Stellate for parosmia due to long COVID

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gaseous_clay

gaseous_clay

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www.everydayhealth.com

New Research Shows Promising Treatment for Long COVID Smell Loss

Loss or distortion of the sense of smell is one of the most common symptoms of long COVID, but a painless injection may help some people smell normally again.
www.everydayhealth.com www.everydayhealth.com

CT-guided…lol
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I have one lady who pays me cash for this every 6 months.
 
Every 6 months? So it comes back? Dang
 
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I did it on my daughter who had profound parosmia. She rated her smell 2/10 after Covid. After bilateral SGB 2 days apart she was up to 8/10 within about 2 weeks. She was very pleased with the result! n=1, but for her it was worth it!
 
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For someone with parosmia for several decades (post-concussion), 2/10 smell has its advantages. I don’t have much use for really expensive food or booze, which is a real cost savings. Think of the last 10 smells you can recall. I bet 7/10 are bad smells.

0/10 sucks. Food isn’t very enjoyable, and I was paranoid about having BO.

I think I’m missing out in the smell/memory association, though.
 
cowboydoc said:
For someone with parosmia for several decades (post-concussion), 2/10 smell has its advantages. I don’t have much use for really expensive food or booze, which is a real cost savings. Think of the last 10 smells you can recall. I bet 7/10 are bad smells.

0/10 sucks. Food isn’t very enjoyable, and I was paranoid about having BO.

I think I’m missing out in the smell/memory association, though.
Click to expand...

The number of patients who come in with BO so rank the room feels wet afterwards and you feel like it’s in your hair
 
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Agast said:
The number of patients who come in with BO so rank the room feels wet afterwards and you feel like it’s in your hair
Click to expand...

If you stop seeing Medicaid or Medicare-Medicaid patients, then 95% of the severe BO patients will no longer be in your practice.

Unpleasant truth.
 
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camkiss said:
I did it on my daughter who had profound parosmia. She rated her smell 2/10 after Covid. After bilateral SGB 2 days apart she was up to 8/10 within about 2 weeks. She was very pleased with the result! n=1, but for her it was worth it!
Click to expand...
I'm happy to hear it helped.

Why do you think it worked, and why did you perform that procedure on your daughter?
 
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gaseous_clay said:
Because she claims it works, stating she is able to taste food and coffee again. She get really emotional when discussing it.
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Do you believe this injection works?

If so, why?

I genuinely want to know why anyone would do this procedure because I've yet to hear any mechanism of action supporting it.
 
MitchLevi said:
Do you believe this injection works?

If so, why?

I genuinely want to know why anyone would do this procedure because I've yet to hear any mechanism of action supporting it.
Click to expand...

Do you believe it works for PTSD? There’s some scant data stating it might have benefit. When performed properly, it doesn’t carry too much risk, and for this patient, it has life changing results.
 
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MitchLevi said:
Do you believe this injection works?

If so, why?

I genuinely want to know why anyone would do this procedure because I've yet to hear any mechanism of action supporting it.
Click to expand...

We don’t know the mechanism of action for volatile anesthetics but we still use them to knock people out…

If a patient says they couldn’t smell anything and enjoy their morning coffee and suddenly can post procedure, are you suggesting it’s in their head?
 
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To piggy back on this point, I can find data to show ESIs do not work for low back pain, yet I bet most of the people here still perform them on patients, especially after they tell you it helps their pain. So are we now supposed to question the patient’s perception of reduced pain because there’s data to show these treatments don’t help?
 
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gaseous_clay said:
Do you believe it works for PTSD? There’s some scant data stating it might have benefit. When performed properly, it doesn’t carry too much risk, and for this patient, it has life changing results.
Click to expand...
I have several patients who tell me that SGBs for their PTSD literally saved their lives. Several patients who could barely leave their house who are back to being productive members of society after an SGB.

Not everyone responds, obviously. But those who do have had very remarkable results.
 
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A little off topic but I had a patient with dysautonomia, very intelligent, asked me if this would help. Gets BP surges with position changes, basically the opposite of orthostasis, bad enough to cause LVH, difficult to manage with meds. I couldn't find any info but would be curious.
 
MitchLevi said:
Do you believe this injection works?

If so, why?

I genuinely want to know why anyone would do this procedure because I've yet to hear any mechanism of action supporting it.
Click to expand...
www.ncbi.nlm.nih.gov

Long-term Results of Stellate Ganglion Block in Patients with Olfactory Dysfunction

Olfactory dysfunction, including anosmia and hyposmia is difficult to treat. Although the mechanism is not well known, stellate ganglion block (SGB) is used to treat olfactory dysfunction. There are no prior studies on the long-term effects of SGB on ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov

Old school stuff but it has shown efficacy preCOVID for this.

