SCS cancelled: again

[chocomorsel]

Sometimes you do things to be nice to the patient, but if a bad outcome happens they sue you. Don't be so sure this 80 year Olds family does not have a lot to gain by suing you for a bad outcome. Just look at the amount of people on here who gave a dissenting opinion to your judegement. Do you think the malpractice lawyers could not find a bunch of legal experts who would say you made a bad decision doing this case at a surgery center?

Always protect yourself and your family before trying to help a patient.

And this is one of the many, many things wrong with Medicine in America.

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[Maz777]

I thought you were advocating for a bolus of esmolol Vs fentanyl and not an esmolol infusion…
‘There are papers’ is not relevant to day to day practical anesthetic cases. So are you routinely doing esmolol infusions instead of giving opioid on induction? If so, you’d be the first anesthesiologist I know to do that…

Exactly. This person is just trying to be a contrarian. "There are papers." You can literally find a paper on anything you want to "prove." It's unlikely this person has critically examined the paper and understands its limitations/potential biases. Giving esmolol only and withholding opioids for painful stimuli does not fall within the accepted standard of care. That being said, it might make you feel like you know better than everyone else.

 

[Tramadeezy]

Check out Dr. Yaksh's research out of USCD. He is the godfather of basic science research looking at acute/chronic pain pathways; he is the man. He has a lot of interesting research showing that if you give opioids prior to a painful stimulus you can prevent "wind up" and the neural plasticity that comes with acute to chronic pain conversion. Its all in animal models but really cool stuff. Changed my mind about giving intraop opioids.

 

[coffeebythelake]

Check out Dr. Yaksh's research out of USCD. He is the godfather of basic science research looking at acute/chronic pain pathways; he is the man. He has a lot of interesting research showing that if you give opioids prior to a painful stimulus you can prevent "wind up" and the neural plasticity that comes with acute to chronic pain conversion. Its all in animal models but really cool stuff. Changed my mind about giving intraop opioids.

There is the science of it and there is the politics of it. And we all know how politics and villianization of opioids have become the last few years.

Just saw this today. Maybe the government isnt going to villianize prescription opioids so much going forward. Wonder what the next few years will be like.

 

[nimbus]

Check out Dr. Yaksh's research out of USCD. He is the godfather of basic science research looking at acute/chronic pain pathways; he is the man. He has a lot of interesting research showing that if you give opioids prior to a painful stimulus you can prevent "wind up" and the neural plasticity that comes with acute to chronic pain conversion. Its all in animal models but really cool stuff. Changed my mind about giving intraop opioids.

Preemptive analgesia was a big buzz in the late 1990s-early 2000s and we all still practice it to some degree. (I actually trained in that department during Dr Yaksh’s time there which I think is part of the reason why many of the faculty were so heavy handed with the opioids). But like many things in medicine, the data for its utility in humans is a mixed bag. And when we try to inhibit central sensitization with opioids, we need to balance its possible benefit against the risk of OIH.

Pre-emptive analgesia

Abstract. Transmission of pain signals evoked by tissue damage leads to sensitization of the peripheral and central pain pathways. Pre-emptive analgesia is a tr

academic.oup.com

Preemptive Analgesia

PREEMPTIVE analgesia is an antinociceptive treatment that prevents establishment of altered processing of afferent input, which amplifies postoperative pain. The concept of preemptive analgesia was formulated by Crile 1at the beginning of the previous century on the basis of clinical...

pubs.asahq.org

 

[coffeebythelake]

Preemptive analgesia was a big buzz in the late 1990s-early 2000s and we all practice it to some degree. But like many things in medicine, the data for its utility in humans is a mixed bag. And when we try to inhibit central sensitization with opioids, we need to balance it possible benefit against the risk of OIH.

Pre-emptive analgesia

Abstract. Transmission of pain signals evoked by tissue damage leads to sensitization of the peripheral and central pain pathways. Pre-emptive analgesia is a tr

academic.oup.com

Preemptive Analgesia

PREEMPTIVE analgesia is an antinociceptive treatment that prevents establishment of altered processing of afferent input, which amplifies postoperative pain. The concept of preemptive analgesia was formulated by Crile 1at the beginning of the previous century on the basis of clinical...

pubs.asahq.org

But OIH is like the exact opposite side of the pendulum. It is giving Mega doses of potent opioids, not the usual clinical practice with balanced aneathesia

 

[Tramadeezy]

not advocating for high dose opioids but I don’t buy the just give esmolol approach. More complicated than that.

 

[deleted875186]

Exactly. This person is just trying to be a contrarian. "There are papers." You can literally find a paper on anything you want to "prove." It's unlikely this person has critically examined the paper and understands its limitations/potential biases. Giving esmolol only and withholding opioids for painful stimuli does not fall within the accepted standard of care. That being said, it might make you feel like you know better than everyone else.

