pain procedures - local only vs sedation

[lobelsteve]

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[Ducttape]

it is up to you, as the judge and apparently jury, to post the society recommendations, as you are the one quoting them.


no society requires or forces us to do preventative medicine towards anxiety-induced complication, and that is exactly what you are espousing.

after all, no organization or government should get in the way of a doctor-patient relationship, or so Ive heard...

 

[SSdoc33]

anyone who is considering sedation should read the thread about ampa's complication. i cant seem to find the link to the old conversation. if someone has some time, they will find it

 

[dhcofc]

Every procedure we do is elective. Injuries are more likely to occur with sedation. If needle phobia is too severe, I don’t do the elective procedure. I don’t think I’ll ever have to defend not doing an elective procedure.

 

[Ducttape]

FWIW, I was just reviewing the Medicare LCD, came across these lines:

Facet joint injections/medial branch blocks are not without risk and can expose individuals to potential complications. As a result, when performing facet joint injections/medial branch blocks, the use of supplemental sedation in addition to local anesthesia is not required and not recommended.

The performance of interventional pain procedures such as a sacroiliac joint injection does not require the need for supplemental anesthesia in addition to local anesthesia.

 

[lobelsteve]

Patient Safety: Conscious Sedation | Pain Medicine | Oxford Academic

Updated.

 

[Doctodd]

PO Xanax or Ativan....unless you work with Dr Malik.

That being said, in my first job we sedated almost everyone with propofol for free. It was quicker not to talk to patients so we turned the room over faster.

 

[cowboydoc]

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.

You have made a compelling argument. Does it apply to decompression treatments as well as injections? What is reasonable charge for this service?

 

[No Pain All gain]

You won't be convinced based on experience, education, and your training. I hope you never have the complication that lands you in front of a jury.

Oh, you never said if you directly profit from unnecessary and potentially unsafe sedation in your patients.

Also, as an anesthesiologist, you have no training in msk exam, so does your NP or PA see the patient and pick your procedure for you? Or do you just go with ESIX3, IAFJ, MBB,RF, DISCO, SCS,IT PUMP?

This is unproductive name calling and baseless when the previous post quoted the same literature you waved around without reading the details.


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[lobelsteve]

This is unproductive name calling and baseless when the previous post quoted the same literature you waved around without reading the details.


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Review the thread and check out the baseless accusations and concrete thinking in the other guy. And no, sedation is not necessary for 99% of all we do. If you feel it is, great. Just never have a complication and nothing to worry about.

 

[No Pain All gain]

Anxiolysis with an awake responsive patient is reasonable. Needle phobia is very common.

Fear of needles--nature and prevalence in general practice. - PubMed - NCBI


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[soccrwz]

Not a statement, just a question, to promote discussion.

For those of you who have done anesthetic blocks via U/S in the ED or prior to surgery for surgical block or rescue blocks in pacu did you routinely give sedation ie minimal/moderate not Deep nor General anesthesia. I'm not talking propofol, I mean ketamine/versed/fentanyl ( single or combination of the drugs). Would the standards change, if so how? Thoughts?

 

[lobelsteve]

Anxiolysis with an awake responsive patient is reasonable. Needle phobia is very common.

Fear of needles--nature and prevalence in general practice. - PubMed - NCBI


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If i was that needle phobic i would not undergo procedures.

And starting an IV? Nice. Try this :

Neuroscience Says Listening to This Song Reduces Anxiety by Up to 65 Percent

 

[callmeanesthesia]

If i was that needle phobic i would not undergo procedures.

And starting an IV? Nice. Try this :

Neuroscience Says Listening to This Song Reduces Anxiety by Up to 65 Percent

I’m on your side here, but I found that song, and the accompanying video, mildly unsettling rather than soothing. I’ll stick to Pandora for my procedure room...

 

[callmeanesthesia]

Hell, I don’t even use local for most of my injections. 25g needle, pop through the skin quickly. Oral sedation is available to those who ask for it.

 

[painfree23]

I’m on your side here, but I found that song, and the accompanying video, mildly unsettling rather than soothing. I’ll stick to Pandora for my procedure room...

what station on pandora?

 

[callmeanesthesia]

what station on pandora?

Shuffle. Mix of classic and alternative rock mostly. Bet the classic rock brings back some good memories for my boomer patients

 

[lobelsteve]

80s throwback 90s comeback.

 

[emd123]

Started with a little Christmas music to start the day on a positive note. Now, Spotify '90s Pop Rock Essentials playing. Will probably end up on a Buffett beach music mix, at some point.

 

[Ducttape]

 

[cowboydoc]

I'm starting to feel old now that the stuff I remember getting released when I was in high school is on the "classic rock" station!

