Stellate Ganglion Blocks for PTSD?

[Baron Samedi]

Just curious what others are doing. In milmed these have become pretty common and I'm doing a few a month with pretty good success. Do any insurances cover it?

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[callmeanesthesia]

I have one patient with PTSD and CRPS from a dog attack who feels like it helps both.

 

[au bon pain]

Are these patients being sent to you by psych? Or do you ask the patient for psych notes showing the dx?

 

[Baron Samedi]

Are these patients being sent to you by psych? Or do you ask the patient for psych notes showing the dx?

Yes, always by psych unless they've had them before.

 

[callmeanesthesia]

To tag onto this, I was approached by a new local cardiologist to ask about doing stellates for refractory Vtach. He said they had them done frequently during fellowship with good results. The patients all have ICDs already but are getting shocked frequently. I really hate to say no because I feel like I could help and it’s always good to build new relationships, but I do almost all my procedures in office, and that doesn’t seem like a good idea to do without cardiac monitoring. Thoughts?

 

[gaspasser127]

To tag onto this, I was approached by a new local cardiologist to ask about doing stellates for refractory Vtach. He said they had them done frequently during fellowship with good results. The patients all have ICDs already but are getting shocked frequently. I really hate to say no because I feel like I could help and it’s always good to build new relationships, but I do almost all my procedures in office, and that doesn’t seem like a good idea to do without cardiac monitoring. Thoughts?

I’ve done it once but in the cardiac surgery ICU on a patient with refractory bouts of v tach.

I suppose in a clinic you would need at least continuous EKG monitoring. Do you need a crash cart/Zoll machine available?

 

[callmeanesthesia]

I’ve done it once but in the cardiac surgery ICU on a patient with refractory bouts of v tach.

I suppose in a clinic you would need at least continuous EKG monitoring. Do you need a crash cart/Zoll machine available?

All we have is AED, oxygen tank, and ambu-bag. This is apparently for outpatients with AED’s, whose quality of life sucks because they keep getting shocked and are refractory to antiarrhythmics.

 

[painfree23]

Yes, always by psych unless they've had them before.

Would u do it in the OR or in the clinic?

 

[Baron Samedi]

Would u do it in the OR or in the clinic?

Definitely in the clinic.

 

[lobelsteve]

I like being a pain doctor. Not a boutique or crossover guy. But Vtach in clinic and sympathetic blocks? Insane. Does Vtach ever convert to another rhythm? PTSD? Not my gig.

Happy to let everyone else do these things, aren't we busy enough? Let IR have at it.

 

[Agast]

Vtach should be done in a hospital setting. Unless you want to call an ambulance to your clinic.

 

[Ducttape]

I discussed this in the Physician Forum....

 

[callmeanesthesia]

Vtach should be done in a hospital setting. Unless you want to call an ambulance to your clinic.

To be clear, these are outpatients with ICDs already, who get shocked a lot by their ICD. I think if it were going to fail to capture they’d already be dead.

 

[Baron Samedi]

PTSD? Not my gig.

Fair. If psych to pain was more viable than it currently is I would have done a psych residency, so I enjoy seeing these patients. I probably prescribe more psych meds than many pain docs, too.. Definitely not for everyone, though.

 

[painfree23]

Definitely in the clinic.

Sedation?

 

[txbackdoc]

They have a crash cart already installed....

 

[Baron Samedi]

Sedation?

Nope, but I don't sedate for anything but implants.

We get an IV placed before but thats about it. 25G 2 inch needle in all but the largest patients attached to tubing using Furman(foraminal view) approach and its a 5 minute procedure. I use an epi wash in the syringe as an intravascular marker, long aspiration, inject 2-3cc at a time of 0.50% ropivicaine(8-10cc total) and monitor vitals. Very quick procedure and very well tolerated. By the time they sit up, most have a Horner's response.

The biggest issue I've had is some patients with severe PTSD have trouble tolerating the draping on their neck and lower face. The injection itself is generally not an issue.

 

[Orin]

Done it for both indications. Insurance will cover in some areas.

For vtach, it's a prequel to a surgical sympathectomy and I've done them more often as an inpatient. They're generally anticoagulated as well. I have done a few in clinic but it's not a fun experience for the nursing team as the alarms on the monitors raise concerns.

For PTSD, the data are so mixed and I worry it's placebo response from the Horner's, but the biggest issue is the significant anxiety/claustrophobia with draping. I try to normally sneak it in with a 25g spinal needle and gentle ultrasound with a lot of excess gel to avoid significant pressure. Agree with a 25g needle

 

[Sooshi]

Done a handful of stellates for VT/storm - worked like a charm to temporize. 10/10 would not do anywhere other than ICU/cath lab.

A couple for PTSD (at the VA) - results have been dramatic but somewhat inconsistent, sample size is tiny thus far.

 

[powermd]

To those of you draping your stellate blocks, why do you need a drape?

 

[Baron Samedi]

To those of you draping your stellate blocks, why do you need a drape?

Because I drape everything and it makes me feel safe.

 

[painfree23]

Nope, but I don't sedate for anything but implants.

