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And are you paid for them?
Who does epidural blood patches
Started by aneftp
Of course. Theres a billable cpt code. What do you mean am I paid for them? How are you not paid for them?
Not for me. This is was a 10am mid week consult
Administrators get paid to make policy. All I want them to do is make a written policy who is responsible. The ball is in their court. And they hate that.
Ironic right? They love to make policies yet hate to devise policies where they can’t control the narrative (like on room start time). Admin needs to sit down with ir, neurology, Ed, anesthesia and figure out what is the best options
It’s like central line service in the old days.
Surgeons took a block of time to place them
Anesthesia got the second week
ED for the 3rd week.
That’s how policy should be made.
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My understanding of the issue... OP @aneftp is locums or contracted in a different department and not paid extra for the procedure. The hospital hasn't defined policy for coverage of the procedure. Why should OP take the risk for something not in the contract, not defined in policy, and not being paid for?
In that case OP should have a discussion with department chair. Its a billable procedure that the anesthesia department should be billing for. Blood patches are most definitely a core skill of anesthesia.
The full timers told me not to do it either. I’ve been at the hospital for years as locums. Not my first rodeo with these guys.
They don’t have a real chief either as the current chief is on his way out.
I’m just trying to judge what people are doing in their practice.
Agree. I’m less inclined to take any risks in this case. It’s not an emergency. If the ed or icu called and said they had a potential difficult airway. No issues. I’d be right down there as it’s a more urgent matter and I have gone down there.
I’m reading over the court records of one of my colleagues regarding epidural blood patch he did in 2010 in ED. The attorney notes said the patient should have been informed the headaches can resolved without treatment and that was an alternative. Patient ended up with abscess and emergent surgery and suffered drop foot as a consequence of the courtesy blood patch. But he’s a cowboy and will do anything
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deleted87051
He didn’t discuss this or did he neglect to document it? I have this discussion and document it for every blood patch I do.
It’s in the standard consent for epidurals and anesthesia consents. And it was discussed
You are up the creek regardless what you tell the patient because the lawyers alternative answer is you could always choose not to do the procedure
Comes down to risk and benefits.
It’s comes down to 101 basic philosophy. Better to do nothing than to do something.
Don’t even interact with the patient at all. No contact, no lawsuit. Don’t talk to the patient. The minute u make contact with the patient. You establish a relationship and subject to lawsuit.
Blood patches have real risks, and there should be discretion when offering to do them. We had a horrible case here where an anesthesiologist offer a blood patch for PDDH in the OB. The patient went home the next day, had a seizure at home, fell on top of her baby and unfortunately the baby passed away from suffocation. His career is never going to be the same again. So the idea that this is just a routine 5 minute procedure and we should offer it to everyone under any circumstance I strongly disagree with.
Arch Guillotti
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I don’t get it, did the blood patch make her seize?
Umm could it not be argued that the pdph could have just as easily caused the seizure? How did that doc take the fall for that…
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Many believe that the blood patch triggered aseptic meningitis and the chemical induced reaction caused the seizure and the death of the baby.
Or they could have just seized by themselves or from something else?
I mean I had a patient have a stroke on the way to preop but if it happened 30 minutes later it would have been chalked up to my anesthesia complication
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deleted643396
That’s a lot of dots to connect.
Intrathecal blood can be a pretty devastating complication.
pmc.ncbi.nlm.nih.gov
I’m pain and anesthesia
I only do them under xray with contrast confirming epidural placement prior to injecting any blood
Intrathecal blood injection: a case report of a rare complication of an epidural blood patch - PMC
Intrathecal injection is a rare complication of spinal anesthesia and an underreported complication of epidural blood patches. Although there are other reported cases of intrathecal blood injection, these cases lack confirmatory imaging and others ...
pmc.ncbi.nlm.nih.gov
I’m pain and anesthesia
I only do them under xray with contrast confirming epidural placement prior to injecting any blood
First of all blood patches are never routine. And I dont think any credible physician here just offers up blood patches at the first sign of a headache. The first goal is to try not to ever wet tap. Second goal is to try not to do a blood patch if at all avoidable (conservative mgmt). Third goal is to proceed with caution if it isn't avoidable. Pretty sure we all know that. One or two freak cases doesn't mean that we dont do blood patches now though.
