Regional gurus: is block for liver intervention a thing?

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IRattending2021

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My shop is kinda weird in that it’s very hard to get anesthesia support but a lot easier to get my pt to have a regional block. Sorry if this is a really dumb question.

I am slated to do a complex hepatobiliary procedure where I need to repeatly stimulate the liver with a 21 gauge needle, probably 10-30 times. It’s one of those cases that’s a bit borderline in IR literature, about 50/50 split between GA and IR directed moderate sedation.

I am wondering if I can get a regional block, but trying to get a sense of how difficult is it for regional anesthesia guys to block the celiac plexus or whatever regional you guys do for liver? Is it even a thing? How difficult is it? I know when I do celiac neurolysis it’s quite a production but then I also inject absolute etoh sooo.
 
No regional block other than a spinal which would require anesthesia present for the case.

We do celiac for chronic pain in the clinic as well, but essentially only for cancer pain as it’s a high risk block.
 
The guys that I know do celiac plexus do it with fluoro through the aorta. If I were the patient I'd rather be under while you're stabbing my liver.

I think an epidural would also be a choice.
 
I think our staffing situation is one where the anesthesiologist rather not come down to do GA with us so if I book a case I can only get GA like 3-4 slots per months, whereas appearently our regional guys are happy to block and bounce. I am not exactly sure why that’s the situation but was told appearently it maybe RVU related as many IR procedures tend to have low RVU.

Trust me, I would want GA as well but getting GA here was essentially impossible. I was asking gas for help for a pregnant pt and required prone position, gas turned around and asked why I wasn’t comfortable sedating such a pt when he would have done the same thing as I did (fent and versed). I told him I simply wasn’t comfortable if I have to manage a crashing pregnant pt’s airway.

Turned on she was on meth...so glad to have the anesthesiologist on board.
 
IRattending2021 said:
I think our staffing situation is one where the anesthesiologist rather not come down to do GA with us so if I book a case I can only get GA like 3-4 slots per months, whereas appearently our regional guys are happy to block and bounce. I am not exactly sure why that’s the situation but was told appearently it maybe RVU related as many IR procedures tend to have low RVU.

Trust me, I would want GA as well but getting GA here was essentially impossible. I was asking gas for help for a pregnant pt and required prone position, gas turned around and asked why I wasn’t comfortable sedating such a pt when he would have done the same thing as I did (fent and versed). I told him I simply wasn’t comfortable if I have to manage a crashing pregnant pt’s airway.

Turned on she was on meth...so glad to have the anesthesiologist on board.
Click to expand...


Youre doing obscure “borderline in the literature” elective IR procedures on meth positive patients that you would prefer to be done under general anesthesia if you had to have the procedure done on yourself and you’re requesting obscure novel regional anesthetics in likely cirrhotic patients.


Just wow. Blocking and bouncing isnt a thing. What you’re asking for sounds dangerous with a side of a malpractice. You seriously wonder why no one wants to do these cases?
 
I always wondered how proceduralists with no airway or CCM experience direct their own sedation--do they know how to do airways to rescue an overshoot? Deal with cardiovascular collapse? It bills for bull**** .15 RVU now not even worth the risk IMO.

Does anesthesia not have to come help to do cases that need to be done in your hospital?
 
chessknt said:
I always wondered how proceduralists with no airway or CCM experience direct their own sedation--do they know how to do airways to rescue an overshoot? Deal with cardiovascular collapse? It bills for bull**** .15 RVU now not even worth the risk IMO.

Does anesthesia not have to come help to do cases that need to be done in your hospital?
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Is this in the US? Blocking and bouncing and an anesthesiologist refusing to help with a prone sedation case in a pregnant patient and then recommending versed/fent for a pregnant patient with a presumed full stomach and medicolegal risk of midazolam in pregnancy is all just very odd.

I’m curious what procedures you’re doing on pregnant patients.
 
SnapperRocks said:
Is this in the US? Blocking and bouncing and an anesthesiologist refusing to help with a prone sedation case in a pregnant patient and then recommending versed/fent for a pregnant patient with a presumed full stomach and medicolegal risk of midazolam in pregnancy is all just very odd.

I’m curious what procedures you’re doing on pregnant patients.
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Im not doing any... op is ir so i imagine the full gambit should the need arise. prone sounds like an lp?
 
Ignoring the politics and availability of your anesthesiologist colleagues - GA. Sad for you (not getting the support you need) and for the suboptimal care your patients get because of the medical system (imo).
 
