Sedation for MB RF

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IV sedation helps patients with fellows doing RFAs with 18g cannulas. Almost every RFA gets some sedation.

MBBs I can generally get them to avoid sedation, but the amount of needle movements and lack of hand holding by the ancillary team makes sedation easier in some of these patients. If they need sedation, I try to use just Versed at 0.5 - 1 mg IV.

I've done it MAC/GA but that's the 1-2% in an academic center where I'm in the hospital because of weight/AICD/LVAD/etc and the anesthesia team gets aggressive/protective
 
I give oral diazepam 10mg for a pretty large percentage of my cervical rfa’s, very few of the lumbar get anything.

I have had to get about 1000% nicer in private practice. I am so kind and smooth talking them through procedures, I am exhausted from all of theatrics at the end of the day. But I don’t want them to get off the table and leave. 😂
 
Just so we're on the same page, this discussion is regarding oral/IV vs. no sedation for RFA, not for MBB.

No one here actually gives any form of sedation or knows someone who gives sedation for MBB I hope.
 
hopefulgasman said:
Just so we're on the same page, this discussion is regarding oral/IV vs. no sedation for RFA, not for MBB.

No one here actually gives any form of sedation or knows someone who gives sedation for MBB I hope.
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Yes. RF only
 
There are many fellowship trained board certified docs still doing iv sedation for rf around here. All of them that do it this way
 
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hopefulgasman said:
Just so we're on the same page, this discussion is regarding oral/IV vs. no sedation for RFA, not for MBB.

No one here actually gives any form of sedation or knows someone who gives sedation for MBB I hope.
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Local OON practice gives IV sedation for almost everything in their ASC including MBB's.
 
GatorCHOMPions said:
Local OON practice gives IV sedation for almost everything in their ASC including MBB's.
Click to expand...
That is crazy. Probably hurts more to give IV than to do MBB with local. Most patients can tolerate 25 gauge needles without any local at the skin. IV sedation for MBB invalidates the diagnostic test in my mind. They probably sleep the rest of the day and report 100% relief. Leads to a lot of false positives.

I don't see an issue with offering PO/IV sedation with RFA. Beating a dead horse on this one.
 
Scottie_Dog said:
That is crazy. Probably hurts more to give IV than to do MBB with local. Most patients can tolerate 25 gauge needles without any local at the skin. IV sedation for MBB invalidates the diagnostic test in my mind. They probably sleep the rest of the day and report 100% relief. Leads to a lot of false positives.

I don't see an issue with offering PO/IV sedation with RFA. Beating a dead horse on this one.
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I’be heard of people using propofol for the procedure so there was no lingering effects of the sedative. Yep, crazy.
 
hopefulgasman said:
Just so we're on the same page, this discussion is regarding oral/IV vs. no sedation for RFA, not for MBB.

No one here actually gives any form of sedation or knows someone who gives sedation for MBB I hope.
Click to expand...
I’ve gotten grief for not giving sedation for lumbar and cervical MBBs as a newish attending when the other doc here does it. I just explain my rationale why and the patient can take it or leave it.
 
Anyone in this thread an Anesthesiologist? Why is there so much machismo over avoiding light to moderate sedation?

Oral diazepam or small doses of IV fentanyl or midazolam are very safe if administered judiciously. Don't need an anesthesia team either if your ASC can provide a sedation nurse who gives the medications under your orders. CPT 99152 (different than MAC anesthesia services that are often denied by insurance).

And yes, standard of care in my neck of the woods is RF with some sort of sedation. No, I do not think anyone should be getting propofol for pain procedures.

For those asking, for smaller or older patients, I use 5 mg oral diazepam. For younger and healthy (and usually more anxious) patients, 10 mg does the trick.
 
Darkside_ said:
Anyone in this thread an Anesthesiologist? Why is there so much machismo over avoiding light to moderate sedation?

Oral diazepam or small doses of IV fentanyl or midazolam are very safe if administered judiciously. Don't need an anesthesia team either if your ASC can provide a sedation nurse who gives the medications under your orders. CPT 99152 (different than MAC anesthesia services that are often denied by insurance).

