What does a wet tap look like?

[deleted162650]

Yea the only other time I did an intrathecal catheter, I ended up pulling it out shortly after delivery. But then some attending ssaid that for "maximal benefit" it should stay in as do some fo the studies. But none really say what the catheter is doing. Is it just hanging out there or are they infusing something through it.

The hypothesis is that the catheter sitting there causes a local inflammatory reaction that helps seal the dural hole when the catheter is pulled.

Unless someone gave me a strong reason to keep it, I was planning on pulling it assuming the patient delivers before 7am. That way my colleague coming on will only have to deal with the possible PDPH and nothing else...

I'm jsut upset that I tapped her. She was only slightly above average in size and had good anatomy. Like I said, got good LOR but catheter didn't thread twice. Probably should have rotated the bevel a little more. Wondering if maybe I was just up against the dura. Oh well... she's comfy. Hopefully she avoids the HA.

DO NOT (let me repeat) DO NOT rotate the tuohy once you are in the epidural space but having difficulty threading the cath. Rotating the tuohy is associated with a high incidence of subdural catheters/blocks. When rotated, the tip of the tuohy corkscrews through the dura just enough and often times into the elusive subdural space. In fact, there is a paper out there where the authors were intentionally studying subdural blocks and their method to reliably get into the subdural space was to, you guessed it, rotate the needle.

Next time you have a stubborn catheter, try lifting upward (cephalad) on the shaft of the tuohy. This forces the tip down and creates a nice little pocket for the cath to slip into. This works so amazingly well that I now just do it empirically right off the bat when I thread the cath.

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[sigrhoillusion]

The hypothesis is that the catheter sitting there causes a local inflammatory reaction that helps seal the dural hole when the catheter is pulled.



DO NOT (let me repeat) DO NOT rotate the tuohy once you are in the epidural space but having difficulty threading the cath. Rotating the tuohy is associated with a high incidence of subdural catheters/blocks. When rotated, the tip of the tuohy corkscrews through the dura just enough and often times into the elusive subdural space. In fact, there is a paper out there where the authors were intentionally studying subdural blocks and their method to reliably get into the subdural space was to, you guessed it, rotate the needle.

Next time you have a stubborn catheter, try lifting upward (cephalad) on the shaft of the tuohy. This forces the tip down and creates a nice little pocket for the cath to slip into. This works so amazingly well that I now just do it empirically right off the bat when I thread the cath.

So when I was trainging the two anesthesiologists that did mostly OB would train all the residents to insert the tuohy needle in perpendicular to the epidural space and then once they got into the space to rotate it so the bevel was up. I NEVER did this when they weren't directly supervising. They said it had to do with the thought that "if you puncture the dura, the up and down tear goes with the dura so it's less disruptive". I thought it was a bunch of hogwash, and I found that having the tuohy oriented like this would lead to drifiting left or right because of the angle of the needle. Where as if you have bevel up, even if you drift up or down a millimeter you're still parallel with the space. Also, many studies have shown that the dural fibers aren't parallel up-and-down, but more interwoven so it really doesn't matter.

That being said, the only reason I turned it was because of the inability to thread the catheter even after pushing some more saline into the needle to hopefully open the space. And I rarely try to readjust the needle in the space anymore but the few time sI have I've never had a puncture from doing so.

I'll try the cephalad bump next time.

 

[deleted162650]

So when I was trainging the two anesthesiologists that did mostly OB would train all the residents to insert the tuohy needle in perpendicular to the epidural space and then once they got into the space to rotate it so the bevel was up. I NEVER did this when they weren't directly supervising. They said it had to do with the thought that "if you puncture the dura, the up and down tear goes with the dura so it's less disruptive". I thought it was a bunch of hogwash, and I found that having the tuohy oriented like this would lead to drifiting left or right because of the angle of the needle. Where as if you have bevel up, even if you drift up or down a millimeter you're still parallel with the space. Also, many studies have shown that the dural fibers aren't parallel up-and-down, but more interwoven so it really doesn't matter.

