happy to review them and get back to you on this topic.

 

[drpainfree]

are the vasovagal events related to trainees doing the procedures?

"All interventions were performed using fluoroscopic guidance in either an office-based fluoroscopy suite or ambulatory surgery center by one of four experienced physicians with and/or without trainee involvement."

With and/or without traineed involvement, sounds to me most procedures were done by attendings, some were done with trainee involvement.

 

[Ducttape]

kennedy i believe was also involved in 2 other studies:
Immediate Adverse Events in Interventional Pain Procedures: A Multi-Institutional Study. - PubMed - NCBI
Adverse Event Rates Associated with Transforaminal and Interlaminar Epidural Steroid Injections: A Multi-Institutional Study. - PubMed - NCBI
from the first one:

RESULTS:
Immediate complication data were available for 26,061 consecutive procedures. A radiology practice performed 19,170 epidural steroid (primarily transforaminal), facet, sacroiliac, and trigger point injections (2006-2013). A physiatry practice performed 6,190 spine interventions (2004-2009). A second physiatry practice performed 701 spine procedures (2009-2010). There were no major complications (permanent neurologic deficit or clinically significant bleeding [e.g., epidural hematoma]) with any procedure. Overall complication rate was 1.9% (493/26,061). Vasovagal reactions were the most frequent event (1.1%). Nineteen patients (<0.1%) were transferred to emergency departments for: allergic reactions, chest pain, symptomatic hypertension, and a vasovagal reaction.

If this data were to be believed, you would still recommend conscious sedation to be offered to all patients on the sole basis of avoiding ONE trip to the ER, out of 26,061 procedures?

in addition, 1.1% rate vasovagal reactions.

My statement recommends the most bullet-proof method to make this medical necessity determination for each patient is to obtain an informed consent regarding conscious sedation, again by 1) evaluating the anxiety level with regard to a particular procedure 2) explaining risk, benefit and alternative of conscious sedation with regard to the particular procedure for the particular patient 3) providing your opinion of why conscious sedation is medically necessary or not for a particular patient undergoing a particular procedure.

face facts. there is no justification for routine use of conscious sedation. there is no justification for having to offer - ie obtain informed consent - conscious sedation for routine procedures. talking about conscious sedation is offering conscious sedation for a procedure. ASA does not recommend this. it says, clear as day, that it can be considered. by the provider.

 

[lonelobo]

I have placed no less than 20,000 IVs in last 16 years, have not had one vasovagal reaction. The closest one was a young male who felt a little nauseated after a simple IV insertion with 22g angiocath.
.

I call BS

Before Medical school I worked a stint as a phlebotomist , I had people Vagal at sight of needle or others giving blood, so I find your numbers truly unbelievable

 

[lobelsteve]

UpToDate

 

[Ferrismonk]

If people vagal in my procedure suite lying down, I stop what I'm doing until it passes. If they vagal when getting from prone to upright, I give them a few moments before they stand. If they vagal in recovery area, lie down and feet up.

If my male patients (it's never a female) vagal during IV placement, I tell them to bring their balls next time. Never had a repeat incidence.

 

[dhcofc]

I really want this thread to end.

 

[SommeRiver]

While I won't label you as a shameless *****, I won't waste my time to defend myself against your mindless insult.

In fact, I just wish one of these days when **** hits the fan and a preventable complication such as vasovagal reaction, hypertensive crisis, traumatic needle injury from inadvertent movement of a anxious patient, or any others anxiety-related complication or combination of these, happens to you in any one of 2 ASCs YOU HAVE, you'd still be able to keep your little job among 20 orthopods.

In my area, PMR guys got hired out of training to work for orthogroup can last no more than 3 years. So keep your arrogant and *****ic attitude up and see how long you will last until a complication happens. Or maybe you won't even get to stay long enough for the complication to happen, who knows.

GD you're one dumb MFer. We live on two different planets.

 

[gdub25]

I’ve followed this for sometime now, and started to post this a while back but didn’t for whatever reason.

I agree that sedation is not necessary and would be happy to invite anyone who would like to see a high volume, interventional, office based practice who uses no sedation to reach out to me. We can set up a site visit and see if we can’t open some good dialogue and gain some insight from what you might learn. I truly believe anyone who thinks sedation should be considered for spinal injections has simply never been taught any other way. Remember, we only know what we’ve been taught and there are a lot of us out there who didn’t get the best teaching and only come to realize it years down the road. I worry every day that pain is going to have the same fate as anesthesia and CRNAs or Family Medicine guys are going to start calling themselves pain and if we as true board certified guys can’t band together and help raise each other to a certain standard it will become hard to differentiate ourselves from the posers

 

[likeaboss]

So, after some discussion with the ASC, they will allow me to do local cases in their ASC. However, they can only be ASA 1+2 patients. All ASA3 patients getting local need MAC (anesthesiologist supervision) without sedation. And all patients including ASA1+2 patients getting local anesthesia still need to get medical clearance from their primary doctor, so I'm still looking at a ~2-3 week delay for all my procedures. This is regardless of whether they get any sedation or not. What they are getting clearance for if its not for anesthesia, I am not sure.