And yes, standard of care in my neck of the woods is RF with some sort of sedation. No, I do not think anyone should be getting propofol for pain procedures.

For those asking, for smaller or older patients, I use 5 mg oral diazepam. For younger and healthy (and usually more anxious) patients, 10 mg does the trick.
Click to expand...
Because it is completely unnecessary. And recommended against by our societies. Increase risk with no benefit.
I see it as an inducement to do further procedures.
 
I agree there is too much machismo/bravado about not using sedation. It's not that big of a deal. Now if some practices give it as a standard of practice and patients aren't even made aware it can be done under local - that's nuts.

Also, propofol is arguably safer than midazolam from a pharmacological perspective. Just because midazolam has a reversal agent doesn't make it not potentially very dangerous. To the commenter above who wrote "... using propofol for the procedure so there was no lingering effects of the sedative. Yep, crazy." But what is crazy about that rationale? The lingering effects of benzos are not to be written off and propofol doesn't have this effect. We would very commonly give propofol as a mild sedative/anxiolytic when transporting a patient to surgery (as an anesthesiologist) from preop instead of midazolam for the very purpose of avoiding the lingering effects of midazolam, especially if the surgery was short. To be clear, I'm not arguing for the use of IV sedatives as a matter of routine for pain procedures. But propofol is arguably much safer than midazolam/fentanyl. Oh but "that's the drug that killed Michael Jackson" so it should never be used. OK.
 
IAmTheOne1 said:
I agree there is too much machismo/bravado about not using sedation. It's not that big of a deal. Now if some practices give it as a standard of practice and patients aren't even made aware it can be done under local - that's nuts.

Also, propofol is arguably safer than midazolam from a pharmacological perspective. Just because midazolam has a reversal agent doesn't make it not potentially very dangerous. To the commenter above who wrote "... using propofol for the procedure so there was no lingering effects of the sedative. Yep, crazy." But what is crazy about that rationale? The lingering effects of benzos are not to be written off and propofol doesn't have this effect. We would very commonly give propofol as a mild sedative/anxiolytic when transporting a patient to surgery (as an anesthesiologist) from preop instead of midazolam for the very purpose of avoiding the lingering effects of midazolam, especially if the surgery was short. To be clear, I'm not arguing for the use of IV sedatives as a matter of routine for pain procedures. But propofol is arguably much safer than midazolam/fentanyl. Oh but "that's the drug that killed Michael Jackson" so it should never be used. OK.
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its not the idea that sedation itself is dangerous. its that the procedures we do have increased morbidity when sedation is used. particularly CESI. how is the patient going to tell you that you are injecting their cord if they are sedated under propofol? or really drowsy with versed/fentanyl? actually, doc, that really hurts my leg as the RF probe is ramping up. recipe for disaster.
 
Nonsense.

Put an IV in a patient and make them fast overnight for a lumbar ESI?

What do all those drugs and supplies cost over the course of a year? Staffing requirements increase. Slows the entire process down substantially.

That's not even taking into account the microplastics you're injecting into that patient.
 
oral benzodiazepine really is not "sedation".

it is more of an anxiolytic.

with regards to true IV sedation, there is clear evidence (Anesthesia Closed Claim database) that sedation has been associated with increased risk for spinal cord injury particularly with cervical epidurals.
 
I don't know how much people are giving to cause someone to be unresponsive during an RFA or a CESI or whatever injection. If I do any procedure under IV sedation, they are fully able to carry out a back and forth conversation.

You might argue then what is the point of the sedation? For a select few number of patients, it makes a difference for them.

Anywhere in the vicinity of losing consciousness is not acceptable for pain procedures - this I can agree with entirely.
 
Moderate Sedation/Analgesia (“Conscious Sedation”) is a drug-induced depression of consciousness during which patients respond purposefully** to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.
 
Our group has about half the docs, who are very against sedation for any MBB saying it'll throw off the results, even 1 or 2mg of versed. This is mostly the older ones. Versus the younger ones seem to have sedated everything with versed in fellowship. The argument is helping with the anxiety of 6 needle pokes, and shouldn't change pain, like an opioid.
I've heard opinions like they could just premedicate themselves before coming in Tylenol, nsaids, lido cream, or opioids or their Xanax that the PCP gives them, so how is it different than us giving it.