The anesthesiooogists probably don’t want to staff an off site location because they are supervising rooms and it’s out of the way, and the cases are a pain in the ass. The anesthesia machine is probably not set up, lack of supplies and such, and staffing wise it is difficult to book an offsite location unless you have multiple cases that needs a dedicated anesthesiologist all day.
 
dipriMAN said:
The anesthesiooogists probably don’t want to staff an off site location because they are supervising rooms and it’s out of the way, and the cases are a pain in the ass. The anesthesia machine is probably not set up, lack of supplies and such, and staffing wise it is difficult to book an offsite location unless you have multiple cases that needs a dedicated anesthesiologist all day.
Click to expand...

Well that’s a systemic problem. They should make it easier to provide anesthesia. We have techs who set up an anesthesia machine so it’s the same as the OR. It’s no big deal for us to do IR cases and our IR docs are awesome so many of us like going there. I can see how it can be a problem if the anesthesia practice is 100% ACT.
 
SnapperRocks said:
Youre doing obscure “borderline in the literature” elective IR procedures on meth positive patients that you would prefer to be done under general anesthesia if you had to have the procedure done on yourself and you’re requesting obscure novel regional anesthetics in likely cirrhotic patients.


Just wow. Blocking and bouncing isnt a thing. What you’re asking for sounds dangerous with a side of a malpractice. You seriously wonder why no one wants to do these cases?
Click to expand...

you may have heard of this obscure “elective procedure” once or twice before. It’s called percutaneous nephrostomy tube in a septic pregnant pt. She was like 2-3 month in so her belly wasn’t in the way, but somehow she was refusing ureteral stenting....

believe or not, some liver procedures are typically done under moderate sedation in some places and GA under others. This happened to be one of those procedure that I usually do under moderate sedation but probably is a bit easier with GA. Patient is not cirrhotic. I am not sure where you are getting all the information from. Elective case in pregnant woman? That was an emergent case that i got push back from but appropriatelt so GA came down after I stood my ground. The hepatobiliary case is not related to that. Pt is a good anesthesia candidate with no substance issues.

Is it so difficult to believe that IR may have trouble getting anesthesia?

BTW i work in an academic hospital. This isn’t off site.
 
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To answer the OPs question, we have started doing bilateral PVBs for hepatic MWA. Liver gets bilateral innervation so you do need both sides. We’re doing it more for postop pain than as a primary anesthetic, but it does work well- with a really well placed block the patient doesn’t even wince with the needles going in and no local.

If your goal is a primary anesthetic, then an epidural would probably also cover it. You would need an anesthesiologist there the entire time to manage it, though, which may mean that in your situation GETA is just as good. Both PVB and epidural share the same risk of neuraxial hematoma, so whether these are feasible options will depend on whether the patient is cirrhotic and how far out of wack the coags are.

Sorry you are not getting the anesthesia support that you need. I bet there is a way your dept/hospital could improve things... But the group at your hospital would need to be properly incentivized.

As an aside, the IR group at my hospital has started asking for high frequency jet ventilation with liver lesions that are very close to the diaphragm. It’s actually pretty cool, has increased their procedural success rates and expanded the range of lesions they can now safely go after. The anesthetic was a bit of a pain in the @ss at first, but once everyone got on the same page it’s really not that bad to do
 
nimbus said:
Well that’s a systemic problem. They should make it easier to provide anesthesia. We have techs who set up an anesthesia machine so it’s the same as the OR. It’s no big deal for us to do IR cases and our IR docs are awesome so many of us like going there. I can see how it can be a problem if the anesthesia practice is 100% ACT.
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Seems like it would be easier with ACT than MD only. A lot of IR cases are terrible, that’s why we are asked to be involved. I don’t really like staffing some of them but it just goes with the territory as far as I am concerned.
 
Hork Bajir said:
To answer the OPs question, we have started doing bilateral PVBs for hepatic MWA. Liver gets bilateral innervation so you do need both sides. We’re doing it more for postop pain than as a primary anesthetic, but it does work well- with a really well placed block the patient doesn’t even wince with the needles going in and no local.

If your goal is a primary anesthetic, then an epidural would probably also cover it. You would need an anesthesiologist there the entire time to manage it, though, which may mean that in your situation GETA is just as good. Both PVB and epidural share the same risk of neuraxial hematoma, so whether these are feasible options will depend on whether the patient is cirrhotic and how far out of wack the coags are.

Sorry you are not getting the anesthesia support that you need. I bet there is a way your dept/hospital could improve things... But the group at your hospital would need to be properly incentivized.