The hand waving in the article is:
"The central nervous system (CNS) of the adult mammalian brain is a non-renewable organ. However, Kaplan and Hinds [15] reported that the olfactory bulb and the dentate gyrus of the hippocampus have the ability to regenerate. Adult neurogenesis in the olfactory bulb is regulated by a specialized microenvironment as well as various factors [16,17]. Among them, intrinsic factors include activator protein 1 (AP-1), Aristaless-related homeobox-homeodomain transcription factor (Arx), Achaete-scute complex-like 1 (ASCL 1) and so on, and the extrinsic factors include neurotransmitters, such as serotonin, γ-amino butyric acid (GABA), glutamate, nitric oxide (NO), opioids, cannabinoids, trophic factors, and hormones, such as prolactin, thyroid hormones, neurosteroids, and neuropeptides [16]. Age, odor, sexual signal, stress, and stroke affect neurogenesis in the olfactory bulb [18-21]. In addition, vasculature is closely associated with the migration of newborn cells [22]. Lee et al. [23] showed that superior cervical ganglionectomy enhances regeneration of olfactory receptor cells in mice anosmia induced by zinc sulphate. Therefore, we suggest that the effect of SGB on olfactory dysfunction may be related to an increased blood flow by the sympathetic block. The effects of SGB on blood flow occur no more than 2 h after SGB [24]. However, the improvement of olfactory function after SGB lasts for a long time as demonstrated in this study. We propose that this is related to neurogenesis in the olfactory nerve under the stimulus of increased blood flow."
 
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Baron Samedi said:
I have several patients who tell me that SGBs for their PTSD literally saved their lives. Several patients who could barely leave their house who are back to being productive members of society after an SGB.

Not everyone responds, obviously. But those who do have had very remarkable results.
Click to expand...
I also have 4 patients that come in monthly for SGB's to treat their PTSD. For these guys it's tremendously beneficial. If they miss one month their PTSD worsens significantly. I can't even propose a mechanism for action, but the results for these 4 patients have been remarkable.
 
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Agast said:
We don’t know the mechanism of action for volatile anesthetics but we still use them to knock people out…

If a patient says they couldn’t smell anything and enjoy their morning coffee and suddenly can post procedure, are you suggesting it’s in their head?
Click to expand...
Mel Gibson spent 6 figures on IV stem cells for his father and he's now 21 yo again. Not at all the same, and I get that...

Doing a stellate ganglion block for PTSD or night terrors isn't that far fetched. It's a sympathetic block...I've done it for night terrors and PTSD and had good results with it.

Again, that's a sympathetic block in a patient with probable elevated sympathetic drive, so yeah...Makes sense.

For example, Prazosin is an alpha 1 blocker and modulates NE. I understand that proposed MoA and why that would be given for the same Dx. Not sure that works though...I've seen it fail repeatedly.

Tachyarrhythmias are certainly targets for SGB bc you've doused the vagal nerve with anesthetic. That too makes sense.

Is COVID indefinitely altering blood flow to the olfactory bulb? It is somehow causing vascular stenosis or spasm to those vessels? I have no idea which vessels those are, but is that what we're thinking?

Edit - Just read an article where autoimmune assault on olfactory cells. WTF...
 
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Force440 said:
I also have 4 patients that come in monthly for SGB's to treat their PTSD. For these guys it's tremendously beneficial. If they miss one month their PTSD worsens significantly. I can't even propose a mechanism for action, but the results for these 4 patients have been remarkable.
Click to expand...
I’m curious what are you injecting?
 
callmeanesthesia said:
A local cardiologist contacted me about sending patients for SGB for refractory vtach. I politely declined.
Click to expand...

I need a stellate now for PTSD. Flashbacks to fellowship where we had IPS call and would get called in for “emergent” stellate ganglion catheter placement on CICU patients with refractory Vtach. Absolute dumbest thing ever.
 
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mdo1738 said:
I need a stellate now for PTSD. Flashbacks to fellowship where we had IPS call and would get called in for “emergent” stellate ganglion catheter placement on CICU patients with refractory Vtach. Absolute dumbest thing ever.
Click to expand...
N=30
Electrical storm refractory to drugs.

No way for me. If it doesn't hurt, if it ain't spine/jointMSK, not my bag. Heck, I don't even look at PF, heel spur, achilles- go to Podiatry.
 
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MitchLevi said:
I'm happy to hear it helped.

