Sedation In Prone Position For Pain Cases

[soorg]

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Any tips on how to avoid apnea? Who's using what drugs? Any considerations in the obese/OSA patients?

I use only propofol, usually 150 mg bolus. Pt. remains immobile for whatever steroid they're injecting, and no one goes apneic. If they're chunky, about 80-100 mg, and I warn the painologist that they're going to move for the initial local injection...

 

[sevoflurane]

150mg bolus will cause apnea in a lot of patients. The key to MAC is titration. Small amounts, asses.... Go up or down. Infusion Pumps are good when you start out.

 

[midazme]

150mg bolus will cause apnea in a lot of patients. The key to MAC is titration. Small amounts, asses.... Go up or down. Infusion Pumps are good when you start out.

i'm all for getting some action, but MAC cases hardly seem like the time for booty calls.

 

[sevoflurane]

Assess.....

Plenty 'o booty in those rooms...

 

[countingdays]

Any tips on how to avoid apnea? Who's using what drugs? Any considerations in the obese/OSA patients?

I use only propofol, usually 150 mg bolus. Pt. remains immobile for whatever steroid they're injecting, and no one goes apneic. If they're chunky, about 80-100 mg, and I warn the painologist that they're going to move for the initial local injection...

Avoid apnea by slowly working in your propofol. Of course that's hard if the pain guy if poking needles in the patient at roughly the same time as you roll into the room before you can even put a pulseox on. Ass.

 

[lobelsteve]

If your pain guy had any skills, he wouldn't need sedation. All risk, little reward. Sedate so when he injects intraneural or goes into a small artery, you don't know til wakeup. Make him do his own sedation.

 

[Ketafol20]

Tis seems extremely odd to me on a number of fronts.
First, why do your pain guys need such sedation?
Second, I induce most of my pts with 150 mg of propofol for surgery.
Third, refer to my login name.

 

[jwk]

If your pain guy had any skills, he wouldn't need sedation. All risk, little reward. Sedate so when he injects intraneural or goes into a small artery, you don't know til wakeup. Make him do his own sedation.

You may find it unnecessary in your practice, but it's done in lots of places. Conscious sedation is perfectly acceptable for pain block cases.

 

[Ketafol20]

You may find it unnecessary in your practice, but it's done in lots of places. Conscious sedation is perfectly acceptable for pain block cases.

Really?
I guess if we want to run up the cost of healthcare. Sure there are cases that may require MAC but not that many.

 

[epidural man]

Any tips on how to avoid apnea? Who's using what drugs? Any considerations in the obese/OSA patients?

I use only propofol, usually 150 mg bolus. Pt. remains immobile for whatever steroid they're injecting, and no one goes apneic. If they're chunky, about 80-100 mg, and I warn the painologist that they're going to move for the initial local injection...

I assume you are talking about Spinal Cord Implant cases - all other pain procedures shouldn't need an anesthesiologist to do the block and steve is right - make them do their own. If they are doing a pump case - just use general. Actually, I use propofol for my celiac plexus blocks as those cancer patients often have a hard time tolerating the prone position - but you don't need much - so propofol for those works great (so I guess I MOSTLY agree with steve). Plus, I make the anesthesia resident rotating through pain do that - cruel I know.....

However, for SCS implantation, we have really found precedex to work extremely well - because at some part, the patient needs to be cooperative and responsive. The precedex keeps them nice and chill and not moving for the lead placement. Encourage your pain guys to use tons of local...that keeps the patient from moving, but that is true with any MAC case.

 

[epidural man]

Oh, and by the way...having been on both sides of the curtain on those cases, I HATE doing the anesthesia for them. They are difficult cases. Good luck. (seriously...use precedex)

 

[Ketafol20]

However, for SCS implantation, we have really found precedex to work extremely well - because at some part, the patient needs to be cooperative and responsive. The precedex keeps them nice and chill and not moving for the lead placement. Encourage your pain guys to use tons of local...that keeps the patient from moving, but that is true with any MAC case.