As an aside, the IR group at my hospital has started asking for high frequency jet ventilation with liver lesions that are very close to the diaphragm. It’s actually pretty cool, has increased their procedural success rates and expanded the range of lesions they can now safely go after. The anesthetic was a bit of a pain in the @ss at first, but once everyone got on the same page it’s really not that bad to do
Click to expand...

i’ll ask my peeps about bilateral PVBs. Are you doing MWA just with that? We usually do our MWA with GA. A biliary drain is far less stimulating than MWA but since this pt has nondilated bile duct he might need a lot of sticks, so I think he might need somethign more than the typical moderate sedation. Usually I do my own sedation with percutaneous biliary drain but this one is a bit different.
 
The IR docs at my non-academic ACT place are great to work with, but they aren't busy enough to have us covering them regularly, and some of their suites don't even have the basics available in the rooms if they do need more involved Anesthesia.

So usually what happens is they have a patient show up for a painful procedure in the prone position that also happens to be BMI 50, OSA, and have a large bushy beard. The docs thankfully are aware enough to say nope not without anesthesia, but by that time we're in full swing and generally can't spare staff to trudge across the United States with all the gear. So they have to wait on us. Nobody likes the current system and we've talked about trying to come up with solutions but nothing has materialized yet.
 
DocVapor said:
The IR docs at my non-academic ACT place are great to work with, but they aren't busy enough to have us covering them regularly, and some of their suites don't even have the basics available in the rooms if they do need more involved Anesthesia.

So usually what happens is they have a patient show up for a painful procedure in the prone position that also happens to be BMI 50, OSA, and have a large bushy beard. The docs thankfully are aware enough to say nope not without anesthesia, but by that time we're in full swing and generally can't spare staff to trudge across the United States with all the gear. So they have to wait on us. Nobody likes the current system and we've talked about trying to come up with solutions but nothing has materialized yet.
Click to expand...

We have a dedicated ir person but position requires a subsidy.
 
IRattending2021 said:
I think our staffing situation is one where the anesthesiologist rather not come down to do GA with us so if I book a case I can only get GA like 3-4 slots per months, whereas appearently our regional guys are happy to block and bounce. I am not exactly sure why that’s the situation but was told appearently it maybe RVU related as many IR procedures tend to have low RVU.

Trust me, I would want GA as well but getting GA here was essentially impossible. I was asking gas for help for a pregnant pt and required prone position, gas turned around and asked why I wasn’t comfortable sedating such a pt when he would have done the same thing as I did (fent and versed). I told him I simply wasn’t comfortable if I have to manage a crashing pregnant pt’s airway.

Turned on she was on meth...so glad to have the anesthesiologist on board.
Click to expand...
To elaborate a few things. Anesthesia is not a unlimited resource. We can’t be at your beck and call, it’s not advantageous for anyone to have a anesthesiologist sitting around waiting for something to happen. IR is not the only location that would like use to have around every now and again (rad onc, bronch, MRI, ECT, etc) and unless you have scheduled block time it can be a pain to find additional anesthesia personnel, unless you discuss with the anesthesia team way in advance.

Out-of-OR/offsite anesthesia is a pain in the ass. Imagine if we asked you to do your procedure in the main ORs (and I’m not talking about a fancy hybrids or neurointerventional OR) just a plain OR, and you have to bring all your stuff. That’s what it’s like when we come to you. The anesthesia machine is likely a generation or two older, the space is not optimized (and usually not designed) to have anesthesia around, and we’re away from all our equipment. If something bad happens (and usually when a offsite place wants our help, it’s not for something good) we can far away from help.
 
0kazak1 said:
To elaborate a few things. Anesthesia is not a unlimited resource. We can’t be at your beck and call, it’s not advantageous for anyone to have a anesthesiologist sitting around waiting for something to happen. IR is not the only location that would like use to have around every now and again (rad onc, bronch, MRI, ECT, etc) and unless you have scheduled block time it can be a pain to find additional anesthesia personnel, unless you discuss with the anesthesia team way in advance.

Out-of-OR/offsite anesthesia is a pain in the ass. Imagine if we asked you to do your procedure in the main ORs (and I’m not talking about a fancy hybrids or neurointerventional OR) just a plain OR, and you have to bring all your stuff. That’s what it’s like when we come to you. The anesthesia machine is likely a generation or two older, the space is not optimized (and usually not designed) to have anesthesia around, and we’re away from all our equipment. If something bad happens (and usually when a offsite place wants our help, it’s not for something good) we can far away from help.
Click to expand...

i understand that, hence I am trying to figure out a compromise with the regional people so they can do their block and send the patient down. Because this patient would otherwise have gotten just moderate sedation (as per standard for those procedures).
 