Insurance has no issues paying for epidural sedation, but doesn't like it for mbbs from what I've seen.
Is there any rule against giving it cash pay for 30 bucks for 1 or 2mg versed or do you have any insurance rules against it that I could point to?

I'm split on it, some people cannot sit still and fidget, but I certainly think it can make things worse too.
 
itzamemario said:
Our group has about half the docs, who are very against sedation for any MBB saying it'll throw off the results, even 1 or 2mg of versed. This is mostly the older ones. Versus the younger ones seem to have sedated everything with versed in fellowship. The argument is helping with the anxiety of 6 needle pokes, and shouldn't change pain, like an opioid.
I've heard opinions like they could just premedicate themselves before coming in Tylenol, nsaids, lido cream, or opioids or their Xanax that the PCP gives them, so how is it different than us giving it.

Insurance has no issues paying for epidural sedation, but doesn't like it for mbbs from what I've seen.
Is there any rule against giving it cash pay for 30 bucks for 1 or 2mg versed or do you have any insurance rules against it that I could point to?

I'm split on it, some people cannot sit still and fidget, but I certainly think it can make things worse too.
Click to expand...
If they cannot be still for MBB, they do not need interventional care.
 
in terms of MAC or moderate sedation, yes there are CMS guidelines.

Limitations

  1. Facet joint interventions done without CT or fluoroscopic guidance are considered not reasonable and necessary. This includes facet joint interventions done without any guidance, performed under ultrasound guidance, or with magnetic resonance imaging (MRI).
  2. Use of Moderate or Deep Sedation, General Anesthesia, and Monitored Anesthesia Care (MAC) is not considered medically reasonable and necessary during facet procedures of IA, MBB, and facet cyst aspiration/rupture.
Click to expand...

oral valium is for the most part considered anxiolysis or light sedation, so technically the above may not apply.

one local insurance carrier has denied one of my colleagues RFA for using oral sedation for MBB, but a different one has not. go figure.
 
itzamemario said:
Our group has about half the docs, who are very against sedation for any MBB saying it'll throw off the results, even 1 or 2mg of versed. This is mostly the older ones. Versus the younger ones seem to have sedated everything with versed in fellowship. The argument is helping with the anxiety of 6 needle pokes, and shouldn't change pain, like an opioid.
I've heard opinions like they could just premedicate themselves before coming in Tylenol, nsaids, lido cream, or opioids or their Xanax that the PCP gives them, so how is it different than us giving it.

Insurance has no issues paying for epidural sedation, but doesn't like it for mbbs from what I've seen.
Is there any rule against giving it cash pay for 30 bucks for 1 or 2mg versed or do you have any insurance rules against it that I could point to?

I'm split on it, some people cannot sit still and fidget, but I certainly think it can make things worse too.
Click to expand...
dont use sedation for MBBs. it slows you down, its more paperwork, its unnecessary, and it may throw off the results.
 
Ducttape said:
in terms of MAC or moderate sedation, yes there are CMS guidelines.



oral valium is for the most part considered anxiolysis or light sedation, so technically the above may not apply.

one local insurance carrier has denied one of my colleagues RFA for using oral sedation for MBB, but a different one has not. go figure.
Click to expand...
FYI those guidelines are for the reimbursement part of using sedation. It does not mean sedation is prohibited.
 
Ducttape said:
those are listed as limitations to the procedure from the CMS guidelines.

LCD - Facet Joint Interventions for Pain Management (L35936)

Use this page to view details for the Local Coverage Determination for Facet Joint Interventions for Pain Management.
www.cms.gov www.cms.gov
Click to expand...
Read it again. It does not mean you cannot use it. It’s not medically reasonable to use sedation. This verbiage was specifically placed to limit the reimbursement for the use of sedation.

We had a reviewer flag our ASC and try to claw back money for all facet procedures done with sedation. We sent it back to the next level of review and the money was returned.
 