 

[lonelobo]

I'm starting to feel old now that the stuff I remember getting released when I was in high school is on the "classic rock" station!

LOL, "Welcome to the Jungle" just doesn't see like it should be on a Classic station

 

[SSdoc33]

last week, a patient asked me if she could listen to head phones during a procedure to keep her relaxed. i told her she couldnt, but asked what song was the key to her relaxation. long story short, i ended up singing "here i go again" by whitesnake during her RF. im guessing she will not return in f/u

 

[SommeRiver]

last week, a patient asked me if she could listen to head phones during a procedure to keep her relaxed. i told her she couldnt, but asked when song was the key to her relaxation. long story short, i ended up singing "here i go again" by whitesnake during her RF. im guessing she will not return in f/u

Better that than Push It by Salt N Peppa.

 

[Ducttape]

I let them listen to headphones....

Much better than my singing.

 

[Mister Mxyzptlk]

I've been offering light sedation as an option in the office since 2003. No problems at all. Patient's happy, I'm happy.

OTOH there are docs who want cadaver-like sedation. I've seen horrible disasters from that. Cord injuries and a C5 root burn (done under GA).

BTW there are case reports of people getting cord punctures while only using local who reported no pain when it happened.

 

[painfree23]

I've been offering light sedation as an option in the office since 2003. No problems at all. Patient's happy, I'm happy.

OTOH there are docs who want cadaver-like sedation. I've seen horrible disasters from that. Cord injuries and a C5 root burn (done under GA).

BTW there are case reports of people getting cord punctures while only using local who reported no pain when it happened.

How do u bill for this in the office? Versed? I think the time it takes to do it all (IV/carrying meds/etc) is worth the reimbursement?

 

[Mister Mxyzptlk]

You get maybe $53 from Medicare for the first 15 minutes (99152) and a few $$ for the meds. There's another code for each extra 15 minute increment. The cost of versed and fentany are $1 or less each for a 2 cc vial. My nurse puts in the IV and gets them ready while I'm seeing office visits. I just walk in and do the procedure. In my area if you don't offer sedation someone else will. It's not a money-maker but if you can add another $45-50 toa $250 procedure and the patient is happy, I'm ok with it. 15 years of office procedures with versed/fentanyl for those who want it, never had a problem.

In my area patients often demand MAC/IV sedation. They've been to other pain docs and had it so they expect it. For some reason the area around Houston does a ton of pain procedures under MAC, and I suspect that if they give propofol they bill TIVA. I've seen the EOBs and the anesthesia is often way higher than the surgeon's fee.

 

[Ducttape]

Texas is indubitably different from NY - be careful of state laws/rules.

while it has never happened to me, the ASC has issued global reminders that the physician has to be physically in the room before the start of the sedation until when the patient is sent to recovery.

 

[Mister Mxyzptlk]

Texas is indubitably different from NY

Yeah, I noticed that when I moved from NY to TX.

 

[painfree23]

You get maybe $53 from Medicare for the first 15 minutes (99152) and a few $$ for the meds. There's another code for each extra 15 minute increment. The cost of versed and fentany are $1 or less each for a 2 cc vial. My nurse puts in the IV and gets them ready while I'm seeing office visits. I just walk in and do the procedure. In my area if you don't offer sedation someone else will. It's not a money-maker but if you can add another $45-50 toa $250 procedure and the patient is happy, I'm ok with it. 15 years of office procedures with versed/fentanyl for those who want it, never had a problem.

In my area patients often demand MAC/IV sedation. They've been to other pain docs and had it so they expect it. For some reason the area around Houston does a ton of pain procedures under MAC, and I suspect that if they give propofol they bill TIVA. I've seen the EOBs and the anesthesia is often way higher than the surgeon's fee.

Meh $53 isn’t bad. Do u have ASA monitors? Or just bp a few times and pulse ox?

Also,
“Billing for moderate sedation services (CPT Codes 99151 or 99152) represents the first 15 minutes of service. All physician work occurs during that first 15 minutes. Usually thereafter, the physician is engaged in performing the procedure, and a nurse will monitor the patient.“

Does this mean the nurse doesn’t have to be in there to only monitor a patient?

 

[Mister Mxyzptlk]

Meh $53 isn’t bad. Do u have ASA monitors? Or just bp a few times and pulse ox?

Also,
“Billing for moderate sedation services (CPT Codes 99151 or 99152) represents the first 15 minutes of service. All physician work occurs during that first 15 minutes. Usually thereafter, the physician is engaged in performing the procedure, and a nurse will monitor the patient.“

Does this mean the nurse doesn’t have to be in there to only monitor a patient?

We adhere to the Texas Medical Board Rules Texas Administrative Code

Main problem I've had over the years is not sedation related but V/V reactions. However, I'm not interested in being engaged in the sedation pissing contest.