Sedation In Prone Position For Pain Cases

[epidural man]

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Sedation will NOT simply things in this sort of scenario.

Actually, versed might - it raises the seizure threshold - and is the treatment for seizures.

I like some milllooooograms for my patients when doing nerve blocks on them for this reason.

 

[epidural man]

Sedation or not in pain procedures....an endless (and probably pointless) debate.

I'll say this about it....most of the closed claims injuries in pain clinics - when really bad sheeet happened - has been under sedation - so the truth is, many of us IN OUR CLINICS don't do it because it is safer - and frankly a lot quicker to not use it.

However, in the OR - with an anesthesiologist/CRNA doing the sedation - probably not as much of an issue - so if people practice that way, it seems reasonable and the patients will most likely appreciate it.

I have had several patients that after doing the block - I WISH I had used sedation. My fellow made 3 people cry last week! I don't think in the years I have been doing this I can remember making someone cry. Two of them were guys for pete's sake. One of them was a stellate ganglion block - wish I had sedation for that case.

But to bring back to topic - i'll state again - precedex works great in SCS cases - the patient sleeps, but will be wide awake for the testing when needed.

Spinal seems interesting to me - I like the idea if it works, which it apparently does. Maybe i'll have the balls to try it some day.

 

[ghost dog]

Sedation or not in pain procedures....an endless (and probably pointless) debate.

I'll say this about it....most of the closed claims injuries in pain clinics - when really bad sheeet happened - has been under sedation - so the truth is, many of us IN OUR CLINICS don't do it because it is safer - and frankly a lot quicker to not use it.

However, in the OR - with an anesthesiologist/CRNA doing the sedation - probably not as much of an issue - so if people practice that way, it seems reasonable and the patients will most likely appreciate it.

I have had several patients that after doing the block - I WISH I had used sedation. My fellow made 3 people cry last week! I don't think in the years I have been doing this I can remember making someone cry. Two of them were guys for pete's sake. One of them was a stellate ganglion block - wish I had sedation for that case.

But to bring back to topic - i'll state again - precedex works great in SCS cases - the patient sleeps, but will be wide awake for the testing when needed.

Spinal seems interesting to me - I like the idea if it works, which it apparently does. Maybe i'll have the balls to try it some day.

Some of this "vocalization" is pain amplification behavior, pure and simple. I have received some of the more benign nerve block procedures (admittedly not a stellate); they ain't that painful.

When your 40 year old male patient is squealing like a little boy /girl during the injections, and your 70 year old scottish lady doesn't make a peep during same said procedure, somethings up....😎

 

[jwk]

Maybe it's just that anesthesiology-trained pain docs are much more used to and comfortable with procedural sedation across a broad continuum and may be more likely to use it.

 

[lobelsteve]

Maybe it's just that anesthesiology-trained pain docs are much more used to and comfortable with procedural sedation across a broad continuum and may be more likely to use it.

That does not make it medically appropriate.

 

[sevoflurane]

Going with jwk on this one. I see no issues with a little versed and fent for a narcotic tolerant patient. No issue at all. They might even appreciate that light sedation. 😉

 

[jwk]

That does not make it medically appropriate.

You could make that same argument with any number of procedures - EGD's and colonoscopies, bronchoscopies. All can be done with zero sedation. And let's see - what are the medical indications and appropriateness for breast augmentations, botox injections, and other plastic surgery procedures ad nauseum?

Clearly there are lots of different ways to do any number of procedures "correctly", and myriad ideas of what constitutes "medically appropriate". To each his own. My original issue was with your assertion that " If your pain guy had any skills, he wouldn't need sedation", which I still think is an incorrect statement.

 

[sevoflurane]

Ok... you are the chronic pain patient getting a SCS. They get you on your belly then expose your ***** to a room full of people. 🙁 The prep is cold and you don't know what is going on. 🙁 You get good placement of your leads while the rep is loudly 🙁 asking you how and where it feels....

and then it's time for the subQ pocket that will house the battery + tunneling....

Patient: Ouch! 🙁

Pain Dude: Oh.. sorry... can I get some more local? 😳

Maybe repeat once or twice.



It happens all the time. Even to the best of the local gurus.

Some mild sedation (precedex, fent, midaz, alfenta... whatever) can make a lot of difference to your patients... and if you know what you are doing, there is minuscule risk if at all.

But it is NOT an absolutely necessary.

My 2 cents. 🙂

 

[lobelsteve]

Going with jwk on this one. I see no issues with a little versed and fent for a narcotic tolerant patient. No issue at all. They might even appreciate that light sedation. 😉

You've maybe never had patients come in for the sedation and get the CESI just to have the sedation.

 

[sevoflurane]

You've maybe never had patients come in for the sedation and get the CESI just to have the sedation.

Then they don't need the procedure. It's hard to tell sometimes.

FWIW, lobelsteve... The only patients I don't give a little something to is my OB population. Open belly needing an epidural... they always get sedation for their epidural placement. I could just go with local, but I choose not to. This includes all the LESI's that our group performs. Just makes the whole experience more pleasant for the patient. We may be splitting hairs a little, but worth the discussion.

 

[lobelsteve]

Then they don't need the procedure. It's hard to tell sometimes.