To be clear, I give a bolus of fentanyl before induction for intubation, or a small bolus of esmolol just before DL to prevent a sympathetic response, both work.

Esmolol infusion during lap cases has many papers suggesting it lower opioid use in the PACU. I’m simply implying that avoiding opioids, even a potent short acting opioid like fentanyl, could reduce postop opioid requirements.

I’m simply arguing that just because putting a tube in awake is uncomfortable, doesn’t mean it requires opioid while askleep.

 

[neutro]

To be clear, I give a bolus of fentanyl before induction for intubation, or a small bolus of esmolol just before DL to prevent a sympathetic response, both work.

Esmolol infusion during lap cases has many papers suggesting it lower opioid use in the PACU. I’m simply implying that avoiding opioids, even a potent short acting opioid like fentanyl, could reduce postop opioid requirements.

I’m simply arguing that just because putting a tube in awake is uncomfortable, doesn’t mean it requires opioid while askleep.

Brother you’re going in circles and arguing for the sake for it.

Giving versed and fentanyl was common practice for endoscopes before propofol became the mainstay - not esmolol.

Thank you

 

[nimbus]

Some people habitually give fentanyl 50-100 mcg for intubation whether the patient is having a painful procedure or not. I often do 4-5hr long Afib ablations under GA/ETT without opioids. They don’t need any intraop or in PACU. When I add opioids, I find I need to run more intraop vasopressors during these cases, especially the frail elderly patients.

 

[nimbus]

Brother you’re going in circles and arguing for the sake for it.

Giving versed and fentanyl was common practice for endoscopes before propofol became the mainstay - not esmolol.

Thank you

But not all patients need both propofol and fentanyl just for intubation. Many patients do better in the postinduction/preincision period without fentanyl.

 

[deleted875186]

Brother you’re going in circles and arguing for the sake for it.

Giving versed and fentanyl was common practice for endoscopes before propofol became the mainstay - not esmolol.

Thank you

You said it yourself, propofol works fine. I often will induce with propofol and muscle relaxant and skip any opioid at all. Other times I will use fentanyl, other times esmolol. I just think we should be thinking critically if fentanyl is needed rather than giving it because putting a tube in the trachea must be painful.

 

[neutro]

But not all patients need both propofol and fentanyl just for intubation. Many patients do better in the postinduction/preincision period without fentanyl.

Did three ESWLs yesterday. No fentanyl for lma

You said it yourself, propofol works fine. I often will induce with propofol and muscle relaxant and skip any opioid at all. Other times I will use fentanyl, other times esmolol. I just think we should be thinking critically if fentanyl is needed rather than giving it because putting a tube in the trachea must be painful.

You mis read me. I said BEFORE propofol was used - endoscopies were done with fentsnyl/ Versed, not esmolol

 

[deleted875186]

Did three ESWLs yesterday. No fentanyl for lma

You mis read me. I said BEFORE propofol was used - endoscopies were done with fentsnyl/ Versed, not esmolol

I never advocated for an all esmolol anesthetic. The initial question was, after a bolus of prop, does one need fentanyl for intubation, versus no fentanyl. I suggested that if the fentanyl was to prevent a sympathetic response, esmolol is just as good. You argument was, intubation while awake is painful, therefore it is painful while under GA, therefore fentanyl is indicated, which I think relies on the false premise that discomfort while awake is equal to stimukation while under GA.

 

[Maz777]

There is the science of it and there is the politics of it. And we all know how politics and villianization of opioids have become the last few years.

Just saw this today. Maybe the government isnt going to villianize prescription opioids so much going forward. Wonder what the next few years will be like.

View attachment 361709

Opioids are indicated for acute pain in addition to a thoughtful approach to non-opioids. The debate is whether or not they are indicated for chronic pain (non-cancer, non-end-of-life). I would argue that they are not but I don't have chronic pain, so I am biased. Unfortunately, operating on someone produces chronic pain in a pretty significant percentage of patients.

 

[Status Sciaticus]

I never advocated for an all esmolol anesthetic. The initial question was, after a bolus of prop, does one need fentanyl for intubation, versus no fentanyl. I suggested that if the fentanyl was to prevent a sympathetic response, esmolol is just as good. You argument was, intubation while awake is painful, therefore it is painful while under GA, therefore fentanyl is indicated, which I think relies on the false premise that discomfort while awake is equal to stimukation while under GA.

Why use two drugs when one drug do trick?
If I am going to give fentanyl anyway for the impending surgical incision, why would I delay it instead of giving it ahead of time to prevent chasing the pain rather than anticipating it?
Why would I give esmolol and then fentanyl when fentanyl in place of esmolol will both blunt the sympathetic response and provide analgesia for the next hour?

 

[coffeebythelake]

Unfortunately, operating on someone produces chronic pain in a pretty significant percentage of patients.