That being said, the only reason I turned it was because of the inability to thread the catheter even after pushing some more saline into the needle to hopefully open the space. And I rarely try to readjust the needle in the space anymore but the few time sI have I've never had a puncture from doing so.

I'll try the cephalad bump next time.

I woulda told those 2 dufuses (dufi?) that an 18g hole in the dura is pretty F'in disruptive no matter which way the bevel is facing.

 

[B-Bone]

my approach to LOR where I can't thread catheter:
either 1) pull out and re-establish LOR or 2) do a needle-through-needle CSF check with the CSE needle. On the rare occasion that I can't thread a catheter, I almost always find I can't get CSF with the CSE needle, and thus had a false LOR. I don't think I would ever just blindly advance the Tuohy at that point. Having negative CSF with the CSE needle means you have at least 1/2" of room to advance without fear of dural puncture and makes me more comfortable advancing for a better LOR.

 

[pgg]

Spring wound catheters are extremely kink resistant. Tying knots in them won't prevent (or even limit) flow most of the time. Try it some time.

 

[Planktonmd]

That whole rotate the needle thing is nothing but a crappy ritual, and the thing about leaving the intrathecal catheter in is probably as useless but they both have a good placebo effect on the one who is doing them.

 

[Wiscoblue]

Well I happen to be one of those dufi! I do my epidurals with the patient on her side. I go with the bevel facing up and then after loss of resistance (using air), I turn the needle so now the bevel is cephalad. I've been doing this for 30 plus years. I can't remember when I had my last wet tap. Must be over a year ago.

 

[Planktonmd]

Well I happen to be one of those dufi! I do my epidurals with the patient on her side. I go with the bevel facing up and then after loss of resistance (using air), I turn the needle so now the bevel is cephalad. I've been doing this for 30 plus years. I can't remember when I had my last wet tap. Must be over a year ago.

Ah... did you quit taking your memory pills again?

 

[deleted162650]

Well I happen to be one of those dufi! I do my epidurals with the patient on her side. I go with the bevel facing up and then after loss of resistance (using air), I turn the needle so now the bevel is cephalad. I've been doing this for 30 plus years. I can't remember when I had my last wet tap. Must be over a year ago.

Well I don't think twisting the needle or not has any impact on your wet tap rate. It's just "supposed" to reduce the chance of a PDPH if you get a wet tap. If it works for you, keep doing what your doing, but realize it's just adding an extra unnecessary dufusy step.

 

[caligas]

I've left one in for 24 hours but I tied a knot in the catheter.

 

[sigrhoillusion]

Patient ended up delivering via SVD in the morning. However she had a lactation which they had to repair after which they turned off infusion.

I then get called at 6am (thinking to pull catheter, which I would of because like others said I didn't want someone having to deal with it any any complications) but outs because she was developing a labial hematoma. So patient was now in pain again, so i went up and bolused and restarted infusion. Plan was to observe hematoma and recheck CBC in a few hours to see out she needed surgical evacuation.

So I signed out the intrathecal catheter to the incoming team. And it looks like they eventually went to the OR for the procedure and the they dosed her up like a spinal and it appears everything went well. I'm assuming they pulled the catheter at the end of the procedure.

 

[Orin]

The parallel/perpendicular thing is probably less critical with 18g Tuohy's, but I'd buy it for the 14g needles for lumbar drains, etc. You got to realize that Tuohy bevel tip orientation will move your needle around, but if loss isn't at 9 cm, you might not care.

Reg the accidental punctures, I've heard of a case of meningitis felt to be related to catheter being left in. Others where I trained felt it was low risk, but that intermittent bolusing/breaking of the circuit introduces risk so keep it attached to a closed circuit.

 

[sigrhoillusion]

On a separate but related note how do EBPs factor into billing? I'm pretty billing native. Even if we cause the PDPH and do another procedure to fix the complication, do we get reimbursed for it, or is it tied to the initial epidural? I'm assuming its completely separate since ours no different than the neurosurgeon doing his 4th spine revision which they ASSURE the morbidly obese diabetic COPD will fix all their issues THIS time.