0kazak1 said:
To elaborate a few things. Anesthesia is not a unlimited resource. We can’t be at your beck and call, it’s not advantageous for anyone to have a anesthesiologist sitting around waiting for something to happen. IR is not the only location that would like use to have around every now and again (rad onc, bronch, MRI, ECT, etc) and unless you have scheduled block time it can be a pain to find additional anesthesia personnel, unless you discuss with the anesthesia team way in advance.

Out-of-OR/offsite anesthesia is a pain in the ass. Imagine if we asked you to do your procedure in the main ORs (and I’m not talking about a fancy hybrids or neurointerventional OR) just a plain OR, and you have to bring all your stuff. That’s what it’s like when we come to you. The anesthesia machine is likely a generation or two older, the space is not optimized (and usually not designed) to have anesthesia around, and we’re away from all our equipment. If something bad happens (and usually when a offsite place wants our help, it’s not for something good) we can far away from help.
Click to expand...
Imagine if someone came in with septic shock from cholecystitis and IR was busy and said that?

Of course every specialty is a limited resource but we have to pitch in to make things happen unless you work in a high resource setting. And you are far from the only specialty to work in suboptimal second-thought conditions. I have done bronchs in a ****ing closet converted in to a 'bronch suite' with endo staff that didn't know how anything ****ing worked because it had been months since someone had done a bronch there so I had to help them figure out how to turn **** on and tell them exactly what to do. I have ICU rooms full of vent/CRRT with barely enough room to intubate at HOB because it used to be a supply closet. Our neurologists can't get EMGs done and MRI is broken for a week at a time and they have to do the best they can without it. Nephrologists have to beg and plead with HD RNs to come in off hours for emergent sessions. Gotta man up sometimes and just because it is painful is not a good reason to say no.
 
This conversation is so strange to me. If our IR guys book a case the day before, we provide coverage, just like we do for EP lab, GI, MRI, etc. If they add on a case on the same day, we still provide coverage although they will have to wait for one of the anesthesiologists with a short room to finish up. For addons, we don’t make any distinction between an OR case and an off site case. They get covered in the order they got booked. A case is a case.
 
0kazak1 said:
To elaborate a few things. Anesthesia is not a unlimited resource. We can’t be at your beck and call, it’s not advantageous for anyone to have a anesthesiologist sitting around waiting for something to happen. IR is not the only location that would like use to have around every now and again (rad onc, bronch, MRI, ECT, etc) and unless you have scheduled block time it can be a pain to find additional anesthesia personnel, unless you discuss with the anesthesia team way in advance.

Out-of-OR/offsite anesthesia is a pain in the ass. Imagine if we asked you to do your procedure in the main ORs (and I’m not talking about a fancy hybrids or neurointerventional OR) just a plain OR, and you have to bring all your stuff. That’s what it’s like when we come to you. The anesthesia machine is likely a generation or two older, the space is not optimized (and usually not designed) to have anesthesia around, and we’re away from all our equipment. If something bad happens (and usually when a offsite place wants our help, it’s not for something good) we can far away from help.
Click to expand...

Again, that’s a systemic and organizational problem. Off site cases don’t have to be a pain in the ass. We tell the hospital and the off site areas what we need to provide safe anesthesia and they provide it. We get the exact same anesthesia machine we always use and a fully stocked cart when we go to IR. I personally get a glidescope for every one of those cases. If we need an Aline we get an Aline.
 
Arch Guillotti said:
Seems like it would be easier with ACT than MD only. A lot of IR cases are terrible, that’s why we are asked to be involved. I don’t really like staffing some of them but it just goes with the territory as far as I am concerned.
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Well if you’re covering 2-4 rooms and one of them is off site, I’d consider that a problem. When you’re MD only, it doesn’t matter where the room is located.
 
nimbus said:
This conversation is so strange to me. If our IR guys book a case the day before, we provide coverage, just like we do for EP lab, GI, MRI, etc. If they add on a case on the same day, we still provide coverage although they will have to wait for one of the anesthesiologists with a short room to finish up. For addons, we don’t make any distinction between an OR case and an off site case. They get covered in the order they got booked. A case is a case.
Click to expand...

in my shop, if we book an elective cases, even weeks in advance, we are given 2-3 dates every month. I wish I can book something the day before that’s elective and get anesthesia. Availability isn’t great, hence I rather just do it with moderate sedation with some regional. But if I can’t do it I’ll just do it the standard way and give good local.
 