Source and more context here is needed

 

[deleted1147063]

Source and more context here is needed

Just think of adhesions.

I've had a mole removed 30 years ago. I still feel occasional discomfort in that scar on my back. I can only imagine what a real surgery does to people. Let's not mention all the truly iatrogenic crap, such as pain from the mesh for hernia repair (which could be avoided).

 

[Maz777]

Source and more context here is needed

You serious? It's well described in the literature. Some rates of chronic postsurgical pain are as high as 30-40% depending on the operation. Most publications cite 10% for all surgeries.

 

[deleted875186]

Why use two drugs when one drug do trick?
If I am going to give fentanyl anyway for the impending surgical incision, why would I delay it instead of giving it ahead of time to prevent chasing the pain rather than anticipating it?
Why would I give esmolol and then fentanyl when fentanyl in place of esmolol will both blunt the sympathetic response and provide analgesia for the next hour?

Fair argument. I simply pointed out that intubation itself does not require fentanyl, I strongly believe it is just entrained in traditional anesthesiology practice.

Also, for what it’s worth, if a patient is deep from sevo or propofol, I don’t give opioid for a small incision, such as laparoscopic port sites, hip pinning, small ortho stuff. They don’t react to the incision. I give an opioid for bigger surgeries, joints, ortho trauma, etc, but I’m typically giving a long acting opioid instead of fentanyl.

 

[IlDestriero]

I’ll give esmolol on induction for the SCS then cancel because of bradycardia.
😬

 

[Aether2000]

Do the procedure under local anesthesia. A gallon of 1/2% lidocaine works for many surgeries.

 

[nimbus]

Do the procedure under local anesthesia. A gallon of 1/2% lidocaine works for many surgeries.

Tumescent lipo

 

[Twiggidy]

You said it yourself, propofol works fine. I often will induce with propofol and muscle relaxant and skip any opioid at all. Other times I will use fentanyl, other times esmolol. I just think we should be thinking critically if fentanyl is needed rather than giving it because putting a tube in the trachea must be painful.

i actually gave this ago today. i will admit, you're probably correct in that fentanyl for intubation is likely unnecessary.

just curious what people think about giving versed prior to induction with propofol. i've been doing it less and less in practice especially with my older patients. I also think the patients wake up faster and with clearer heads. i've deemed it unnecessary since people dont remember anything with propofol alone more often than not.

thoughts.

 

[GravelRider]

i actually gave this ago today. i will admit, you're probably correct in that fentanyl for intubation is likely unnecessary.

just curious what people think about giving versed prior to induction with propofol. i've been doing it less and less in practice especially with my older patients. I also think the patients wake up faster and with clearer heads. i've deemed it unnecessary since people dont remember anything with propofol alone more often than not.

thoughts.

I often intubate without narcotic. If I’m going to be using narcotic anyway, I’ll give 25-50mcg fentanyl for induction. I find that if I am doing an induction/intubation without narcotic, that ventilating with volatile for a minute or so blunts the sympathetic response and any sympathetic response to laryngoscopy tends to be short lived. I hardly ever give narcotic prior to placing an LMA.

Every case is different, but my bottom line is that I use a lot less narcotic than I did during training. If I’m doing a block or it’s not a painful procedure, I will often use no opioids at all. Part of it is selfish…faster wake ups and less nausea…, part of it is the hoops they make us jump through to monitor opioid usage, and part of it is trying to think about whether a patient actually needs it or not.

 

[GassYous]

I give versed for blocks. I will also give it to very anxious or unreasonable people. It definitely helps decrease propofol usage in short endo cases for young people. I almost never give any to people above 65.

I like giving 50-100 of fentanyl for lma placement because I find that propofol only isn't enough for some people to be flailing arms. With upper extremity blocks, opioids are unnecessary. For everything else I give opioids.

 

[sevo00]

t definitely helps decrease propofol usage in short endo cases for young people

i agree it def decreases propofol usage. But have you noticed in increase in pacu length stay with versed? I try to just do cetacaine throat spray, IV lidocaine and propofol for endo

 

[GassYous]

i agree it def decreases propofol usage. But have you noticed in increase in pacu length stay with versed? I try to just do cetacaine throat spray, IV lidocaine and propofol for endo

Not really. I usually use it for the 20-30 year olds and they're still out within 20-30 mins

 

[GravelRider]

I give versed for blocks. I will also give it to very anxious or unreasonable people. It definitely helps decrease propofol usage in short endo cases for young people. I almost never give any to people above 65.

I like giving 50-100 of fentanyl for lma placement because I find that propofol only isn't enough for some people to be flailing arms. With upper extremity blocks, opioids are unnecessary. For everything else I give opioids.