Why do you think it worked, and why did you perform that procedure on your daughter?
Click to expand...
I read a few articles from this forum. She was desperate for anything to help and I figured it was low risk. As to why it worked, I’m not real certain of the mechanism. As with a lot of things with SGB, it seems to be like a cntl-alt-delete for things. Fortunately for her, she had excellent results, so it was worth trying!
 
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lobelsteve said:
N=30
Electrical storm refractory to drugs.

No way for me. If it doesn't hurt, if it ain't spine/jointMSK, not my bag. Heck, I don't even look at PF, heel spur, achilles- go to Podiatry.
Click to expand...

Unfortunately I know of that study, that’s the study that led my old institution to start doing it back in 2019. I was there for the 5th year of them doing that, according to our IPS director whose pet project it was, we had done north of 50 over that time with zero successful results. But I did have somebody code on me right as I was about to thread the catheter (no meds injected or anything, dude just coded because he’s refractory V tach) so that was cool. I declined to do any more after that.
 
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mdo1738 said:
I need a stellate now for PTSD. Flashbacks to fellowship where we had IPS call and would get called in for “emergent” stellate ganglion catheter placement on CICU patients with refractory Vtach. Absolute dumbest thing ever.
Click to expand...

Wow that’s ridiculous
 
Ducttape said:
I have had personal experience that SGB can help with refractory v tach

There are also published case reports of efficacy.
Click to expand...
So no data at all but you had it done personally? You know I’m going to throw this at you when you criticize regen medicine every chance I get now, right?
 
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I do a lot of these for PTSD and long COVID symptoms. Some local psychs refer to me, and there is a trauma-recovery group of psych NPs that love my work. For PTSD the batting average is very good, and responders do report life-changing experiences. You may need to repeat the block periodically, but the benefits greatly outweigh the risks. For long COVID the batting average is considerably lower, but I do see positive effects. For some patients you see partial or total reversal of parosmia, for others it lasts a few months and needs be repeated. For many, probably at least 50%, it doesn't do anything. I have seen patients who responded very dramatically to blocks on one side, but not at all on the other. I've had some patients with chronic fatigue syndrome who wanted to do the multi-block protocols you see some doing in the medical literature. I can't say it did much for these folks. One guy (a doctor, no less) flew in to see me from the UK!
 
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BobBarker said:
What are you charging?
Click to expand...

$575 with a card, $500 cash/check. I use Athena, so I want some payback on their fees if I put a self-pay through the system. This rate seems to work well, even for those of modest means. I get some people driving from other states for these rates. Stella is like $2-3k!
 
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powermd said:
$575 with a card, $500 cash/check. I use Athena, so I want some payback on their fees if I put a self-pay through the system. This rate seems to work well, even for those of modest means. I get some people driving from other states for these rates. Stella is like $2-3k!
Click to expand...

Are you placing an IV for safety, adding IV sedation, or doing live DSA with your stellates?

I frequently do all three, so a stellate becomes a bigger deal than an epidural. I’m fine with 500 for an epidural but I’d want more for stellate.

But if you’re comfortable charging that, more power to you.
 
bedrock said:
Are you placing an IV for safety, adding IV sedation, or doing live DSA with your stellates?
Click to expand...
No, no, and no. I used to place IVs but after never actually using one after several hundred I stopped a while back. Same with C-ESI.

IV sedation seems overkill. The entire procedure takes about 3 minutes and can be done with a 25G. On occasion I'll give 5mg PO diazepam if the patient is particularly nervous about it.
 
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Baron Samedi said:
I have several patients who tell me that SGBs for their PTSD literally saved their lives. Several patients who could barely leave their house who are back to being productive members of society after an SGB.

Not everyone responds, obviously. But those who do have had very remarkable results.
Click to expand...
How do you get this approved/reimbursed?
 
bedrock said:
Are you placing an IV for safety, adding IV sedation, or doing live DSA with your stellates?

I frequently do all three, so a stellate becomes a bigger deal than an epidural. I’m fine with 500 for an epidural but I’d want more for stellate.

But if you’re comfortable charging that, more power to you.
Click to expand...

I used to years ago, but stopped. With ultrasound you can clearly see and avoid the carotid and vertebral arteries, and provided you're getting obvious fascia expansion, the likelihood of intravascular injection is low. I've done tons of these and the closest I've had to a complication was one patient with transient ringing in the ears and racing thoughts. This was just after injecting some local under the skin- probably caught the EJ or something. It resolved and we continued with the block. I've also had a few hypertensive patients shoot up close to 200/100 before settling down. They were asymptomatic for it. I do keep IV labetolol around just in case.
 