Spinals work great for SCS placement cases.

 

[jwk]

Really?
I guess if we want to run up the cost of healthcare. Sure there are cases that may require MAC but not that many.

There's a difference between MAC and conscious sedation. I didn't mention MAC, and agree that most cases certainly would not need that. However, lobelsteve's implies that only lousy practitioners use sedation at all, which I think is simply incorrect.

 

[Ketafol20]

There's a difference between MAC and conscious sedation. I didn't mention MAC, and agree that most cases certainly would not need that. However, lobelsteve's implies that only lousy practitioners use sedation at all, which I think is simply incorrect.

That's more clear, thx.

 

[Trisomy13]

I came from a training program where all the LESI, SI joint, etc. were done in the office. No sedation. Maybe 2mg versed for the MBB RF ablations. Now I practice at a place where they all get MAC in the surgery center. It's overkill, unnecessary, and adds 20+ cases. I don't get it. I rarely get stuck in that room but when I do it's usually 30 mg propofol for the local infiltration, just so I have something to chart.

 

[jwk]

I came from a training program where all the LESI, SI joint, etc. were done in the office. No sedation. Maybe 2mg versed for the MBB RF ablations. Now I practice at a place where they all get MAC in the surgery center. It's overkill, unnecessary, and adds 20+ cases. I don't get it. I rarely get stuck in that room but when I do it's usually 30 mg propofol for the local infiltration, just so I have something to chart.

Easier $$$ than the butt hut!

 

[epidural man]

Spinals work great for SCS placement cases.

This is a joke, right?

 

[Jeff05]

Spinals work great for SCS placement cases.

Not sure how that works since you need to test stim prior to closing.

 

[Gasworks]

I do 2 types of pain cases.. the clean service is in the hospital where 100mcg of fentanyl plus a few 20mg prop boluses are enough since none of the patients are on heavy narcs and the docs are lightning quick. The other type of practice is the in the surgery center where the patients tend to be hardcore addicts on massive doses of oxy/roxy plus high dose benzos. Our docs there are also on the slow side so it isn't rare for me to use 2mg versed + 100 mcg fentanyl + 4-5 bottles of prop for an approx 10-15 minute procedure. That usually keeps them out long enough to get to pacu where the screaming for dilaudid starts. As far as technique goes, I crank up the O2 and gradually titrate to no EtCO2 whether its apnea or obstruction and just wait for breathing to come back before I give more. As long as you give fentanyl up front and keep some narcan handy you have a rescue path if you overshoot on the prop. It is also most definitely overkill for what is essentially an office procedure but the patients are very happy to have zero awareness & recall and the docs love having a barely moving patient to work on.

 

[Gasworks]

I came from a training program where all the LESI, SI joint, etc. were done in the office. No sedation. Maybe 2mg versed for the MBB RF ablations. Now I practice at a place where they all get MAC in the surgery center. It's overkill, unnecessary, and adds 20+ cases. I don't get it. I rarely get stuck in that room but when I do it's usually 30 mg propofol for the local infiltration, just so I have something to chart.

I'll be happy to come work that room. 20+ insured ESI's a day is a nice little independent practice!

 

[sevoflurane]

The only cases we are involved in are the ones where a battery pocket will be created... ie dorsal column stimulators/ sacral stimulators/ etc. We are helpful in those cases....especially if the patient has hyperalgesia.

 

[ssmallz]

I've done some for minimally invasive lumbar decompression. 1-2mg versed, 50mcg fentanyl and 30mcg/kg/min of propofol, titrate up and down prn. The pain guys are really great about using local and this usually chills the pt out enough to tolerate the procedure but they are awake enough to be responsive

 

[Ketafol20]

This is a joke, right?

No joke.

 

[Ketafol20]

Not sure how that works since you need to test stim prior to closing.