Darkside_ said:
Anyone in this thread an Anesthesiologist? Why is there so much machismo over avoiding light to moderate sedation?

Oral diazepam or small doses of IV fentanyl or midazolam are very safe if administered judiciously. Don't need an anesthesia team either if your ASC can provide a sedation nurse who gives the medications under your orders. CPT 99152 (different than MAC anesthesia services that are often denied by insurance).

And yes, standard of care in my neck of the woods is RF with some sort of sedation. No, I do not think anyone should be getting propofol for pain procedures.

For those asking, for smaller or older patients, I use 5 mg oral diazepam. For younger and healthy (and usually more anxious) patients, 10 mg does the trick.
Click to expand...
I may have a unique perspective here. I am an anesthesiologist and have had 5 RFAs done personally as a patient. I did them all awake. I would describe it as a manageable challenge to get through it without complaining about the burn (The needle placements are nothing). I view it as an opportunity to demonstrate some pain tolerance and that I’m not crazy.

edit: I’d estimate 2/3 of patients I take care of for surgery could do it awake based on their responses to stimulation/pain.
 
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If you’re practicing in my neck of the woods and don’t offer patients sedation, you will have very few patients. Texans nowadays are all hat no cattle. I can get maybe 40% of my procedures to agree to local only.
 
I do probably 95% of my RFs in office, mostly with Xanax or Valium, sometimes also with a hydrocodone. I have some people who either due to anxiety or low pain tolerance or both don’t do well in office, but do get enough pain relief that they keep coming back for it when it wears off (no med management practice so they aren’t sticking around for pills). I can see the rationale for just telling those patients that if their pain threshold is too low to tolerate RF, then they’re not worth doing procedures on.

However, what do you all do with patients who are legitimately resistant to local anesthetic? I’ve asked about it before on this forum. I have maybe a couple dozen such patients. They do fine with needle placement, although it’s often noticeable that they flinch when inserting the RF needles, when I’d expect them to be numb. However, they can feel the burning with the RF, even after extra local and adjusting needle position. Incidentally, there is one study showing meoivacaine works better for those patients and that is indeed often the case. I keep a stock of it on hand. They all give a history of trouble getting numb at the dentist as well.

RFs are darn near research grade when it comes to a painful stimulus. Standard temperature, time, and placement. Very instructive on differences between patients. I don’t think these patients are just wimps - their tolerance of the rest of the procedure is similar to other patients who tolerate it in office. Not anxious (unless they’ve had bad RF experiences in the past), many of them ex-military/construction workers/salt of the earth blue collar types who are pretty stoic. But if you’re not numb, having a few 90 degree C probes in your back for 2 minutes isn’t really tolerable without some sedation.
 
Just give a little sedation. Don’t listen to all the machos here. Using sedation in some cases is not the end of the world. Well tolerated, generally very safe if you know what you are doing and have the appropriate safe guards in place.
 
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IAmTheOne1 said:
Just give a little sedation. Don’t listen to all the machos here. Using sedation in some cases is not the end of the world. Well tolerated, generally very safe if you know what you are doing and have the appropriate safe guards in place.
Click to expand...
My patients can opt to wait 6-8 weeks for IV sedation in Asc vs 1-2 weeks max in office with local and po benzo if they want….. somehow everyone does perfectly fine in the office. I place a 25 gauge 3.5-5” needle skin to bone plus skin wheal w 1% lido prior to 18g rfa. Sometimes a little more for fine-tuning on periosteum. Then 1ml 2% on mbb.

In the rare case where someone is too uncomfortable during the burn despite my 2% lidocaine….. I take my gloves off and go check messages/emails, come back in a few minutes and they then feel next to nothing.
 
When it comes ton having to poney up cash, people will suck up the “discomfort” and just take the po Valium. Some will pay the range of $300-500 for the sedation that I have to make up because anesthesia doesn’t want to get involved at all with any aspect of payment, because they are my patients even though I have no idea what they are going to have to pay…dinguses, but I digress…yeah they can pay or they can take some Valium
 
The word I put there was def not dinguses..but thanks sdn for your choice of word correction
 
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