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Ducttape said:
I have had personal experience that SGB can help with refractory v tach

There are also published case reports of efficacy.
Click to expand...
Did this on a patient in the unit during fellowship for refractory vtach on heparin gtt w/o benefit from ablation. Pt did well and allowed to bridge to some other cardiac intervention. Pt ultimately recovered, came off pressors, went to rehab. They hadn’t had vtach in a day or so when I did it though so it is tough to tell if they would have gone into that rhythm again had we not done the procedure.
 
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PMROralBoards said:
Did this on a patient in the unit during fellowship for refractory vtach on heparin gtt w/o benefit from ablation. Pt did well and allowed to bridge to some other cardiac intervention. Pt ultimately recovered, came off pressors, went to rehab. They hadn’t had vtach in a day or so when I did it though so it is tough to tell if they would have gone into that rhythm again had we not done the procedure.
Click to expand...

Dang I thought mine was the only program doing that nonsense. Sorry to hear you had to deal with those as well. Glad your patient recovered, i doubt it was from the block though. I just really don’t see these doing anything for Vtach.
 
Doctodd said:
So no data at all but you had it done personally? You know I’m going to throw this at you when you criticize regen medicine every chance I get now, right?
Click to expand...
sure fine, but please dont forget the significant differences between the 2 situations.

i did it based on case reports as desperation treatment for a life-threatening condition.

in addition, this was a once of a career situation, not one where a primary focus is reimbursement.

im not sure i got any rvus as this was done on an inpatient.



i realize that many here cannot read the thread, as it was in the Physician forum, but here it is.




reading some of those old posts from Stim4Me.... wow they remind me of a current poster...
 
Ducttape said:
sure fine, but please dont forget the significant differences between the 2 situations.

i did it based on case reports as desperation treatment for a life-threatening condition.

in addition, this was a once of a career situation, not one where a primary focus is reimbursement.

im not sure i got any rvus as this was done on an inpatient.



i realize that many here cannot read the thread, as it was in the Physician forum, but here it is.




reading some of those old posts from Stim4Me.... wow they remind me of a current poster...
Click to expand...
fair enough.....so when you say personally, you werent the patient? And the refractory vtach didnt kill the patient, or they would have died unless you treated them right then and there? You have impeccable timing.

I do plenty of probono PRP.
 
academic.oup.com

Stellate ganglion blockade for treatment of ventricular arrhythmia storm: a meta-analysis

AbstractBackground. Autonomic neuromodulation and particularly stellate ganglion blockade (SGB) has been tested in ventricular arrhythmia (VA) storm, but there
academic.oup.com academic.oup.com

The ventricular arrhythmia literature is from multiple sites, countries, and very well supported with functional data and a mechanistic effect.
I'm happy to do it for that indication when asked, but definitely a different mindset as compared to pain procedures.
 
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Doctodd said:
fair enough.....so when you say personally, you werent the patient? And the refractory vtach didnt kill the patient, or they would have died unless you treated them right then and there? You have impeccable timing.

I do plenty of probono PRP.
Click to expand...
you might want to read the entire thread.

the patient was able to go home on anti-arrhythmics and her AICD. had no further incidences the remaining 10 or so days she was hospitalized.

she was scheduled for an outpatient appointment to see me 8 weeks post procedure.

she developed vtach again 1 day before her appointment and was admitted to the local academic institution.

they put her on iv antiarrhythmics, attempted ablation. ICU intubated and completely sedated.

noone did a stellate.

after 2 weeks, the family withdrew care.
 
I did a stellate on a patient for parosmia 2/2 Covid. He said that certain food/drinks such a coke tasted like “outer space.” 🤷🏻‍♀️Did a right stellate with 8 ccs 0.2% lidocaine. 30 min after procedure gave him a coke and he took a sip and smiled. Said it tasted like coke. Haven’t seen him since though. This was about 6 months ago. Who knows if it cured him.
 
Ducttape said:
sure fine, but please dont forget the significant differences between the 2 situations.

i did it based on case reports as desperation treatment for a life-threatening condition.

in addition, this was a once of a career situation, not one where a primary focus is reimbursement.

im not sure i got any rvus as this was done on an inpatient.



i realize that many here cannot read the thread, as it was in the Physician forum, but here it is.




reading some of those old posts from Stim4Me.... wow they remind me of a current poster...
Click to expand...

It sounds fishy to me.
 
Here's an AI image of the Mad Scientist Ducttape right after the stellate (AI always screws up the fingers, and that flag on his sleeve has like 80 stars...LOL):

1701878861089.png
 
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