IRattending2021 said:
in my shop, if we book an elective cases, even weeks in advance, we are given 2-3 dates every month. I wish I can book something the day before that’s elective and get anesthesia. Availability isn’t great, hence I rather just do it with moderate sedation with some regional. But if I can’t do it I’ll just do it the standard way and give good local.
Click to expand...

That’s really too bad.
 
IRattending2021 said:
i’ll ask my peeps about bilateral PVBs. Are you doing MWA just with that? We usually do our MWA with GA. A biliary drain is far less stimulating than MWA but since this pt has nondilated bile duct he might need a lot of sticks, so I think he might need somethign more than the typical moderate sedation. Usually I do my own sedation with percutaneous biliary drain but this one is a bit different.
Click to expand...
We typically do a pretty deep sedation for hepatic MWA, using propofol (deeper than what you could or should normally be doing without an anesthesiologist). However, I will run the patient a bit lighter if the block is good- and indeed, I can usually tell whether the blocks are good by whether I can get away with less sedation. So for your purposes, since this is hopefully less stimulating than an ablation, I would venture to guess that you’ll be OK with just RN sedation.

Of course, the caveat is that paravertebral blocks are some of the trickiest blocks that we do, and the success rate is not 100%. It’s highly dependent on operator skill and experience... So if your regional dudes do them all the time and know their way around a PVB, great. If not it may be a bit more of a crapshoot
 
chessknt said:
Imagine if someone came in with septic shock from cholecystitis and IR was busy and said that?

Of course every specialty is a limited resource but we have to pitch in to make things happen unless you work in a high resource setting. And you are far from the only specialty to work in suboptimal second-thought conditions. I have done bronchs in a ****ing closet converted in to a 'bronch suite' with endo staff that didn't know how anything ****ing worked because it had been months since someone had done a bronch there so I had to help them figure out how to turn **** on and tell them exactly what to do. I have ICU rooms full of vent/CRRT with barely enough room to intubate at HOB because it used to be a supply closet. Our neurologists can't get EMGs done and MRI is broken for a week at a time and they have to do the best they can without it. Nephrologists have to beg and plead with HD RNs to come in off hours for emergent sessions. Gotta man up sometimes and just because it is painful is not a good reason to say no.
Click to expand...
I didn’t say it couldn’t be done. But, just mentioned reasons why some people would be hesitant. And I’ve totally seen IR hem and haw over a case about whether it was emergent and needed to go now, or if it could wait till morning. Our anesthesia bronch suite is a closet that at least s closer than the non-anesthesia bronch suite.


nimbus said:
This conversation is so strange to me. If our IR guys book a case the day before, we provide coverage, just like we do for EP lab, GI, MRI, etc. If they add on a case on the same day, we still provide coverage although they will have to wait for one of the anesthesiologists with a short room to finish up. For addons, we don’t make any distinction between an OR case and an off site case. They get covered in the order they got booked. A case is a case.
Click to expand...

Being able to provide coverage, and people willing to do it are not the same. We’ll make it happen too, but sometimes cases got to wait (either way someone is always grumbling.)
 
IRattending2021 said:
in my shop, if we book an elective cases, even weeks in advance, we are given 2-3 dates every month. I wish I can book something the day before that’s elective and get anesthesia. Availability isn’t great, hence I rather just do it with moderate sedation with some regional. But if I can’t do it I’ll just do it the standard way and give good local.
Click to expand...
I don’t understand this at all. You might not get the 7:30 start time, but they should be able to look at the OR schedule and give you a rough estimate of when you can schedule your case. It could be delayed because of a slow surgeon or other emergency…just like in the OR, but they should be able to accommodate you. On any given day we have random, non-block time cases in IR, MRI, TEE, etc.. that either pop up or are scheduled. Add-ons get done in order of urgency and/or who scheduled it first. If you book an add-on then you get in line with the other surgeons and their add-ons. We coordinate with the OR desk and make it work. Every hospital I’ve worked at does it this way.

The “just block em and send em down” is not really a thing I have ever seen done.
 
BLADEMDA said:
I do these EXACT cases at my shop. They all get GA with ETT ... end of story. Safety comes first and IMHO, the best anesthetic for these procedure is a GA.
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just for the record, we are talking about transhepatic biliary drainage? Most IRs do those under moderate sedation. In my experience those can be sometimes slightly more uncomfortable than what I can do with moderate sedation so I was wondering if regional is possible.