For LMA placement, I may give the young men a little opioid up front, but for everyone else I just use a little extra propofol than I would on inductions where I am using a paralytic….sometimes 300-400mg of propofol to young men. I don’t start giving fentanyl until they are back spontaneously breathing. I’ve been burned on knee scopes and hysteroscopies where the case is 5 minutes and I’m awkwardly sitting there waiting for a patient to breathe while the cleaning crew is peeking in the window. In surgery centers where turnovers are minutes, opioids end up being a major drag on the day. The PACU nurses also love the opioid-free cases because there is noticeably less nausea. If the patients need it, I give it, but I’ve stopped giving every patient 100mcg of fentanyl for every case, no matter what.

 

[coffeebythelake]

You serious? It's well described in the literature. Some rates of chronic postsurgical pain are as high as 30-40% depending on the operation. Most publications cite 10% for all surgeries.

you said opioids are great for acute pain, but shouldn't be used for chronic (non cancer, non end of life) pain.

then you said lots of patients get chronic pain after surgery.

ok, and? the important question is whether this is modifiable, something you never elaborated on. that's the thing that really matters in the discussion.

 

[Maz777]

you said opioids are great for acute pain, but shouldn't be used for chronic (non cancer, non end of life) pain.

then you said lots of patients get chronic pain after surgery.

ok, and? the important question is whether this is modifiable, something you never elaborated on. that's the thing that really matters in the discussion.

I didn't say they were "great" for acute pain. I said opioids are indicated for acute pain.

For anyone that deals with chronic pain on a daily basis, do we really think that escalating long- and short-acting opioids leads to increased quality of life? You'd have to be nuts to actually think that. They get prescribed because all of the other options suck just as much, and patients with chronic pain want to numb their sensoria. Opioids are very good at that (numbing sensoria).

Yes, there is something modifiable. Don't perform unnecessary surgery. Chronic pain is caused by direct trauma to nerves and tissue during surgery. The only way to "modify" that is for surgeons to be more selective on who gets operated upon. That is not the American way unfortunately. Patients expect surgery to magically fix everything. They are rarely fully consented that their symptoms/pain will improve with surgery (or may actually worsen). Just like we rarely consent patients about the risks of POCD.

Even a complete/dense peripheral nerve block has not been shown to change the rate of subsequent chronic pain (let alone, systemic multimodal analgesia). You can block all afferent/efferent conduction for an extended period of time. That still doesn't change the underlying issue (direct surgical trauma, neuroma formation, etc.) and risk of chronic pain. I get annoyed when people talk about what we do on day of surgery and how it could impact their long-term outcome/quality of life from a pain perspective. We can't. We are here to make them comfortable perioperatively and opioids are indicated for that. Doing an opioid-free anesthestic is ridiculous (from that perspective) if the surgeon is going to send them home routinely with 20-30 tabs of oxycodone. Or they bounce back to the ED on POD1 seeking opioids and it gets prescribed there.

 

[coffeebythelake]

I didn't say they were "great" for acute pain. I said opioids are indicated for acute pain.

For anyone that deals with chronic pain on a daily basis, do we really think that escalating long- and short-acting opioids leads to increased quality of life? You'd have to be nuts to actually think that. They get prescribed because all of the other options suck just as much, and patients with chronic pain want to numb their sensoria. Opioids are very good at that (numbing sensoria).

Yes, there is something modifiable. Don't perform unnecessary surgery. Chronic pain is caused by direct trauma to nerves and tissue during surgery. The only way to "modify" that is for surgeons to be more selective on who gets operated upon. That is not the American way unfortunately. Patients expect surgery to magically fix everything. They are rarely fully consented that their symptoms/pain will improve with surgery (or may actually worsen). Just like we rarely consent patients about the risks of POCD.

Even a complete/dense peripheral nerve block has not been shown to change the rate of subsequent chronic pain (let alone, systemic multimodal analgesia). You can block all afferent/efferent conduction for an extended period of time. That still doesn't change the underlying issue (direct surgical trauma, neuroma formation, etc.) and risk of chronic pain. I get annoyed when people talk about what we do on day of surgery and how it could impact their long-term outcome/quality of life from a pain perspective. We can't. We are here to make them comfortable perioperatively and opioids are indicated for that. Doing an opioid-free anesthestic is ridiculous (from that perspective) if the surgeon is going to send them home routinely with 20-30 tabs of oxycodone. Or they bounce back to the ED on POD1 seeking opioids and it gets prescribed there.

OK it sounds like you are saying there is essentially nothing that can be done to prevent chronic pain afterwards, and the only thing that is modifiable is to avoid unnecessary surgery.

So what about necessary surgery? You say that choice of anesthetic technique doesn't seem to matter (block, multimodal, etc),

I'm not a pain guy so I don't know as much as you do about the topic, but I distinctly remember reading about wind-up, and how undertreated acute pain can lead to chronic pain? But maybe that doesn't matter either