To me it sounds like a typical case of- the malpractice insurance company didnt want to risk fighting it in court so they settled it for some ungodly sum, and threw the doctor under the bus. That or just a flat out incompetent malpractice firm.
I would assume none of them get nerve blocks. Too much risk, but also very little benefit. Elite athletes don't have the same benefit from decreasing narcotic dosing a little bit. Conversely if they get a 5% reduction in nerve function it could be the end of their career as compared to some random other patient that might never even notice.
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deleted643396
Nobody needs nerve blocks. That’s all fake news anyway. We made that up as a specialty to keep ourselves relevant. It was a way to gatekeep from CRNAs.
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deleted87051
And to make money and hustle people out of surgicenters. God help them when the block wears off.
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deleted643396
I’ve worked with orthopedic surgeons who refuse nerve blocks for many supposedly painful procedures. You know what, their patients do just fine. Maybe it’s patient selection, but it has certainly made me wonder what the point is of sticking needles in the neck of otherwise healthy patients.
I do blocks when requested, but I certainly don’t insist on them.
i work full time in an ortho center, and i have seen very often when they dont do fine. 8/10 pain after achilles surgery, RCR, ankle fx, dilaudid IV and discharge home - phone calls all night for pain issues. i could have solved that problem in 5 minutes giving 30 plus hours of no narcotic.. hard to watch a patient splinting in pain in PACU after surgeon has given 10cc of local randomly in the subQ tissue after a bone fx sx.
patient in the pacu after knee surgery 9/10 pain, i do an ACB and 10 minutes later, a smile and a thank you - feels good no? without that option, i would have had to admit many patient who would rather be in their house pain free
blocks have their place.. i agree you dont want to "Sell" them, but i offer them when appropriate as a necessary evil, a calculated risk that I feel is worth it, do you agree? good then lets do it
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I insist when I'm the late charge and have to stay until everyone is out of the PACU. Especially when I have a young marijuana smoker as the last patient of the day.
Whatever the hospital policy is.
I've only worked at places with OB and interventional pain - come back during their banker's hours and get a blood patch.
We didn't manage other office's complications (e.g. outpatient neurologist LP PDPH). Our policy was go back to who did the wet tap.
One time did get ER consult at 0200 for LP PDPH. Asked for records: at 0800 they got them, was for FUO and turns out tests were positive for Spirochetes. That would have been a fun neurosyphilis lawsuit.
I've only worked at places with OB and interventional pain - come back during their banker's hours and get a blood patch.
We didn't manage other office's complications (e.g. outpatient neurologist LP PDPH). Our policy was go back to who did the wet tap.
One time did get ER consult at 0200 for LP PDPH. Asked for records: at 0800 they got them, was for FUO and turns out tests were positive for Spirochetes. That would have been a fun neurosyphilis lawsuit.
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deleted87051
Neurologists and EM docs do most of the LPs but do they ever do EBPs? Who’s gonna do the blood patch if the patient needs one?
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same hereIntrathecal blood can be a pretty devastating complication.
Intrathecal blood injection: a case report of a rare complication of an epidural blood patch - PMC
Intrathecal injection is a rare complication of spinal anesthesia and an underreported complication of epidural blood patches. Although there are other reported cases of intrathecal blood injection, these cases lack confirmatory imaging and others ...
I’m pain and anesthesia
I only do them under xray with contrast confirming epidural placement prior to injecting any blood
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This is a weird discussion.
There's a world of difference between
1) Recent labor epidural. Headache. OB evaluates. Consults us for EBP. We evaluate patient. Offer EBP if we deem appropriate.
2) Recent LP. Headache. ER evaluates. Consults us for EBP. We evaluate patient. Offer EBP if we deem appropriate.
3) Rando headache shows up in ER. ER orders EBP. We go do EBP.
One of these things is not like the others.
