Without ASC access for 6 weeks…which procedures would you advise against performing in an office setting?

[Baron Samedi]

The only things I wouldn't do in clinic are SCS/pump implants(trials ok) and BVNA.

The only procedure I routinely offer PO sedation for is genicular nerve RFA. SCS trial/Lumbar/cervical/sacral RFA only if they ask for it and I usually try to talk them out of it. Never for ESI/SIJ unless documented hx of anxiety. Never for celiac blocks d/t risk of hypotension and usually medically frail. Very rarely for SGB if I'm doing it for severe PTSD.

Valium remains active for 30 hours or so. Most of these procedures take less than 2 minutes of actual needle time. None of these patients are waiting 30 hours to drive.

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[deleted185747]

I didn’t read any of the comments, just skipped to the bottom to let you know I did a Vertiflex with local only. Guy didn’t complain at all.

 

[Ducttape]

Zero reason to use Dex in an ILESI.

In the foramen, use Dex but please understand you're more likely to see pts with sustained improvement from your ESI if you drop particulate in there...It's just the truth and yes, I hate to say that.

...but we don't have to derail the thread (which I probably just did).

Clinic procedures are easy with Valium.

BTW - Speaking of clinic procedures and Dex...If you do a CESI with Dex, and the pt startd having chest pain, it is just the Dex. Give it 15 min and don't get an EKG.

not completely zero....

dex is very helpful compared to depo for inpatients, because it is subjectively faster acting. and maybe the duration of effect is 1 or 2 weeks less with dex.

if radicular pain is the main hold up for discharge, use dex for both cervical and lumbar.


in office, i use no local sedation. the walk from the parking garage is pretty long. local sedation gets done at ASC.

 

[MitchLevi]

not completely zero....

dex is very helpful compared to depo for inpatients, because it is subjectively faster acting. and maybe the duration of effect is 1 or 2 weeks less with dex.

if radicular pain is the main hold up for discharge, use dex for both cervical and lumbar.


in office, i use no local sedation. the walk from the parking garage is pretty long. local sedation gets done at ASC.

I haven't seen a hospital pt in yrs! I feel bad for ppl who get consulted on inpt pain. My God is that awful.

 

[Baron Samedi]

I haven't seen a hospital pt in yrs! I feel bad for ppl who get consulted on inpt pain. My God is that awful.

To each their own, I suppose. I enjoy inpatient consults. Usually fairly complex and good teaching opportunities for fellows. Most of our less common procedure referrals come from the inpt side -- blood patches, regional blocks, facial injections, sympathetic blocks, ketamine infusions, intrathecal txs.

The key is to work somewhere that has a separate Acute Pain Service that handles all the post op pain and difficult opioid patients. Saves a ton of headache.

 

[Analgesia108]

I’m thinking of oral Valium based on someone’s recommendation…

Do you prescribe it beforehand and have them take it before they come in?

Oral sedation patients ( at both ASC and office) come and sign the consent, take their benzo and wait for 30 min ( in their car or lobby) prior to procedure and then driven home

 

[lobelsteve]

Oral sedation patients ( at both ASC and office) come and sign the consent, take their benzo and wait for 30 min ( in their car or lobby) prior to procedure and then driven home

Sounds stupid. Consent in office prior to day of procedures. You are NOT stupid, but your administration doesn’t know what to do.

 

[MitchLevi]

Sounds stupid. Consent in office prior to day of procedures. You are stupid, but your administration doesn’t know what to do.

Yes.

Consent in the office.

Valium to pharmacy.

Take the Valium in the car on the way to the procedure.

Become something on the order of a 2/3 - 3/4 baller while providing your pts a seemless, quick and simple procedure day.

Also, I'm sure Steve didn't mean to call you stupid. He probably meant to say you're not stupid.

 

[drrosenrosen]

This is a tricky one!

1. I see periscapular pain and chest pain fairly frequently with cervical ILESI with Dex, zero local. I warn patients a couple times about this prior to the procedure "You may have pain and burning between your shoulder blades as I inject the steroid, we do not know why this happens but it is safe and it will pass."
2. Adding 2-3 cc of saline to the dex prior to injection seems to eliminate or reduce this phenomenon, not sure why.
3. RE: "and the pt startd having chest pain, it is just the Dex." ; I actually had a patient in this situation once and the patient was indeed having an acute MI on the table, just after I injected the steroid. Patient survived.

Lesson; you are fine 99.9% of the time until you are not...then #3 happens.

That sounds more like #2 happens

 

[lobelsteve]

Yes.

Consent in the office.

Valium to pharmacy.

Take the Valium in the car on the way to the procedure.

Become something on the order of a 2/3 - 3/4 baller while providing your pts a seemless, quick and simple procedure day.

Also, I'm sure Steve didn't mean to call you stupid. He probably meant to say you're not stupid.

editing now, thanks.

 

[Ligament]

Yes.

Consent in the office.

Valium to pharmacy.

Take the Valium in the car on the way to the procedure.

Become something on the order of a 2/3 - 3/4 baller while providing your pts a seemless, quick and simple procedure day.

Also, I'm sure Steve didn't mean to call you stupid. He probably meant to say you're not stupid.

Steve called your mom stupid! ;-)

 

[Analgesia108]

Sounds stupid. Consent in office prior to day of procedures. You are NOT stupid, but your administration doesn’t know what to d

woes of working in corporate medicine my friend - the ASC RN director was terrified when a patient that took Vailum signed a consent and drove home after the procedure, triggering this 'policy change'.....

 

[Ducttape]

you can alleviate a lot of issues by getting the ASC to provide the valium and have the nurse give the patient the valium after consent is signed.

1. you dont have to provide a prescription (and dont have to check PMP, send in script, etc)
2. you dont have to field calls that the patient already took the valium so send in another prescription, or lost it, etc.
3. you can ensure that the patient has a driver to take them home and have less legal liability if they get in an accident
4. the consent would be signed prior to administration of the medication.