The medical director (anesthesiologist) knows that, if it takes me just 4 days to get in the OR in a patient under local (because there is no delay for medical clearances), i'll end up doing all my cases under local. So by making the local cases delayed by a couple weeks for preops like the MAC cases, then I am less likely to rush patients in for procedures under local. They are all equally delayed.

And of course, I tried to do a couple of cases under local this week, and the medical director of the ASC says these patients are ASA3. One of them had a O2 sat of 91% on room air one time a while back. Basically, the anesthesiologists want to bill for these procedures, and they are doing everything in their power to ensure that they can do this.

 

[cbest]

That’s brutal! Any other ASCs you can take your cases to?


Sent from my iPhone using Tapatalk

 

[likeaboss]

Yes it is very irritating. Quick question, what percent of ASCs would be ok with me doing cases with local anesthesia only? And will they require pre-op clearance or EKG for a medial branch block in a 60 year old otherwise healthy patient under local?

I'm working with the administrators in my group on getting me credentialed at another ASC. Problem is the ASC making life miserable is partly owned by my employer...

 

[pastafan]

Yes it is very irritating. Quick question, what percent of ASCs would be ok with me doing cases with local anesthesia only? And will they require pre-op clearance or EKG for a medial branch block in a 60 year old otherwise healthy patient under local?

I'm working with the administrators in my group on getting me credentialed at another ASC. Problem is the ASC making life miserable is partly owned by my employer...

Depends on who owns/controls ASC. Ridiculous getting pre-op clearance for our procedures under local. If associated with a hospital is the same required of surgeons doing local cases at the hospital?

 

[myrandom2003]

i've never had to get any clearance for patients just getting local at the hospital.
Hospital still billed their facilty fee and just had nurses in there to monitor. I don't even think I had to get clearance at the hospital if I was giving versed. Maybe take the cases to the local hospital you are credentialed with.

 

[Taus]

Been at multiple ASC and hospitals. Never needed Ekg or clearance for a pain case regardless of local or Mac. Only clearances needed are for anti coagulation hold.

 

[Dr. Ice]

This is a whole lot of bs. All these completely unnecessary requirements. I think the concept of doing these procedures in a facility is going to soon become a thing of the past

 

[painfree23]

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

500??? That’s a lot. I’ve maybe had 2 in 3 years of local only procedures

 

[SSdoc33]

500??? That’s a lot. I’ve maybe had 2 in 3 years of local only procedures

anytime anyone feels a bit woozy sweaty at all, i would count it as a vaso vagal. after 20,000 shots, i think 500 isnt that bad. also, i just pulled that number out of a hat. may be an overestimation.

 

[deleted131481]

In my admittedly green experience, those patients who are very anxious and insist on sedation generally are worse procedural candidates.

I am in a practice where we do both in-office procedures (local only) and at ASC with MAC/sedation. Those who strongly prefer sedation tend to be higher maintenance, don't benefit as much, and often need other therapy (psych). Those who are hesitant I steer to in-office procedure without sedation almost always say something to the effect of "That was it? It wasn't that bad". Over time I'm hoping to do nearly all procedures in-office without sedation.

There are exceptions of course.

 

[drpainfree]

I'm back onto the thread, just with this one post.

ALL society recommendations/guidelines say while conscious sedation is NOT required for ALL procedures, conscious sedation is indicated for anxious patients.

As the interventionist you need to evaluate your patient's anxiety level. Document it and explain why you would offer or refuse conscious sedation or not in ASC or procedure suite in your office.

If you did not document a patient's anxiety level and simply choose to NOT discuss or offer conscious sedation, and when anxiety-induced complication occurs, the claim is non-defensible as it's not only against society guidelines, but most likely also against standard of care in your locality.

This statement is put on record in this searchable, archived public forum. Let it be known that simply refusing to offer conscious sedation regardless of patient's anxiety level or the type of procedures is against society guidelines and most likely standard of care in locality.

I'll stay off from this thread now as I have laid out more than enough pros and cons of offering and not offering conscious sedation and gave thorough evidence-based discussion along with society guidelines analysis.

If you feel you want to put your name on the thread and continue to leave your footprint arguing otherwise, feel free to do so.