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INTRODUCTION

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  • Many patients with acute and chronic pain may require sedation for interventional pain procedures.

  • Patients may have extreme anxiety about the pending procedure or be in so much pain that even positioning them without some analgesia and/or sedation becomes impractical.

  • There is great variability in type of sedation required to perform minimally invasive procedures, and depends on the procedure, the surgeon, and the patient.

  • Some physicians perform most procedures without any sedation, while other physicians may want deeper level of sedation for some or many of their procedures.

  • The personnel may differ depending on the locations of the procedures performed. Sometimes, a sedation nurse (RN or other) trained in OR sedation administers the medication, and other times the sedation is administered by an anesthesiologist.

  • The choice of anesthesia may differ depending on locations: (1) office-based procedures, (2) surgicenters, and (3) hospital.

  • While both scenarios occur, it should be noted that current FDA recommendations state that propofol should only be administered by an individual trained in airway management (ie, anesthesiologist or CRNA).

  • Currently, there is no consensus on the appropriate overall strategy.

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There are a wide range of procedures being performed—from epidural steroid injections to implantation of spinal cord stimulators. Different procedures may require different levels of and different sedation techniques in order to optimize the outcome and the experience for the patient. Some proponents of using an anesthesiologist for sedation point to an appropriate analgesic experience for the patient, lack of movement, and safety in the operating room. Others are less inclined to utilize an anesthesiologist, citing risk of overuse of sedative medications, sometimes even resulting in spinal cord injury with deep sedation, along with an increased cost of care. When appropriately used, sedation can make the experience safer, more effective, efficient, and more comfortable without jeopardizing patient safety. Clearly if sedation is utilized, it is important to follow safe guidelines. There remain some principles that should be followed in providing sedation when performing interventional procedures.

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TYPES OF ANESTHESIA

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  • General anesthesia: rarely used for pain management procedures and will not be covered in this chapter.

  • Monitored anesthesia care or moderate sedation: used most often.

  • Conscious sedation or light anesthesia: appropriate for some procedures where patient’s feedback is important, eg, cervical blocks.

  • Local anesthesia: can be used for many of the minor procedures, such as trigger points and some epidural steroid injections. The payment for anesthesia for some of the more minor procedures can be dictated by particular insurers/providers in the region; this will also not be covered in this chapter.

  • Regional anesthesia: rarely used and will not be covered in this chapter.

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PREOPERATIVE ASSESSMENT

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As with any patient undergoing anesthesia of any kind, patients need an appropriate preoperative assessment, including risk level. While many of the procedures performed by the interventional pain physician may be considered minor, it is important to consider preoperative risk factors. ...

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