You are testing spinal cord stim not nerve root stim. Therefore, it works very well. The pts are able to verify accurate placement.

 

[epidural man]

No joke.

Wow. I tip my hat to you. I must say you are by far the most skilled spinal placer I have run across. Those are mad skills to be able to do that.

 

[epidural man]

No joke.

http://www.ncbi.nlm.nih.gov/pubmed/14580282

 

[Ketafol20]

Wow. I tip my hat to you. I must say you are by far the most skilled spinal placer I have run across. Those are mad skills to be able to do that.

Thanks, I think😕

I cant tell if you are poking fun at me or not. Not too many people here hand out praise like that.
👍

 

[lobelsteve]

Making fun. SCS should not be placed under GA or without ability to have patient fully awake to verify appropriate parasthesia location.

 

[epidural man]

Thanks, I think😕

I cant tell if you are poking fun at me or not. Not too many people here hand out praise like that.
👍

I was, but then I saw that article I linked - and was humbled. I had no idea these were being placed under spinal. That is why I posted the link to show can 'eat crow' as well. Apparently, it can work - so good on ya.

However, I don't think I would want to implant someone under spinal.

 

[Ketafol20]

Making fun. SCS should not be placed under GA or without ability to have patient fully awake to verify appropriate parasthesia location.

Yes and this is why the spinal works so damn well. The pt can be "fully" awake in order to verify appropriate placement.

Make fun all you wish. But there is more than one way to skin a cat. And some are better than others. 😉

 

[Ketafol20]

However, I don't think I would want to implant someone under spinal.

why not?

 

[lobelsteve]

Yes and this is why the spinal works so damn well. The pt can be "fully" awake in order to verify appropriate placement.

Make fun all you wish. But there is more than one way to skin a cat. And some are better than others. 😉

The spinal technique is really interesting and I have never seen it used. Tough wrapping the brain around it. Was it a single shot or catheter? Would you still give a little versed iv?

 

[Ketafol20]

The spinal technique is really interesting and I have never seen it used. Tough wrapping the brain around it. Was it a single shot or catheter? Would you still give a little versed iv?

I've only used single shot spinals for this. Versed can be used but it isnt mandatory. Pt dependent of course.

 

[epidural man]

Yes and this is why the spinal works so damn well. The pt can be "fully" awake in order to verify appropriate placement.

Make fun all you wish. But there is more than one way to skin a cat. And some are better than others. 😉

But if he is fully awake, but completely numb, how do you test?

That article said that it worked....at least in that series, but they needed a lot higher voltages to test. As mentioned, it's just a hard pill to swallow.

 

[epidural man]

why not?

Sometimes it is hard to get coverage of the area you are wanting to stimulate. It can be frustrating.

What concerns me about doing it under a spinal, is if it happens that I can't get coverage or I am unable to stimulate the area of pain - is it because of the patient's anatomy? Or is it because the spinal has changed the way the spinal cord responds to stimulation (all that sodium channel blocking and such.)

For pain in the leg or back (a very typical scenario), the SCS leads can be placed anywhere from T8 below. Your spinal will most likely numb this area.

In general I think spinals are the best anesthetic we can give to a patient if the surgery is appropriate. Having said that, I have never heard of it for an SCS. It would be cool to see done - and maybe make a believer out of me.... If it could be shown to not interfere with testing -

but again, that just seems so strange to me that you give a block strong enough to take out complete sensory and motor - but still able to stimulate.....I don't know. Interesting to say the least.

 

[Ketafol20]

Just reading your comments makes me think you are starting to come around.😉

I haven't had trouble with the pt needing higher voltages to test. Like I said, the spinal works on the nerve roots not the SC. Thoracic placement is fine bc it's mostly the generator pocket that requires all the sedation in these pts. And the pocket is still within the spinal distribution.