I don’t know if I would consider doing transhepatic biliary drain under sedation a safety issue. I would certain love to have GA for every single one of those cases but that is absolutely not the norm.

pubmed.ncbi.nlm.nih.gov

Sedations and analgesia in patients undergoing percutaneous transhepatic biliary drainage - PubMed

According to our experience, interventional radiologists practising biliary procedures can administer low doses of midazolam and minimize the doses of fentanyl, without loss of adequate sedation and analgesia.
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov
 
Sounds like your hospital needs to consider a stipend or another way to augment the incentive for the anesthesiologists. No one wants to work for free - least of all with high risk patients
 
IRattending2021 said:
just for the record, we are talking about transhepatic biliary drainage? Most IRs do those under moderate sedation. In my experience those can be sometimes slightly more uncomfortable than what I can do with moderate sedation so I was wondering if regional is possible.

I don’t know if I would consider doing transhepatic biliary drain under sedation a safety issue. I would certain love to have GA for every single one of those cases but that is absolutely not the norm.

pubmed.ncbi.nlm.nih.gov

Sedations and analgesia in patients undergoing percutaneous transhepatic biliary drainage - PubMed

According to our experience, interventional radiologists practising biliary procedures can administer low doses of midazolam and minimize the doses of fentanyl, without loss of adequate sedation and analgesia.
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov
Click to expand...
Yes. I work in a busy facility with many IR cases each day. Typically, when I see any chance of "aspiration" risk in the IR suite I choose GA with ETT. Now, can I do this case with "moderate sedation" like a propofol drip? Yes. But, would I choose to do a Transhepatic biliary drain without a secure airway? No.

Who needs percutaneous biliary drainage?​



The commonest indication for percutaneous biliary drainage (PBD) is blockage or abnormal narrowing (stricture) of the bile ducts. Many conditions can cause this, including:

  • Gallstones (stones in the gallbladder or within the bile ducts)
  • Tumors of the bile ducts, liver, gallbladder or pancreas
  • Pancreatitis (inflammation of the pancreas)
  • Sclerosing cholangitis (a type of inflammation of the bile ducts)
  • Enlarged lymph nodes in the region of the liver and pancreas
  • Postoperative strictures (narrowing of the bile ducts or perforation due to injury to the bile ducts during surgery)
  • Perforation
  • Infection
Percutaneous biliary drainage provides an alternative pathway to the bile to exit the liver. The drainage may be needed in preparation for surgery or other procedures on the bile ducts, such as removal of a bile duct stone or tumor.
 

The application of intravenous general anesthesia in percutaneous transhepatic biliary drainage​

  • September 2016
DOI:10.3969/j.issn.1008-794X.2016.09.011
Authors:

​

​

Abstract​

Objective: To investigate the safety and effect of percutaneous transhepatic biliary drainage (PTBD) performed under intravenous general anesthesia by comparing PTBD performed under local anesthesia. Methods: The clinical data of 125 patients, who received PTBD during the period from October 2012 to August 2015, were retrospectively analyzed. Of the 125 patients, intravenous general anesthesia was employed in 48 and local anesthesia was adopted in 77. The intraoperative and postoperative pain degree, heart rate and blood pressure, the operation time, duration of postoperative pain and incidence of puncture-related complications were recorded. Results: In intravenous general anesthesia group, only 5 patients (6.5%) complained of mild pain during the operation and 8 patients (10.4%) had mild pain after the operation, which were significantly lower than those in local anesthesia group (P<0.01), and the visual analog score (VAS) of intravenous general anesthesia group was much lower than that of local anesthesia group (P< 0.05). In local anesthesia group the intraoperative heart rate and blood pressure were obviously increased with large fluctuation when compared with the preoperative and postoperative data, while in intravenous general anesthesia group the intraoperative heart rate and blood pressure were decreased with less fluctuation when compared with the preoperative and postoperative ones. The operation time of local anesthesia group was markedly longer than that of intravenous general anesthesia group (P<0.05). The duration of postoperative pain in intravenous general anesthesia group was strikingly shorter than that in local anesthesia group (P< 0.05). With aspect to puncture-related complications, in local anesthesia group hepatic artery injury occurred in 3 patients, biliary-cardiac reflex syndrome in 2 patients and pleural injury in 2 patients, while in intravenous general anesthesia group only 2 patients developed hepatic artery injury; no other procedure-related complications or procedure-related death occurred. Conclusion: In performing PTBD, the use of intravenous general anesthesia can effectively reduce the risk of operation, shorten the operation time, relieve the pain and improve the patient's comfortableness, therefore, it is worthy of clinical application and promotion.
 
