Vasovagal prevention?

[Baron Samedi]

Just curious what others do for patients who desire procedures but have history of vasovagal reactions with needle sticks.

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[mid|ine]

Xanax and sudafed pre-procedure. Tell patient to drink plenty of fluid.

IV IF they have a history of bad vasovagal response

 

[lobelsteve]

Tell them all of the complications you have seen and heard about regarding the procedure as they are getting on the table.
Let them know you have a dumpster outside and if they try any of that nonsense they are getting tossed in there.

 

[Baron Samedi]

In patients without an anxiety history or significant procedural anxiety do benzos prevent vasovagal reactions? I've tried looking for literature on the subject without success.

I've typically thought of them as more of an anxiolytic and less so as a preventative measure for vasovagal reactions, but I know a lot of people use them.

 

[soccrwz]

have them lay down, raise their legs, Tberg; make sure they arent standing or going to fall, keep pulse ox on. Ice pack. No need for routine benzo use. talk to them in a calming voice. Ask yourself R/B/A of intervention. Make sure they drank fluids the night before. Have atropine available, rarely needed, can give IM

 

[NOSfan]

Drink plenty of fluids and have them CROSS their legs for the IV insertion.

Cheers

 

[SommeRiver]

How about this instead - No IV. Buffer the lido with bicarb. Give PO Valium 2mg 30 min prior.

I'm still waiting on this vasovagal thing everyone's talking about...

 

[lobelsteve]

How about this instead - No IV. Buffer the lido with bicarb. Give PO Valium 2mg 30 min prior.

I'm still waiting on this vasovagal thing everyone's talking about...

Finished fellowship in 2005. Not one yet. Excited to see this one day. Had a fellow have it happen during knee injection. Sent from surgeon due to VV with prior injection. Let him fall onto the fellow from sitting in chair. Woke up before he even hit.

 

[SommeRiver]

NPO + IV = This procedure must be a big deal.

 

[joshmir]

Agree with Midline

I would add for us it’s a minor thing, but for some patients it’s a big deal, so I think Treating it/preventing it is worth the investment in time and effort

 

[Ferrismonk]

I have a couple people with POTS and severe vasovagal. Just have them get off the table slowly.

 

[clubdeac]

Finished fellowship in 2005. Not one yet. Excited to see this one day. Had a fellow have it happen during knee injection. Sent from surgeon due to VV with prior injection. Let him fall onto the fellow from sitting in chair. Woke up before he even hit.

You've never had one Steve?! No way, how's that possible

 

[lobelsteve]

You've never had one Steve?! No way, how's that possible

Im very soothing.

 

[deleted131481]

I offer PO valium 5mg 1-2 pills to patients to pickup at pharmacy. About 1/3 to 1/2 patients want it. I've had 2 vasovagal in the past 2 years, neither had BZD. One was lumbar mbb had to abort 2nd side and CESI able to finish.

I've gotten faster but probably not as fast procedurally as many on here, although both of the above were quick and straightforward.

Quick search on on BZD and vasovagal:

Anesthesiology

pubs.asahq.org

 

[manowar rules]

You've never had one Steve?! No way, how's that possible

I agree, I think it’s something we don’t have complete control over. Not necessarily patients passing out, but I definitely very occasionally have had people be lightheaded and bradycardic after a procedure. Was more common when patients were mistakenly told to be NPO day of the procedure, I made sure that policy was stopped. I sometimes see vagal reaction a minute or 2 after RFA, even when the patient was talking through procedure with no complaints of discomfort. It’s like even if properly numbed with lidocaine, the body still knows some noxious stimulation is going on.

 

[bedrock]

Im very soothing.

You've never had one Steve?! No way, how's that possible

Sorry, but I think Steve is FOS. Kinda like the time he claimed he had never tickled a spinal nerve during a lumbar TFESI........

Both of those happen to all pain physicians at least infrequently, no matter their technique or training.

 

[lobelsteve]

Yup. Just trolling. Or you can email my nurses on the website and ask them. Or PM anyone else on the board. Im pretty sure I have talked to 90% of the posters privately.

Never skewered a nerve. Hit the sheath 2-3 x for painful paresthesia. Numb it, pull back, swim away.

 

[kstarm]

Im very soothing.

Hypnosis is actually a pretty slick way to prevent vasovagal reactions, just not very practical in a interventional pain setting.

.....Was more common when patients were mistakenly told to be NPO day of the procedure, I made sure that policy was stopped...

Our same day surgery center requires NPO before procedures which is how I was trained. The thought being if there was an adverse reaction you could get gunk in the lungs. Are most people not requiring NPO?