FWIW, lobelsteve... The only patients I don't give a little something to is my OB population. Open belly needing an epidural... they always get sedation for their epidural placement. I could just go with local, but I choose not to. This includes all the LESI's that our group performs. Just makes the whole experience more pleasant for the patient. We may be splitting hairs a little, but worth the discussion.

Yes, I use propofol via an Anes. for my implants.
But pain patient's are a different bag. THey could be going for the drug and not the procedure. Many are less than honest in their presentations. It just goes with the territory.

 

[Arch Guillotti]

You could make that same argument with any number of procedures - EGD's and colonoscopies, bronchoscopies. All can be done with zero sedation.

I don't think comparing a block to the above is a very good comparison.

 

[ghost dog]

Going with jwk on this one. I see no issues with a little versed and fent for a narcotic tolerant patient. No issue at all. They might even appreciate that light sedation. 😉

I guess the question is how much the "appreciation factor" enters into the equation in regards to the chronic pain population, and how appropriate this is in regards to a minimally invasive procedure (such as a MBB).

I have received a MBB, and I had minimal discomfort with no sedation at all. However, I am not your average patient. I think a significant portion of the discomfort pts experience with such a procedure is a psychological component / fear of the unknown. To a certain extent, this can be addressed with a fulsome discussion of the procedure.

 

[jwk]

I get the impression that it's the anesthesia guys who generally have no issues with IV sedation for blocks, and the PMR guys that do.

I've had a spinal and an epidural placed for surgery, both done without sedation. They sucked. I've had local infiltration for removal of a rather large skin lesion. It sucked. I had a metacarpal block when I attempted to slice off my finger with a table saw. That REALLY sucked.

You want yours done without sedation - fine. Maybe you're just manly men and can "take it". But having been on the patient side of various blocks on more than one occasion, I'm glad I have the choice, and it's a real easy one because I work with great anesthesia-trained pain docs who aren't afraid to offer IV conscious sedation to their patients (including me) that would clearly benefit from it. With the exception of OB patients, we sedate virtually all of our patients having blocks placed for surgery and post op pain, so I just don't get what the big deal is. I had no idea that there was such a difference in philosophy. Maybe we should market that aspect of our practice.

 

[lobelsteve]

I get the impression that it's the anesthesia guys who generally have no issues with IV sedation for blocks, and the PMR guys that do.

I've had a spinal and an epidural placed for surgery, both done without sedation. They sucked. I've had local infiltration for removal of a rather large skin lesion. It sucked. I had a metacarpal block when I attempted to slice off my finger with a table saw. That REALLY sucked.

You want yours done without sedation - fine. Maybe you're just manly men and can "take it". But having been on the patient side of various blocks on more than one occasion, I'm glad I have the choice, and it's a real easy one because I work with great anesthesia-trained pain docs who aren't afraid to offer IV conscious sedation to their patients (including me) that would clearly benefit from it. With the exception of OB patients, we sedate virtually all of our patients having blocks placed for surgery and post op pain, so I just don't get what the big deal is. I had no idea that there was such a difference in philosophy. Maybe we should market that aspect of our practice.

Yes, you should. Do you accept Medicaid? 😀

 

[bedrock]

Yes, you should. Do you accept Medicaid? 😀

Exactly, you can corner the market on the Medicaid patients who will happily undergo all kinds of procedures just to get the high from the sedation.

You won't be reimbursed for the sedation and will make about $35 per procedure. That should supply the necessary seed money to expand your practice, as you'll "own" that market.

 

[jwk]

Exactly, you can corner the market on the Medicaid patients who will happily undergo all kinds of procedures just to get the high from the sedation.

You won't be reimbursed for the sedation and will make about $35 per procedure. That should supply the necessary seed money to expand your practice, as you'll "own" that market.

We see and treat as indicated every patient that walks in the door. Do you guys do the same?

 

[lobelsteve]

We see and treat as indicated every patient that walks in the door. Do you guys do the same?

No. We do not accept medicaid and I let know self-pay patients know ahead of the visit that I'll happily evaluate but do not Rx controlled substances. THey then drive to Atlanta to see you. 😉

 

[ghost dog]

I get the impression that it's the anesthesia guys who generally have no issues with IV sedation for blocks, and the PMR guys that do.

I've had a spinal and an epidural placed for surgery, both done without sedation. They sucked. I've had local infiltration for removal of a rather large skin lesion. It sucked. I had a metacarpal block when I attempted to slice off my finger with a table saw. That REALLY sucked.

You want yours done without sedation - fine. Maybe you're just manly men and can "take it". But having been on the patient side of various blocks on more than one occasion, I'm glad I have the choice, and it's a real easy one because I work with great anesthesia-trained pain docs who aren't afraid to offer IV conscious sedation to their patients (including me) that would clearly benefit from it. With the exception of OB patients, we sedate virtually all of our patients having blocks placed for surgery and post op pain, so I just don't get what the big deal is. I had no idea that there was such a difference in philosophy. Maybe we should market that aspect of our practice.

"great" anesthesia-trained pain docs? Isn't amazing how a patient's perception of their health care provider's awesomeness is directly related to whether or not they get what they want?

Who would of thunk it? 😀