Spinal for TKA and THA post-op pain

[Southpaw]

Classic SDN. It’s a freaking LMA. Not how I do my standard total joints, but big friggin’ whupty doo.

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[Southpaw]

And oh yeah, once the LMA is in you need very little sedation to maintain it. In fact, I find patients tolerate them much better than oral airways!

 

[Urzuz]

Classic SDN. It’s a freaking LMA. Not how I do my standard total joints, but big friggin’ whupty doo.

And oh yeah, once the LMA is in you need very little sedation to maintain it. In fact, I find patients tolerate them much better than oral airways!

Watch out, the first year graduate is about to drop some knowledge bombs on you. Take cover.

 

[facted]

I'll just leave it at this: You have a lot to learn, not the least of which is getting over your arrogance in thinking you know better than everyone else (see above - you are directly contradicting people, including Blade, who were practicing while you were probably in Huggies), and thinking your practice is far and away the best and safest without even seeing the "other side." I hope for your patients' sake you open yourself up to learning and modifying your practices based on experiences of others -- or at the very least acknowledging and seeing the utility in other practices, even if you don't adopt them yourself.

Dude, get over yourself.

 

[acidbase1]

Watch out, the first year graduate is about to drop some knowledge bombs on you. Take cover.

Bag on me all you want virtually nobody does a GETA + Neuraxial

Is there a time and place for everything? Sure, but it’s out there an pretty uncommon. The reason i can say this with quite a bit of certainty is bc i contacted folks back in residency in addition to friends all over the country. The CRNAs here do GETA + SAB every single time they do certain cases. I do the same with sedation (propofol 25-50 mcg/kg/min), rarely need an oral airway much less LMA/OETT.

It’s unnecessary and the other guys do it so they can bill for both and keep the OB happy

 

[Urzuz]

What a douche

Bag on me all you want virtually nobody does a GETA + Neuraxial

Is there a time and place for everything? Sure, but it’s out there an pretty uncommon. The reason i can say this with quite a bit of certainty is bc i contacted folks back in residency in addition to friends all over the country. The CRNAs here do GETA + SAB every single time they do certain cases. I do the same with sedation (propofol 25-50 mcg/kg/min), rarely need an oral airway much less LMA/OETT.

It’s unnecessary and the other guys do it so they can bill for both and keep the OB happy

Ok last post, but this has nothing to do with the actually discussion. Let's recap what happened: I posted initially explaining to you all why some people put LMAs in (+/- gas) for joint replacements. You (and others) said it's stupid, doesn't make sense, etc. I didn't make any inflammatory remarks about the way you practice, yet you all have the hubris to tell me and others on this board that what we are doing is wrong and unnecessary. This is AFTER I told you that plenty of people put airway devices in following a spinal. Despite what all the people you contacted said, you should understand that practices vary drastically geographically and from institution to institution. I am here telling you that I trained at a very good anesthesia residency program, and I know many other people (including myself) that put airway devices in following a spinal.

You, especially as a first year graduate, should at least have the humility to try to learn the advantages and disadvantages of different techniques out there, yet you chose to simply write off and discount us as being wrong and you as being right...rather than taking a minute to experiment with a different technique, try it out for yourself, and really try to weigh the advantages and disadvantages. So tell me again, who was being a massive douche to start this whole discussion?

 

[acidbase1]

Urzuz, i wasn’t trying to be inflammatory until you started attacking me. There’s more than one way to skin a cat. However, the I’m rigid about this subject simply bc I’ve had an issue w similar practices at my facility and have discussed it at great length with many people, some attendings who are incredibly gifted in Anesthesia and have been in the game for decades (ie Blade). Believe it or not I’m pretty malleable when it comes to new techniques, one reason i come to this forum.

Though there’s a time and place for many practices, the one I’m describing which seems to be similar to yours, is a little off the beaten path IMO

If i offended, my apologies

 

[nimbus]

Though there’s a time and place for many practices, the one I’m describing which seems to be similar to yours, is a little off the beaten path IMO

It’s not.

 

[dhb]

It’s not.

I don't see the difference between sedating with an oral airway or not.
You sedate or you don't but whether you stick something in the patients mouth or not is kind of irrelevant.

 

[acidbase1]

It’s not.

Disagree

Forget the LMA, you’d say it’s common to tube spinals?

 

[Southpaw]

UCSF recently did a large retrospective analysis of their total joints and found that PF morphine does help with postoperative pain scores, ambulation distance, etc, even in addition to multimodal analgesia. As with all things in medicine, I'm sure the true best practice is somewhere in the middle between adding 500 mcg of Duramorph and completely avoiding it altogether.