 

[callmeanesthesia]

Hypnosis is actually a pretty slick way to prevent vasovagal reactions, just not very practical in a interventional pain setting.



Our same day surgery center requires NPO before procedures which is how I was trained. The thought being if there was an adverse reaction you could get gunk in the lungs. Are most people not requiring NPO?

If IV sedation, yes. Otherwise, no.

 

[SommeRiver]

I use no sedation other than Valium PO and I cannot tell you the last time I had a pt vagal on me.

Has it happened? Once that I can say without question, and that was around 2018. Same pt had a vagal episode when his daughter's pediatrician walked into the exam room bc he "smelled medical stuff." Actually put a hole in the pediatrician's wall bc his face hit it...DUBYA TEE EFF...

Other than him, I truly can't say I've had another in my current set up and I'm doing 50 fluoro injxns per week, with another 20 clinic joint shots...

I honestly don't get some of y'all who sedate for epidurals or ablations. Completely unnecessary and does nothing more than drive up the cost of healthcare and set unreasonable standards in pt care.

When those pts come see me and I tell them I won't put them "to sleep" or "give a twilight" for an SIJ they freak out in the clinic...Until I do the shot or the RFA or epidural and they walk out of there openly stating it was not only easier without sedation but they prefer it this way...

Oh, I've had a zing down the leg during a TFESI plenty of times. Who cares? It is an absolute guarantee you'll get that at least once every...X number of epidurals. I hesitate to quantify X but it is less than 50 but more than 10.

Someone once posted in this forum they don't let pts talk during the procedure so they "can concentrate," and I would bet that doctor has vagaled dozens of pts. The entire experience of the procedure plays a role. Chill out, skip the IV and hell no for NPO...Jesus. NPO for an L5-S1 and then an IV and run fentanyl and Versed. WTF.

 

[Ronin1]

It’s real. Back in my fellowship in the 90s we used to do all intralaminar epidurals in the clinic without fluoroscopy. This was in DC and we had a young Mitch Rapp kind of guy fell over and started seizing right in the middle of an esi! He came back for the next one and we put him on a monitor first and he bradyed down to the teens before passing out again.

 

[SommeRiver]

It’s real. Back in my fellowship in the 90s we used to do all intralaminar epidurals in the clinic without fluoroscopy. This was in DC and we had a young Mitch Rapp kind of guy fell over and started seizing right in the middle of an esi! He came back for the next one and we put him on a monitor first and he bradyed down to the teens before passing out again.

I have an horrific story from fellowship about a thoracic epidural prior to CT surgery. I had the catheter tunneling up no problem and the guy went down hard. Dude had a HR in the 20s for like 2 minutes. It was awful, but no bedside catheter placement should be compared to a fluoro guided ESI or RFA or whatever. They just simply are not the same.

 

[lobelsteve]

Ive brady’d down to 27 in the office while seeing an OV. Computer screen turned all white and i could not read it. Got an ekg and i was up to 37. Happens 2-3x per year. Meh. Drink more water.

 

[SSdoc33]

It’s real. Back in my fellowship in the 90s we used to do all intralaminar epidurals in the clinic without fluoroscopy. This was in DC and we had a young Mitch Rapp kind of guy fell over and started seizing right in the middle of an esi! He came back for the next one and we put him on a monitor first and he bradyed down to the teens before passing out again.

Tattooed young guys are always the worst.

Nice vince flynn reference. Mitch rapp went downhill once the new author took over

 

[callmeanesthesia]

I have an horrific story from fellowship about a thoracic epidural prior to CT surgery. I had the catheter tunneling up no problem and the guy went down hard. Dude had a HR in the 20s for like 2 minutes. It was awful, but no bedside catheter placement should be compared to a fluoro guided ESI or RFA or whatever. They just simply are not the same.

Labor epidural - husband, on the other side of the room, no view of the needle, goes down hard - nurse couldn’t get to him in time to get him in a chair. Wife tries to jump off the bed to go to his aid, needle still in her back and catheter halfway in.

 

[epidural man]

In patients without an anxiety history or significant procedural anxiety do benzos prevent vasovagal reactions? I've tried looking for literature on the subject without success.

I've typically thought of them as more of an anxiolytic and less so as a preventative measure for vasovagal reactions, but I know a lot of people use them.

I have collected data (over 1000 patients) on this.

My hospital stats guy doesn’t seem to want to work with me crunching the numbers.

Any stats guy on here that would like to publish with me and would be willing to do the regression analysis?

To be clear, we didn’t have a hypothesis. We just collected data on all our patients, hoping to see if we could find a trend on who and why people vasovagal.