Wet taps

[405251986]

I have been doing OB for quite some time and I was doing ok with my epidurals but recently, I have been having problems with wet taps. i have had 4 by now. There are just times with obese women, even I go slowly, then I wouldn't even feel a LOR, then suddenly, boom, it's CSF. I know the feel of ligament flavum, but for some people, I just don't really feel my needle passing through it. Do some people just have soft ligaments? I don't know if it makes sense but I usually encounter it when I use the lower interspace. I use saline in the plunger with a little amount of air. it's just frustrating. Any more tips on how to prevent this complication? 1 of them needed to have a blood patch and I just feel bad.

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[Planktonmd]

I have been doing OB for quite some time and I was doing ok with my epidurals but recently, I have been having problems with wet taps. i have had 4 by now. There are just times with obese women, even I go slowly, then I wouldn't even feel a LOR, then suddenly, boom, it's CSF. I know the feel of ligament flavum, but for some people, I just don't really feel my needle passing through it. Do some people just have soft ligaments? I don't know if it makes sense but I usually encounter it when I use the lower interspace. I use saline in the plunger with a little amount of air. it's just frustrating. Any more tips on how to prevent this complication? 1 of them needed to have a blood patch and I just feel bad.

When you say you have been doing OB for quite some time... could you define what that means in years?
Missing the ligament is common when you are entering in a paramedian approach, but on rare occasions you could encounter patients with Spina bifida occulta and the ligament could be simply absent!

 

[405251986]

When you say you have been doing OB for quite some time... could you define what that means in years?
Missing the ligament is common when you are entering in a paramedian approach, but on rare occasions you could encounter patients with Spina bifida occulta and the ligament could be simply absent!

Well actually not in years, 6 months really

 

[deleted50478]

I have been doing OB for quite some time and I was doing ok with my epidurals but recently, I have been having problems with wet taps. i have had 4 by now. There are just times with obese women, even I go slowly, then I wouldn't even feel a LOR, then suddenly, boom, it's CSF. I know the feel of ligament flavum, but for some people, I just don't really feel my needle passing through it. Do some people just have soft ligaments? I don't know if it makes sense but I usually encounter it when I use the lower interspace. I use saline in the plunger with a little amount of air. it's just frustrating. Any more tips on how to prevent this complication? 1 of them needed to have a blood patch and I just feel bad.

There's a huge difference in the feel of the ligament between women. I do continuous pressure and continuous advancing of the needle and stop with LOR whether I feel ligament or not. >95% of the time ligament is obvious, occasionally it isn't. If I have LOR and didn't feel ligament I inject fluid. If it doesn't feel right I still don't advance after LOR. At that point I go up a level and start from scratch. Usually it feels better. If not, I bolus after LOR and see if it sets up or not. It almost always does, confirming my decision not to advance until i feel ligament and letting me know i would have wet tapped if I had advanced.
If you are training your attending might think you are nuts with continuous advancing of the needle instead of 1mm tap tap tap, 1mm tap tap tap, etc., but i think it is better and faster than the usual way.

 

[Orin]

Wet taps are part and parcel of putting a needle blindly into someone's back. 4 in 6 months is okay if the denominator is 200, but if it is 4 in 20, then you should worry more about your technique.

For advice, LOR is probably more appropriately thought of as a change of resistance rather than true loss in some circumstances. If you're afraid of a wet tap, then you should double check at the slightest hint of LOR.

A continuous technique does seem less prone to false LOR, but not sure if it'll prevent wet taps for relatively inexperienced hands. It beats the hanging drop...

I would debrief about your wet taps and try to figure out why you missed a LOR if one was present.

 

[BobBarker]

I think you are doing fine. People that act like they have never had a wet tap are liars. Some people dont seem to have much flavum back there.

Your phone number as your username is a much more pressing problem than your wet tap rate.

 

[Wiscoblue]

It can't be his phone number. One digit less.

 

[WholeLottaGame7]

I think you are doing fine. People that act like they have never had a wet tap are liars. Some people dont seem to have much flavum back there.

Your phone number as your username is a much more pressing problem than your wet tap rate.

You mean SSN. Definitely a bold move.

 

[pgg]

You might try doing CSEs for a while. When you think you got a LOR with the Tuohy, put the spinal needle through.

CSF - you're probably in the epidural space.

No CSF - it was a false loss and you can safely advance the Tuohy.

You don't necessarily have to dose anything through the spinal needle, but you can (and the patients will love you for it).

 

[BobBarker]

You mean SSN. Definitely a bold move.

Yes you are right! I live in the 405 so that made me ignore the missing digit.

 

[Ezekiel2517]

hmm, I disagree a little with the others. That's a lot of wet taps dude. While the feel of the flavum may differ slightly from patient to patient, you should definitely know when your needle is in it. Not just from the tactile feedback from the Touhy entering the flavum itself but also from what you feel when you tap on the syringe. We're talking about young healthy women here. I do a ton of epidurals and can't remember the last one where I didn't know my needle was in flavum. I think it will come with more experience but you should definitely gain a sense of the different tactile feedback you get when you are going thru different tissues. The next time you do an epidural, try to make your goal to be feeling the Touhy in flavum, instead of simply getting an LOR without knowing where you are for sure.