All total joints? Total hips in my experience don’t hurt much, in fact patients often are hurting so much coming into surgery they feel considerably better after. I see no role for duramorph here.

Total knees - there may be some pain benefit, I just feel like the downsides outweigh the upsides, especially as total knees begin to move to outpatient surgery. Though my hospital is nowhere near that, and I do appreciate you telling me UCSF’s findings. I may revisit adding small doses of duramorph for knees.

 

[nimbus]

Disagree

Forget the LMA, you’d say it’s common to tube spinals?

No I’m referring to LMA/spinal. It is very common. I’ve been out a long time, work in a practice with partners from all 10 top 5 programs. We all do it. I know for a fact that the director of regional at your old program also did it.

 

[acidbase1]

No I’m referring to LMA/spinal. It is very common. I’ve been out a long time, work in a practice with partners from all 10 top 5 programs. We all do it. I know for a fact that the regional guru at your old program also did it.

You’re 100% incorrect. Nobody ever placed LMAs + spinals much less OETT. In fact, i contacted the regional guru about this very thing a couple months ago. He didn’t say he’d NEVER do it, rather a general + SAB is unnecessary but if the patient was obstructing then he’d consider it

 

[acidbase1]

But to be clear, these guys would place CSE (15mg hyperbaric bupivicaine) thread catheter to give duramorph. Once the block set up they induce the patient with sux and put in a tube. This was 100% every time they conducted this particular case (which was a lot). Then they’d run them on about 0.7 of gas so the patient could tolerate the tube.

Would you agree with this practice? (In general I’m sure you’d give intrathecal duramorph)

Can see your logic with the LMA, I’ve just never needed one

 

[nimbus]

You’re 100% incorrect. Nobody ever placed LMAs + spinals much less OETT. In fact, i contacted the regional guru about this very thing a couple months ago. He didn’t say he’d NEVER do it, rather a general + SAB is unnecessary but if the patient was obstructing then he’d consider it

I mean before he got there.

 

[deleted162650]

What code are they using to bill for the "post-op pain" spinal??

I don't think there's a code that lets you bill for it like a PNB - at least not one worth 7 units.

 

[NoodleIncident]

What code are they using to bill for the "post-op pain" spinal??

I don't think there's a code that lets you bill for it like a PNB - at least not one worth 7 units.

I don’t know for certain. Likely the “single injection of a diagnostic or therapeutic substance, not including neurolytic substances, directly into the subarachnoid or epidural space.” CPT 62311 for 8 RVUs.

 

[nimbus]

I don’t know for certain. Likely the “single injection of a diagnostic or therapeutic substance, not including neurolytic substances, directly into the subarachnoid or epidural space.” CPT 62311 for 8 RVUs.

You need long acting opioid for 62311. At least in our practice.

 

[caligas]

You need long acting opioid for 62311. At least in our practice.

To bill it as post op pain you will have to subtract out the time in the o.r. spent placing the spinal, you will need a follow up visit, and you will not get paid much.

 

[dannyboy1]

This thread makes me very happy to be an employee of an AMC. I neither know, nor care, about billing.

 

[deleted162650]

This thread makes me very happy to be an employee of an AMC. I neither know, nor care, about billing.

Translation: I'm happy 'cuz I'm too ignorant to know just how hard I'm taking it in the rear.

 

[dannyboy1]

It’s not just the billing shenanigans, I work in a hospital that is anything but efficient. I spend a good portion of my day drinking coffee in the lounge, waiting for cases/room turnover. If I was in an eat what u kill setup that would kill me. Now I can just chill.

 

[Arch Guillotti]

This thread makes me very happy to be an employee of an AMC. I neither know, nor care, about billing.

That’s what the billing company is for.

 

[Southpaw]

It’s not just the billing shenanigans, I work in a hospital that is anything but efficient. I spend a good portion of my day drinking coffee in the lounge, waiting for cases/room turnover. If I was in an eat what u kill setup that would kill me. Now I can just chill.

Billing is like finances, learning even a little is very helpful. There’s also nothing wrong with knowing and understanding where your paycheck comes from, so long as it doesn’t effect the care you provide. Also, just as an aside, if you truly are drinking coffee all day, I wouldn’t be surprised if your AMC employer starts cutting your benefits/pay/vacation,
or all three. Those cats ain’t paying something for nothing, and their overhead runs reallllll fat.

 

[acidbase1]

Translation: I'm happy 'cuz I'm too ignorant to know just how hard I'm taking it in the rear.

Ding ding ding ding

 

[BLADEMDA]

To bill it as post op pain you will have to subtract out the time in the o.r. spent placing the spinal, you will need a follow up visit, and you will not get paid much.