We get an IV placed before but thats about it. 25G 2 inch needle in all but the largest patients attached to tubing using Furman(foraminal view) approach and its a 5 minute procedure. I use an epi wash in the syringe as an intravascular marker, long aspiration, inject 2-3cc at a time of 0.50% ropivicaine(8-10cc total) and monitor vitals. Very quick procedure and very well tolerated. By the time they sit up, most have a Horner's response.

The biggest issue I've had is some patients with severe PTSD have trouble tolerating the draping on their neck and lower face. The injection itself is generally not an issue.

no ultrasound? C6?

 

[Baron Samedi]

no ultrasound? C6?

I prefer fluoro approach, and yes C6.

 

[painfree23]

I prefer fluoro approach, and yes C6.

Nice. So you barrel down on this transformational view ? What’s ur target on this view?

 

[Baron Samedi]

Nice. So you barrel down on this transformational view ? What’s ur target on this view?

Posterior third of the C6 vertebral body. Image from Furman

 

[10KHertz]

Joe Rogan did a podcast on PTSD and SGBs, and there has been tons of interest. The literature is really fair and a limited , there is a study out of the VA. Variables of the procedure , like volume , side, duration in between are nebulous. I’ve done a couple with mixed results. Patients are typically desperate and don’t want any more oral meds from therapists. Some insurances pay...

I addressed this In the psych forum and they were pretty skeptical as well ...

 

[Baron Samedi]

Patients are typically desperate and don’t want any more oral meds from therapists.

Yeah, thats a big factor. My criteria are the following:

1. Must be referred from a Psychiatrist
2. Must have DSM-V criteria for PTSD, at least moderate in severity with a PCL 40 or higher
3. Must be actively engaged in therapy and have had adequate trial of medication. I always explain to patients that SGB is an adjunct, not replacement, to standard of care.
4. No contraindications to procedure

The two biggest reasons I decline to do them are lack of adequate medication trial and relatively mild symptoms(PCL<40).

The tricky thing is data collection. I don't typically follow up these patients so I am depending on the referring providers to document efficacy. In those who do, I've seen pretty remarkable results with most patients PCL scores going from the mid 50s to low-mid 20s for at least a couple months.

 

[drusso]

The Successful Use of Left-sided Stellate Ganglion Block in Patients That Fail to Respond to Right-sided Stellate Ganglion Block for the Treatment of Post-traumatic Stress Disorder Symptoms: A Retrospective Analysis of 205 Patients

Sean W Mulvaney, MD, James H Lynch, MD, Kamisha E Curtis, MS, Tamara S Ibrahim, MS

Military Medicine, usab056, Successful Use of Left-sided Stellate Ganglion Block in Patients That Fail to Respond to Right-sided Stellate Ganglion Block for the Treatment of Post-traumatic Stress Disorder Symptoms: A Retrospective Analysis of 205 Patients

Published: 13 February 2021 Article history

ABSTRACT

Introduction
Ultrasound-guided stellate ganglion block (SGB) is an injection of local anesthetic (8mL of 0.5% ropivacaine) in the neck to temporarily block the cervical sympathetic trunk which controls the body’s fight-or-flight response. This outpatient procedure takes less than thirty minutes and is immediately effective. Our goal was to determine if a left-sided stellate ganglion block is effective for treating posttraumatic stress disorder (PTSD) symptoms. While right-sided SGB has been extensively studied, left-sided SGB has not been formally evaluated for this indication.

Materials and Methods
Our hypothesis was that patients who fail to improve following a right-sided SGB will report significant improvement following a left-sided SGB. A retrospective chart review was conducted for patients who received SGB for PTSD symptoms between August 2019 and March 2020. All procedures were performed at an established musculoskeletal practice by the same anesthesia/pain fellowship-trained physician. Subjects included those who underwent a left-sided SGB (LSGB) only after non-response to a right-sided SGB (RSGB). Non-response was defined as less than 10 points of improvement on a PTSD Checklist (PCL-5).

Results
Out of 205 patients, 20 did not respond to an RSGB and were included in our analysis. Ten of these patients subsequently received an LSGB, and 90% responded favorably (PCL-5 mean improvement = 28.3 points).

Conclusions
Based on our sample of 205 patients receiving SGB for PTSD, we concluded that at least 4.4% did not respond to a right-sided SGB but did have a significant response to a left-sided SGB.

 

[lobelsteve]

We flipped coins. They were quarters. This is not worthy of publication.

 

[Ducttape]

retrospective analysis. single physician.

null hypothesis is that the left sided injection would work when the right sided one did not. not really how you want to prove that SGB are effective... doesnt really prove much.

 

[Baron Samedi]

The hypothesis could have easily been that some that fail to respond to a single injection respond to a second with the exact same conclusion. Definitely not a study I'm going to change my practice off of.

Tomorrow I'm doing an SGB on one of these "left responders"(possibly even included in the study?). I'm doing a right sided one because that's what I'm comfortable with.

 

[hyperalgesia]

Anyone know which VA centers are doing SGB for PTSD?

 

[soccrwz]

I believe san diego

 

[drusso]

Anyone know which VA centers are doing SGB for PTSD?

Portland, Oregon

 

[Sparkymd]

I have one with CRPS and PTSD and she feels the SGB is very helpful. I also had a Vet sent from Psych with severe PTSD and they were sent for a series of SGB and he felt fairly dramatic improvement in some of the "reliving," preservation, and a lot with sleep. (He was sent from VA who couldn't get him in for it)