Doing an EBP for a person with a headache, after being consulted, after doing an evaluation, after offering treatment and alternatives to the patient, after documenting all of that and getting informed consent ... is no different than ANY physician in ANY specialty seeing ANY patient with ANY complaint and offering a procedure. I don't understand the liability angst at all.
There's a world of difference between
1) Recent labor epidural. Headache. OB evaluates. Consults us for EBP. We evaluate patient. Offer EBP if we deem appropriate.
2) Recent LP. Headache. ER evaluates. Consults us for EBP. We evaluate patient. Offer EBP if we deem appropriate.
3) Rando headache shows up in ER. ER orders EBP. We go do EBP.
One of these things is not like the others.
Doing an EBP for a person with a headache, after being consulted, after doing an evaluation, after offering treatment and alternatives to the patient, after documenting all of that and getting informed consent ... is no different than ANY physician in ANY specialty seeing ANY patient with ANY complaint and offering a procedure. I don't understand the liability angst at all.
Same here as well. In residency we did them like an OB epidural. We did them in the ED for pdph’s for our own service but also anybody else’s.
That is a very rare thing and you have seen multiple of these?
I think its mostly about cleaning up other people's sloppy mess...
Also cause its low paying relatively speaking, it does include some risk, and most often no one helps you with either the procedure or the logistics of doing the thing like getting a room and monitoring etc...
Emerg doesn't want to help as they think pacu should do all that. Pacu won't help cause theyre not admitted etc. Who is mrp? Bla bla bla
Some hospitals have a smooth setup but some lose their minds over these things
Seems like that ought to be an easy problem to solve.
We tell the OR charge RN and preop RN we're going to do a blood patch. The OR charge RN posts it as a procedure. Preop RN calls for transport. The patient shows up, eventually. We see them, eventually.
Preop RN draws blood as we put the Tuohy in.
Patient stays there for an hour or so, we see them again, close out the chart, preop RN sends them back to the ER to get discharged, or the floor if they're an inpatient.
Because the ob service takes care of it 24/7. Dedicated team. The blood patches.
I’m covering 1:6 last week with no ob service when they asked me to do the blood patch at community hospital with no ob. Yes. I can probably do it around 2-3pm when things slow down. IR has down time they can do it as well.
Do u cover a beeper hospital with no ob that does blood patches on non anesthesia patients?
I've done a few LPs for neurologists over the years. Maybe the patient is having an MRI under sedation and, gee, can we help by getting the LP while they're still asleep (this was at a VA). I've tried the smaller needles and it's shocking how slow the flow is. I get the whole PDPH thing, but I can see why they don't want to use smaller needles.
IR does their own blood patches.
Not doing them is lazy and they are very capable in doing them.
We cover the rest… ie ED or Neurologist who have no business doing an EBP.
Not doing them is lazy and they are very capable in doing them.
We cover the rest… ie ED or Neurologist who have no business doing an EBP.
Did a LP for IIH work up when at prior small military overseas hospital after seeing virtual neurologist. Did the LP so patient didn’t have to fly to where neurologist was located. Patient had a prior PDPH so I used a 25g. Took forever to get opening pressure and to drip for laps! Was a test of my patience and ability to hold pressure tube steady
But at least patient didn’t get a PDPH
Another fun question…
Who does lumbar drains where you all are? I’ve been in places where the anesthesiologists do them and others where neurosurgery does them. Luckily I’m pure peds now so it doesn’t come up anymore.
Who does lumbar drains where you all are? I’ve been in places where the anesthesiologists do them and others where neurosurgery does them. Luckily I’m pure peds now so it doesn’t come up anymore.
We have a subpanel that does them.
Sometimes neurosurgery will put them in at the end of a case that had a dural tear.
Personally, I am not a big fan of doing them in patients rooms post op.
I do them, but only if I get a procedure room to do them in.
I have done them in the OR under fluoro with tough patients w hardware.
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deleted87051
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For TEVAR we’ve moved toward IR from Anes. Neurosurgery is the neurosurgeon.
Why is a lumbar drain needed for TEVAR? Honest question.
So that they can blame the anesthesia if there's paralysis
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deleted87051
To that I would say 22g pencil point needles exist.
There is no reason to ever use a 22g cutter like they do for their LPs.
