SCS implants and aspiration risk

[Timeoutofmind]

Quick question

At my hospital, we have had three aspirations this year during SCS implants with different pain docs and anesthesiologists.

(They are a deep MAC)

The anesthesiologists were trying brainstorming...

Is it an issue where we really need just a light sedation vs GETA (no deep MAC)

Have you guys had similar issues?

Thanks!

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[dhcofc]

I think you either have to go light MAC that is hard to achieve because the CRNA wants to snow the patient even after you tell them not to or GETA. They slip into GA most of the time during a MAC case in my experience. In these cases GETA would probably be safer. I’ve seen some scary events during MAC SCS cases from oversedation. Now I either do GETA or light sedation, letting patient choose basically.

 

[Timeoutofmind]

I think you either have to go light MAC that is hard to achieve because the CRNA wants to snow the patient even after you tell them not to or GETA. They slip into GA most of the time during a MAC case in my experience. In these cases GETA would probably be safer. I’ve seen some scary events during MAC SCS cases from oversedation. Now I either do GETA or light sedation, letting patient choose basically.

If GETA do you do Neuromonitoring?

if light sedation… is that you ordering the nurse to give versed etc. or are you saying it is an anesthesiologist doing a light MAC?

 

[lobelsteve]

GETA. No monitoring. Save laterals with LOR under lateral and first 1-2 cm lead advanced under live lateral.

 

[Agast]

Why are so many patients vomiting during their case? I'm assuming you mean they aspirated abdominal contents and not secretions. Were these big belly patients?

 

[Timeoutofmind]

Why are so many patients vomiting during their case? I'm assuming you mean they aspirated abdominal contents and not secretions. Were these big belly patients?

Yeah it was abdominal contents… Bilious etc.

They were all appropriately NPO.

I mean they were overweight but not whales or anything

 

[callmeanesthesia]

Tip head down. Let gravity do the work.
The anesthesiologist who usually does mine at the ASC runs them more in the moderate sedation range - I.e. still responsive to verbal stimuli.

 

[Orin]

To be clear, did they aspirate or have emesis while prone? Aspirating in the prone position itself is challenging, but possible. I do suspect it is an anesthetic issue.

I ask for a clean prone MAC/GA with a natural airway with just propofol plus/minus dexmedetomidine. Zero benzodiazepines. Zero to minimal opioids. Low dose ketamine boluses if necessary. When they start mixing too many agents and doing the usual touch of midazolam, it does not go great intra-op/post-op. If I'm doing an intra-op wake up, rather hard with too many agents. GETA only when necessary due to airway risk/medication tolerance concerns, but 90-95% of cases are natural/awake.

The aspiration events I've seen are patients that're too deep when flipped supine, nauseated by the antibiotics/opioids, and generally patients on the heavier side with delayed gastric emptying from various things.

 

[dhcofc]

I do GETA without neuromonitoring or MAC with anesthesiologist.

 

[deleted875186]

Seems strange, I never had an aspiration prone. Are they turning the head? Perhaps tell them to use a probe pillow and let the head remain neutral.

Is it from nausea? If so then clean up the sedation like mentioned above, I prefer straight prop with small boluses of fent if needed to remain still.

perhaps the specific patient were just bad sedation candidates

 

[Blackmateria]

Yeah it was abdominal contents… Bilious etc.

They were all appropriately NPO.

I mean they were overweight but not whales or anything

I have done a lot of these, trials and implants. Surgeon I work with doesn't want GA.

If the patient is over like 75 and somewhat decrepit, usually 2 of versed 50 of fent upfront and then 1 or 2 ccs of propofol every couple minutes is enough to do the job. They will sleep but they MUST be arousable.

If they are a relatively normal looking 60 year old it gets a lot trickier. If you're doing a MAC, again they must be arousable, which means you must set the expectations preop, and do some hand holding throughout because they will not be as asleep as the older patients. If you do more than that, like keep them under a GA with just propofol and no airway device in the prone position, you may even get away with it in a skinny patient. BUT not infrequently, they can get disinhibited and try to get of the table or worse, start obstructing, saliva will start pooling in their mouth, they will inhale and cough uncontrollably on the saliva, and then vomit leading to aspiration.

 

[RoloTomassi]

I don't have a lot of experience with MAC, just IV conscious and general. PM&R background too. Can someone school me on pros/cons of MAC vs general?

 

[Ducttape]

MAC means monitored anesthesia care.

it is not specifically a patient's state of being. it means that an anesthesiologist will be involved in level of arousal, monitoring of the patient, safety issues amongst other measures.

you can have MAC with light or no sedation.

the pros - allows you to focus entirely on what you are best at - the procedure. can allow a higher level of sedation if necessary.

the cons - there may be increased patient cost.

and sometimes you will hear mutterings of how the stock market is doing from beyond the curtain.

 

[Ducttape]

the positioning of the patient may contribute to aspiration, btw.

using a big abdominal bump will put increased pressure on the gastric contents.

if you havent, might be something to look into and changing that practice may reduce aspiration risks...

 

[RoloTomassi]

MAC means monitored anesthesia care.

it is not specifically a patient's state of being. it means that an anesthesiologist will be involved in level of arousal, monitoring of the patient, safety issues amongst other measures.

you can have MAC with light or no sedation.

the pros - allows you to focus entirely on what you are best at - the procedure. can allow a higher level of sedation if necessary.

the cons - there may be increased patient cost.

and sometimes you will hear mutterings of how the stock market is doing from beyond the curtain.