I am not saying that we should be doing all of the SCS's this way. I still do some with sedation on the easier pts. And that sedation is pretty minimal, a little versed and maybe some fentanyl. As long as the local is liberal. But for those difficult pts that "request" huge doses of narcotics whether they need them or not, this is a good alternative. And who knows, after you try a few you may like it so much that you do them all this way. It can take longer to DC them if you place them quickly. Which is why I still do some with sedation.

 

[cleansocks]

I have to say spinals sound like a wonderful solution to these terrible anesthetics but convincing surgeons of that sounds challenging to say the least.

When I was a CA1 I had two SCS placement/testings in a row where the surgeon insisted the prone obese OSA chronic pain patient not move, not complain at all. Had to titrate up remi and propofol slowly (much to the surgeons dismay - the slowly part I mean) to the balance point where they were asleep making good CENTRAL respiratory effort. Despite that those flubbery patients couldn't maintain an open airway prone to save their lives - a nasal trumpet did the trick both times. Terrible experience with an unpleasant surgeon though.

Pain adjuncts next time! Some combination of ketamine, magnesium, lidocaine gtt depending on how much the surgeons use themselves, precedex. The thing about ketamine though is if u give too much u can't just wake them up on a dime for the test dose.

 

[jetproppilot]

There's a difference between MAC and conscious sedation. I didn't mention MAC, and agree that most cases certainly would not need that. However, lobelsteve's implies that only lousy practitioners use sedation at all, which I think is simply incorrect.

As always JWK,

you are right.👍

 

[lushmd]

At one of the hospitals that I've rotated through they do these cases using a combination of an epidural catheter (which is removed by the surgeon during the case) and light MAC. Seems to work pretty nicely.

 

[bedrock]

There's a difference between MAC and conscious sedation. I didn't mention MAC, and agree that most cases certainly would not need that. However, lobelsteve's implies that only lousy practitioners use sedation at all, which I think is simply incorrect.

I mostly support steve on this (as generally speaks in absolutes), but definitely the majority of pain procedures don't require IV sedation/MAC.

I do close to 95% of my pain procedures in-office with PO valium and generous local. The other 5% are done at a local ASC, (about 4% IV sedation and 1% MAC).

IV sedation/MAC is not required for most pain procedures short of pump/SCS implants, vertebroplasty, etc.

 

[jwk]

I mostly support steve on this (as generally speaks in absolutes), but definitely the majority of pain procedures don't require IV sedation/MAC.

I do close to 95% of my pain procedures in-office with PO valium and generous local. The other 5% are done at a local ASC, (about 4% IV sedation and 1% MAC).

IV sedation/MAC is not required for most pain procedures short of pump/SCS implants, vertebroplasty, etc.

Nor is it required for removal of wisdom teeth, drainage of pilonidal cysts, cardioversion, or any other number of elective procedures. However, the option can and should be available for those who need or want it.

 

[bedrock]

Nor is it required for removal of wisdom teeth, drainage of pilonidal cysts, cardioversion, or any other number of elective procedures. However, the option can and should be available for those who need or want it.

Sedation will certainly be available for those patients who actually need it, but not for those who just think they need it.
Part of being a physician is making clinical decisions and not just caving to whatever the patient wants, which is particularly important in pain medicine. I don't know how much time you've spent in an outpatient pain clinic, but many chronic pain patients will say they definitely "need" IV sedation for a standard knee injection that takes 15 seconds.

 

[lobelsteve]

Nor is it required for removal of wisdom teeth, drainage of pilonidal cysts, cardioversion, or any other number of elective procedures. However, the option can and should be available for those who need or want it.

They are chronic pain patients. They want Oxyocontin, Vicosomaxanax all qid.😀

 

[jwk]

They are chronic pain patients. They want Oxyocontin, Vicosomaxanax all qid.😀

Gee Steve, I'd actually prefer to avoid Oxycontin since I work in the OR doing anesthesia 60 hrs a week. So if I get a little Versed and fentanyl to help keep me comfortable, verbal, and still during my bilateral facet blocks that give me many months of relief, I'm happy as a clam.