 

[vector2]

Tuohy

 

[Arch Guillotti]

You might try doing CSEs for a while. When you think you got a LOR with the Tuohy, put the spinal needle through.

CSF - you're probably in the epidural space.

No CSF - it was a false loss and you can safely advance the Tuohy.

You don't necessarily have to dose anything through the spinal needle, but you can (and the patients will love you for it).

I favor this approach also for you.

I would use caution advancing after a loss with no CSF thru the spinal needle though. Every now and then I get a great loss but no CSF thru the spinal needle. Thread the cath and it works fine though.

 

[ranvier]

Watch someone experienced use the continuous technique. Even better, put your hands on the syringe. If you are engaged in ligament early in the midline approach, you know the ite question on the sequence, skin..fat...supraspinous....etc....the lor is pretty crisp with continuous pressure. I suspect you are not truly midline.

Also, some needles give better feedback. I teach with the cse needle which is more dull and gives a very distinct feeling through the LF and LOR.

Keep at it and report back!

 

[Ezekiel2517]

Tuohy

I smell bacon.

 

[vector2]

I smell bacon.

usually it's burnt toast but i think you're still in the tpa window

 

[Ezekiel2517]

usually it's burnt toast but i think you're still in the tpa window

You really not following? come on man think a little harder. don't hurt yourself though buddy

 

[vector2]

hehe, hadn't thought about the phrase spelling police in awhile

 

[Ezekiel2517]

To find midline in obese patients, press your finger where you think midline is and ask the pt if it feels as if you are pressing in the exact middle of her back or if she feels you are slightly off to the left or right. She will direct you to where the midline truly is.

 

[caligas]

my wet tap rate as resident: 5%

My wet tap rate 10 years out : nearly 0% (last one was 3 years ago and I do a lot of OB)

 

[fakin' the funk]

Agree with others on a few things:
a) many OB patients have a nice firm LF -- to me it feels like that really badass styrofoam that like new TVs or electronics come in; but some patients just have crappy connective tissue and their LF is mushy
b) being off midline can give you a "mushy" LOR, since you are going through the LF obliquely as opposed to perpendicularly -- remember the LF is kind of a round-bottomed V shape or parabolic. Being in midline is really important!
c) if you have a question about where you are, just pass a 24g spinal needle through and see if you get CSF. You either get a dural puncture -- dose it or not -- or you confirmed that you're not in epidural space, so try again

 

[deleted162650]

Tuohy

I think for the OP it's more like T-uh-oh-hy

 

[Mman]

my wet tap rate as resident: 5%

My wet tap rate 10 years out : nearly 0% (last one was 3 years ago and I do a lot of OB)

mine as a resident was 0% and I thought I was awesome, now as an attending it's probably in the realm of 0.2-0.5% or so. Every now and then you just can't help it. I've had women who moved right after I got LOR and then it wet tapped them. I've had ones that I never got a LOR. I've had ones that were just way damn shallower than I could've guessed.

It happens. That's why you explain the risk of a headache to them before you start.

 

[deleted162650]

I've had ones that were just way damn shallower than I could've guessed.

It happens. That's why you explain the risk of a headache to them before you start.

Had my personal record for shallowest LOR on my last OB call. 2.7cm.

 

[ZzzPlz]

My patients are way more likely to be 10+ than 5-

 

[camkiss]

First, for the OP, I would say be sure to put the stylet back in the needle if you contact bone at any point to clear out any small fragments that may have clogged up the tip of the needle. Also, go with your gut feeling more than actual loss of resistance. Any change in pressure and I will attempt to thread the catheter if its at the depth I think the space should be based on habitus.
Second, speaking of shallow LOR: I was about to place an epidural on a very reasonable sized laboring patient one night. Just before I started to inject lidocaine, she says, "oh-wait- I'm supposed to tell you something! The last anesthesiologist told me to tell the next anesthesiologist that 'it's closer than you think it should be'- whatever that means". Sure enough, her LOR was at just over 2.5cm! It was as if she kept this tiny gift packaged up for me for a few years, waiting for the exact right moment to open it.

 

[deleted162650]

My patients are way more likely to be 10+ than 5-

When I changed jobs my average LOR depth got cut in half. Lead me to develop


Salty's Law:

Quality of payer mix is inversely proportional to average LOR depth.


The above holds true for every hospital in the country that has an L&D unit.

 

[fakin' the funk]

I'd say about 5-10% of my L&D epidurals have LOR < 3cm, payer mix consistent with Salty's Law

 

[NavyFlightDoc]

I'd say about 5-10% of my L&D epidurals have LOR < 3cm, payer mix consistent with Salty's Law

I work in a hospital with a bimodal distribution of payer types, a large portion Medicaid, and another large portion private payer. While this is perhaps a misapplication of Salty's law, the two groups do follow the rule, if it is applied independently.

 

[deleted162650]

Wow, 3 of us in consecutive posts. Way to represent boys.