Thanks, I was more referring to rationales/patient selection for light/mod sedation vs GETA, since it seems like there's a lot a variance in what everyone is going for stim, kypho, etc

 

[Ducttape]

as a non-practicing anesthesiologist, I am a big fan of MAC.... except it does cost money.


so I never request it unless absolutely necessary. I just do light conscious sedation...

 

[NJPAIN]

I’m surprised to hear people suggesting GA without neuromonitoring. I could be wrong but don’t NACC guidelines recommended “awake” or GA with monitoring?
As an aside, is anyone using GA having issues with their malpractice carrier because they define MAJOR SURGERY as that which utilities GA and therefore they consider you doing major surgery?

 

[BobBarker]

Pretty much always a heavy enough MAC it is GA without an airway. If a lead gets anterior their leg will still jump. I’m sure the majority of the NACC authors are invested in neuromonitoring companies.

 

[deleted875186]

Thanks, I was more referring to rationales/patient selection for light/mod sedation vs GETA, since it seems like there's a lot a variance in what everyone is going for stim, kypho, etc

I would say most prefer MAC if patient is a good candidate.

they have to be reasonable, expectation that they will remember parts of surgery possible. Usually can’t be on big doses of benzodiazepines or opioids, these patients take too much anesthesia to sedate and are poor candidates. If you get past moderate sedation pretty much deep to be deep or GA because the patient will be disinhibited with any stimulation and start flailing. Airway should be favorable, although obstructing is less of an issue in prone. Most people would not offer a MAC, especially prone to a obese patient.

 

[Timeoutofmind]

Thanks everyone for your thoughts.
My two cents.

1.
not a fan of ETT without neuromonitoring. Especially for cervical SCS. U search for my prior thread about a dicey cervical case I had …very thankful the patient was not deeply sedated in that instance.

further we do have some professional society guidelines that advise against

Also GA is not without risks, over and above MAC/sedation, and added expense.


2
deep Mac is not good

you lose the benefit of an awake Pt to alert u if u are misbehaving. Additionally, increases anesthesia related risks such as aspiration (see OP)

3.
I am not a fan of ETT + neuromonitoring. Because I’m not a fan of neuromonitoringBig pain in the butt and added expense. And from my experience seems to be specific, but not sensitive, for neural injury.


so I am just gonna roll with Mac but tell anesthesia light sedation and arrousible patient from here on out. Bonus of propofol for local.

I think letting patients know they will be awake and setting expectations is key.

thanks all

 

[NJPAIN]

I really think one needs to be very careful when practicing contrary to established guidelines. Although we all don’t like to practice defensive medicine, the fact of the matter is we must. You can be the slickest interventionalist and perhaps even have been the best fellow in your class but that won’t make your opinion authoritative in a court of law.

 

[BobBarker]

Everyone of those authors is on the take. They will sell anything, including neuromonitoring.

I did a trial on a lady who was fused T11 to sacrum today. It was difficult and took like 20 minutes. She was comfy as could be with 15ml lido, nitrous, Valium. I don’t see how neuromonitoring could improve the safety. I know when the lead is wrong spot. We have how it feels first, we have lateral fluoroscopy second, and we have impendance checking finally.

We did around 40 implants with neuromonitoring in fellowship. It never helped with anything other than extending case time by 100%.

 

[Espn123]

If your patient is under general and something bad happens, I’m don’t sure saving a lateral while the lead is advancing is going to be a good defense.

 

[Agast]

Am I missing something? If you confirm posterior entry and advance keeping midline, what catastrophic event are you anticipating that you need neuromonitoring for?

 

[BobBarker]

And additionally, these are patients for implant that you have already done successful trials on which demonstrated that the epidural space can accommodate the leads.

 

[lobelsteve]

If your patient is under general and something bad happens, I’m don’t sure saving a lateral while the lead is advancing is going to be a good defense.

Go on.....explain. And let us know your experience in the courts...

 

[Espn123]

Go on.....explain. And let us know your experience in the courts...

Is it a good defense? You are an authority, I was simply wondering based on the fact it goes against consensus guidelines…

 

[lobelsteve]

If something bad happens, you are getting sued. If you have appropriate consent, imaging, technique, etc. it means little compared ro the skills of your attorney.
With IOM, you are notified you are screwed the moment it happens.

 

[Espn123]

If something bad happens, you are getting sued. If you have appropriate consent, imaging, technique, etc. it means little compared ro the skills of your attorney.
With IOM, you are notified you are screwed the moment it happens.

Honest question here and changing gears - so if you follow generally accepted practices and still there is a complication (that is mentioned as possible in the consent) are you still on the hook in most cases?
Any other pearls for avoiding litigation throughout a career?

 

[lobelsteve]

Bad outcomes associated with suit being filed. No deviation from SOC generally means winning the suit. Before trial. But our system penalizes us for just being named.

 

[RoloTomassi]

Any other pearls for avoiding litigation throughout a career?

Like Steve said, don't deviate from SOC but also:

-Document exactly what was said regarding the risks, alternative options, etc. not just "obtained consent"
-Document medical necessity for the procedure
-Document thorough procedure notes that are defensive, ie explain why you got the lateral/CLO views, what they showed, what they didn't show
-Be likeable. Statistically much less likely to get sued if patient likes you.
-If there is even a potential complication, be all over it. Phone calls, stat work-in, MRI, ER--all documented to CYA.
-If there is a complication, be even more all over it. That's going to be your personal VIP patient for life (or at least your state's statute of limitations). Docs have tendency to distance themselves. Patients sue when they feel they are left high and dry. If you show empathy and tell them you are going to manage their complication every step of the way, less likely to get sued.