 

[lobelsteve]

Gee Steve, I'd actually prefer to avoid Oxycontin since I work in the OR doing anesthesia 60 hrs a week. So if I get a little Versed and fentanyl to help keep me comfortable, verbal, and still during my bilateral facet blocks that give me many months of relief, I'm happy as a clam.

Missing the point. Pain patients aren't OR patients. They will want fent/versed for cutting their nails if they could get it. We practice in different worlds, even when I'm in the OR as the surgeon, I'd prefer my patients not get snowed out for their implants. I need them wide awake for neuromodulation trial before the implant. I think propofol is the best choice for these folks and they still are often too sedated for my comfort level in interpreting their responses to the stimulation. I'm glad there is an Anesthesiologist on the other side of the curtain whenever I'm in the OR. I use sedation for vertebroplasty, SCS trial, and disco only half the time. I rarely if ever need it for RF and do not use it for MBB, ESI, SIJ. I do use a minimum of 5 cc local in every case. Rarely anything more than a pin prick. Thousands of cases between me and the fellows I've trained.

 

[Noyac]

Missing the point. Pain patients aren't OR patients. They will want fent/versed for cutting their nails if they could get it. We practice in different worlds, even when I'm in the OR as the surgeon, I'd prefer my patients not get snowed out for their implants. I need them wide awake for neuromodulation trial before the implant. I think propofol is the best choice for these folks and they still are often too sedated for my comfort level in interpreting their responses to the stimulation.

I have done spinals for SCS case for over 10 yrs now. It works great for those that want Fent/versed for a hair cut. You can still give a whiff of versed and even some Fent to keep them happy but they are not at all sedated. It is an excellent way to do these cases.

 

[ghost dog]

Gee Steve, I'd actually prefer to avoid Oxycontin since I work in the OR doing anesthesia 60 hrs a week. So if I get a little Versed and fentanyl to help keep me comfortable, verbal, and still during my bilateral facet blocks that give me many months of relief, I'm happy as a clam.

Gee, balancing between you being as a "happy as a clam" OR potentially missing / noticing a local anesthetic tox rxn later than would have been recognized due to sedation ?

No contest. Pts don't typically need sedation for most pain procedures (eg. mbb).

 

[jwk]

Gee, balancing between you being as a "happy as a clam" OR potentially missing / noticing a local anesthetic tox rxn later than would have been recognized due to sedation ?

No contest. Pts don't typically need sedation for most pain procedures (eg. mbb).

I think you both missed the point - I'm the patient. I don't want to be on oxycontin, soma, xanax, et al while trying to administer anesthesia to a patient. (BTW, how much local are you giving that you're worried about a toxic reaction?)

If you want to save money in your own clinic by not offering IV sedation, fine, that's your call. I've had pain procedures without sedation, and I don't like it. So if the service is available, why wouldn't I take advantage of it?

 

[ghost dog]

I think you both missed the point - I'm the patient. I don't want to be on oxycontin, soma, xanax, et al while trying to administer anesthesia to a patient. (BTW, how much local are you giving that you're worried about a toxic reaction?)

If you want to save money in your own clinic by not offering IV sedation, fine, that's your call. I've had pain procedures without sedation, and I don't like it. So if the service is available, why wouldn't I take advantage of it?

Have you seen a LA tox rxn?

One of the more common reasons (if not the most common) is inadvertent vascular / IV infiltration. This can occur even in very experienced hands, and with
therapeutic doses.

When it occurs, you better look sharp and get your game face on.

Sedation will NOT simply things in this sort of scenario.

I myself have received neural blockade, and no, you don't require sedation for this sort of procedure. Gimme a break. What gauge needle did you receive ??

 

[pjl]

We do single shot epidurals in the area of the pack placement. T8-9ish most of the time. Then light propofol if needed, turned off when it is time for the stim testing.