BLADEMDA said:
Yes. I work in a busy facility with many IR cases each day. Typically, when I see any chance of "aspiration" risk in the IR suite I choose GA with ETT. Now, can I do this case with "moderate sedation" like a propofol drip? Yes. But, would I choose to do a Transhepatic biliary drain without a secure airway? No.

Who needs percutaneous biliary drainage?​



The commonest indication for percutaneous biliary drainage (PBD) is blockage or abnormal narrowing (stricture) of the bile ducts. Many conditions can cause this, including:

  • Gallstones (stones in the gallbladder or within the bile ducts)
  • Tumors of the bile ducts, liver, gallbladder or pancreas
  • Pancreatitis (inflammation of the pancreas)
  • Sclerosing cholangitis (a type of inflammation of the bile ducts)
  • Enlarged lymph nodes in the region of the liver and pancreas
  • Postoperative strictures (narrowing of the bile ducts or perforation due to injury to the bile ducts during surgery)
  • Perforation
  • Infection
Percutaneous biliary drainage provides an alternative pathway to the bile to exit the liver. The drainage may be needed in preparation for surgery or other procedures on the bile ducts, such as removal of a bile duct stone or tumor.
Click to expand...

thank you for explaining what percutaneous biliary drainage is to a board certified IR staff physician. I don’t disagree with you that a secured airway is better for any procedure that can be uncomfortable. I just hope our anesthesia colleague can have the same opinion or availability. They do not.

I am sure you are aware, but I do not use prop for sedation. We only use small amount of fentanyl and versed.
 
Airway said:
We have danced around this (or I missed it) what is the exact case, ablation of tumor?
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preoperative percutaneous biliary drainage in a nondilated system. Surgeon wants it. You can debate the merit / indications for those but our surgeons are pretty insistent if they want something. As a result there is a timing involved and the whole 2-3 dates a month thing doesn’t work because essentially I do it when the surgeon tell me it’s the best timing in relation to the surgery they are about to do.
 
IRattending2021 said:
thank you for explaining what percutaneous biliary drainage is to a board certified IR staff physician. I don’t disagree with you that a secured airway is better for any procedure that can be uncomfortable. I just hope our anesthesia colleague can have the same opinion or availability. They do not.
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My post was for the med students and residents reading this thread on SDN. They will want to know and understand why an old goat like myself insists on GA with ETT. I want to avoid an aspiration pneumonia on a patient in IR. It's just that simple.
 
IRattending2021 said:
thank you for explaining what percutaneous biliary drainage is to a board certified IR staff physician. I don’t disagree with you that a secured airway is better for any procedure that can be uncomfortable. I just hope our anesthesia colleague can have the same opinion or availability. They do not.

I am sure you are aware, but I do not use prop for sedation. We only use small amount of fentanyl and versed.
Click to expand...
Fentanyl and Versed in the IR suite? No thanks. I will pass on that in favor of a secure airway in no man's land.
 
Now, would I be willing to do a block on these patients? Most likely yes.




Ultrasound guided erector spinae plane block for percutaneous radiofrequency ablation of liver tumors​

Shaimaa F. Mostafa &Mona B. El Mourad ORCID Icon
Pages 305-311 | Received 26 Aug 2020, Accepted 17 Nov 2020, Published online: 30 Nov 2020


Since the ES muscle extends inferiorly to the lumbar spine, performing ESPB at a lower vertebral level (e.g., T7 or T8) should result in local anesthetic spread to the lower thoraco-abdominal nerves that innervate the abdomen [6]. The analgesic efficacy of the ESPB has been proven in various thoracic [8] and abdominal procedures [9,10]. To the best of our knowledge, our study is the first prospective randomized study that assesses the analgesic effect of ESPB during procedures performed under conscious sedation.

The aim of the current study was to compare the effectiveness of right-sided ultrasound-guided ESPB versus local anesthetic infiltration for pain relief in patients undergoing PRFA of liver tumors.


Conclusions: Ultrasound-guided ESPB provided efficient analgesia during intraoperative and early postoperative periods with reduced analgesic requirements and fewer patients needing general anesthesia as compared to local infiltration technique.

As a final point, there was a significantly higher degree of satisfaction among both the interventional radiologist and the patients
 
BLADEMDA said:
Yes. I work in a busy facility with many IR cases each day. Typically, when I see any chance of "aspiration" risk in the IR suite I choose GA with ETT. Now, can I do this case with "moderate sedation" like a propofol drip? Yes. But, would I choose to do a Transhepatic biliary drain without a secure airway? No.