I disagree. If non CMS the AMCS collect a lot of money from postop pain blocks. As for subtracting 10 minutes for the spinal the additional RVUs more than make up for it.

I'm not a fan of spinal duramorph in the elderly. Still, you could use Fentanyl 15 micrograms along with your Bupivacaine and bill for postop pain relief.

I do agree much of this stuff is highly unethical but it's legal. In the end there will always be providers willing to stretch the limits of what is ethical to collect as much money as possible.

 

[Southpaw]

Again, I don’t believe charging a post-op injection for a plain local spinal is even legal. This my per my business manager, and I know this is on the radar of insurance companies and CMS as this is the ONLY part of my chart that’s been audited to my knowledge. If anesthesiologists are doing this (billing post op pain for spinal only injection) they’re opening themselves up to a widespread audit for something very small and insignificant (the billing code doesn’t reimburse very many units; 2-3 for my group).

The only correct, legal, and ethical way to do this is to inject duramorph as a post op pain injection. No OR time is subtracted (like a regional block), because the billing has specific post op management criteria. I must manage post-op pain for 24hrs (not the surgeon), I must visit and examine the patient on POD1, and I must write a note.

And again, I don’t find IT duramorph to be helpful and worth the downsides, except for CS.

 

[caligas]

How’s this for ethics:

Just did a right total knee for a 91 year old (had left done a few months ago). Nice little spinal with ACB and a bit of propofol. Turned off the prop and she says, “ that wasn’t bad, now I’ve get to get to work on these shoulders”

 

[acidbase1]

How’s this for ethics:

Just did a right total knee for a 91 year old (had left done a few months ago). Nice little spinal with ACB and a bit of propofol. Turned off the prop and she says, “ that wasn’t bad, now I’ve get to get to work on these shoulders”

Why didn’t you drop an LMA?

 

[BLADEMDA]

Neuraxial anesthesia was also associated with reduced risk of surgical site infection and thromboembolic events, albeit with smaller effect sizes. Neuraxial anesthesia was associated with a reduced length of stay in our analysis of both RCTs and observational studies


Neuraxial and Combined Neuraxial/General Anesthesia... : Anesthesia & Analgesia

 

[Ezekiel2517]

How’s this for ethics:

Just did a right total knee for a 91 year old (had left done a few months ago). Nice little spinal with ACB and a bit of propofol. Turned off the prop and she says, “ that wasn’t bad, now I’ve get to get to work on these shoulders”

Wow, you're so cool. I had the exact same case not too far back. Frail little old 91 year old. Did a spinal then ran a low dose prop gtt. VS were train tracks, woke up perfectly comfortable. Perfectly stable in PACU and that whole night. Massive MI POD 1. I guess I'm not a badass like you.

 

[caligas]

Wow, you're so cool. I had the exact same case not too far back. Frail little old 91 year old. Did a spinal then ran a low dose prop gtt. VS were train tracks, woke up perfectly comfortable. Perfectly stable in PACU and that whole night. Massive MI POD 1. I guess I'm not a badass like you.

No, you’re not.

 

[deleted697535]

The issue I have isn’t with putting an LMA in after the SAB (though it’s unnecessary the vast majority of the time IMO), it’s with billing the SAB for postop pain and a GA (especially when we are talking about a plain bupi spinal). That is subjecting a patient to an unnecessary procedure (either the SAB or the GA) for the sole purpose of billing them more. It’s unethical and it’s bushleague bullshi* period.

I think its not as unethical as that.

Like try to argue the opposite.
That a spinal with plain bupi gives 0 post op pain relief? Good luck with that.

I think we've all been stung by someone hanging around pacu for hours with what you thought was a low dose spinal.

So if the opposite definitely is not true, then maybe there is something to it?

 

[Hoya11]

I think its not as unethical as that.

Like try to argue the opposite.
That a spinal with plain bupi gives 0 post op pain relief? Good luck with that.

I think we've all been stung by someone hanging around pacu for hours with what you thought was a low dose spinal.

So if the opposite definitely is not true, then maybe there is something to it?

It honestly never crossed my mind as unethical. Although I do find that point of view interesting now...

But IME, the spinal block does indeed provide post op pain control for 3-5hrs after surgery in some cases.

And it allows the anesthesia/sedation to be lighter/cleaner/narcotic free. Creating a very decent experience for most


Also, the spinal in these cases is usually free...right?

Because you bill for the GA/MAC for the case

plus EITHER the spinal or ACB. I dont believe you can separately bill for 2 post op blocks for the same case

So usually we bill for the ACB or FNB, plus the GA, and include a record of the spinal but not bill.. i think..