Who needs percutaneous biliary drainage?​



The commonest indication for percutaneous biliary drainage (PBD) is blockage or abnormal narrowing (stricture) of the bile ducts. Many conditions can cause this, including:

  • Gallstones (stones in the gallbladder or within the bile ducts)
  • Tumors of the bile ducts, liver, gallbladder or pancreas
  • Pancreatitis (inflammation of the pancreas)
  • Sclerosing cholangitis (a type of inflammation of the bile ducts)
  • Enlarged lymph nodes in the region of the liver and pancreas
  • Postoperative strictures (narrowing of the bile ducts or perforation due to injury to the bile ducts during surgery)
  • Perforation
  • Infection
Percutaneous biliary drainage provides an alternative pathway to the bile to exit the liver. The drainage may be needed in preparation for surgery or other procedures on the bile ducts, such as removal of a bile duct stone or tumor.
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I do the same. Tubed and paralyzed so everybody can just chill. Our guys do most of these on their own but if they ask for my help for a difficult patient, that’s what I give them.
 
BLADEMDA said:
Fentanyl and Versed in the IR suite? No thanks. I will pass on that in favor of a secure airway in no man's land.
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I'm finding it hard to understand why we're giving this person a hard time. His entire problem is lack of anesthesia support. Think he wants to do it with fentanyl/versed? Doesn't sound like it to me - it sounds like they want anesthesia to help with his cases and anesthesia isn't interested.

I'm sure the case at hand could be done with some block or another. But I wish the anesthesia department at the hospital where this IR attending works would be more reasonable and just staff the case with their anesthesia of choice.
 
Southpaw said:
I'm finding it hard to understand why we're giving this person a hard time. His entire problem is lack of anesthesia support. Think he wants to do it with fentanyl/versed? Doesn't sound like it to me - it sounds like they want anesthesia to help with his cases and anesthesia isn't interested.

I'm sure the case at hand could be done with some block or another. But I wish the anesthesia department at the hospital where this IR attending works would be more reasonable and just staff the case with their anesthesia of choice.
Click to expand...

I am using fentanyl and versed to sedate all my patients who needs moderate sedation. It’s part of my hospital privilege. Is moderate sedation not a thing in blademda’s hospital?

i read this subforum a lot and respect my anesthesiologist a ton and always tell them to do it in whatever way that they find to be the best approach for our patients because honestly anesthesia approaches don’t affect me much. It’s the availablity that is an issue. I have no preference nor desire to change my anesthesiologists plan. I just happened to notice that it’s difficult for them to provide anesthesia down in our area but they are happy to block our patients.
 
IRattending2021 said:
I am using fentanyl and versed to sedate all my patients who needs moderate sedation. It’s part of my hospital privilege. Is moderate sedation not a thing in blademda’s hospital?

i read this subforum a lot and respect my anesthesiologist a ton and always tell them to do it in whatever way that they find to be the best approach for our patients because honestly anesthesia approaches don’t affect me much. It’s the availablity that is an issue. I have no preference nor desire to change my anesthesiologists plan. I just happened to notice that it’s difficult for them to provide anesthesia down in our area but they are happy to block our patients.
Click to expand...
Sorry for being an ass earlier, I was getting sleep deprived. But, realistically speaking, if you know certain cases are going to require anesthesia and you have the volume for it, you can try requesting block time from the anesthesia folks (if that was their issue). Same thing with the perc biliary drains. Have a three way discussion with yourself, the surgeons, and anesthesia, (Hey, if you want these drains in before surgery, can you make is you guys have chole tuesdays, and in IR will have drain Mondays.) Septic/emergent patients are a separate issue.
 
IRattending2021 said:
I am using fentanyl and versed to sedate all my patients who needs moderate sedation. It’s part of my hospital privilege. Is moderate sedation not a thing in blademda’s hospital?

i read this subforum a lot and respect my anesthesiologist a ton and always tell them to do it in whatever way that they find to be the best approach for our patients because honestly anesthesia approaches don’t affect me much. It’s the availablity that is an issue. I have no preference nor desire to change my anesthesiologists plan. I just happened to notice that it’s difficult for them to provide anesthesia down in our area but they are happy to block our patients.
Click to expand...
You should request Right Sided Erector Spinae Blocks for your "liver procedures" where you use moderate sedation. The Block is fast, easy and simple to perform using 30-40 mls of local at T7-T8. If I was at your institution I would gladly do this for you in return for an occasional thank you.
 
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