 

[deleted162650]

On a separate but related note how do EBPs factor into billing? I'm pretty billing native. Even if we cause the PDPH and do another procedure to fix the complication, do we get reimbursed for it, or is it tied to the initial epidural? I'm assuming its completely separate since ours no different than the neurosurgeon doing his 4th spine revision which they ASSURE the morbidly obese diabetic COPD will fix all their issues THIS time.

You bill for it separately. It's a flat fee, not start-up/time based like typical billing.

 

[B-Bone]

Patient ended up delivering via SVD in the morning. However she had a lactation which they had to repair after which they turned off infusion.

That must have been one hell of a lactation.




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[sigrhoillusion]

That must have been one hell of a lactation.


Laceration haha. Post-call daze...

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[pjl]

On a separate but related note how do EBPs factor into billing? I'm pretty billing native. Even if we cause the PDPH and do another procedure to fix the complication, do we get reimbursed for it, or is it tied to the initial epidural? I'm assuming its completely separate since ours no different than the neurosurgeon doing his 4th spine revision which they ASSURE the morbidly obese diabetic COPD will fix all their issues THIS time.

They actually bill pretty highly. I was surprised. High enough that someone from the central office was annoyed that we forgave the bill for all the EBP related to the few OB wet taps that we had last year.

Technically, you should bill for every single one of these that you do, and you deserve the money. It is a known complication of epidurals and the treatment of choice. This is a separate procedure you do, thus the billing is separate. Our group however feels that we should provide a different and better level of customer service by not charging for EBP that we caused. We do ~1500 epidurals a year and have ~5 symptomatic dural punctures related to those per year. For us it is a low cost to save negative word of mouth, similar to dental repairs.

 

[deleted682700]

Csf gushes out. Its very classic. Old teachers would say if it continues to flow out and feels warm to feel at elbow you have created a wet tap.
So what, it will happen. It may not be your aggressive or fast technique to blame. Its just way too thin ligamentum flavum. History of prior dural puncture head ache by anesthesiologist before should make you slow way down
Just leave the catheter and inject 15-20 ml of sterile blood in it.

 

[deleted171991]

Just leave the catheter and inject 15-20 ml of sterile blood in it.

AFAIK, there is no proof that prophylactic epidural blood patches help more than injecting the same volume of sterile saline.

 

[partydoc]

One of my attendings taught me this recently: have the patient take a deep breath when trying to advance, seems to work with my n = 3.

 

[Wiscoblue]

Ah... did you quit taking your memory pills again?

Ah and you're so fricking smart!

 

[Planktonmd]

Ah and you're so fricking smart!

Thank you!

 

[scudrunner]

Have you ever seen a garden hose flowing without an attachment? That's it.

 

[sigrhoillusion]

So far so good. Two days later no HA.

 

[dhb]

Have you ever seen a garden hose flowing without an attachment? That's it.

Well not always, i supervised i resident place an epidural and he had a little back flow but it looked like the saline dripping back. He threaded the catheter which endend being intrathecal.

 

[Arch Guillotti]

Have you ever seen a garden hose flowing without an attachment? That's it.

Except when it isn't.

 

[OneFellSwoop]

That's why I like LOR to air. I have no doubt to its source if fluid comes back. We use plastic LOR syringes and using air is a crisper loss than using saline as well.


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[Mman]

Unless someone gave me a strong reason to keep it, I was planning on pulling it assuming the patient delivers before 7am. That way my colleague coming on will only have to deal with the possible PDPH and nothing else...

I'm jsut upset that I tapped her. She was only slightly above average in size and had good anatomy. Like I said, got good LOR but catheter didn't thread twice. Probably should have rotated the bevel a little more. Wondering if maybe I was just up against the dura. Oh well... she's comfy. Hopefully she avoids the HA.

Of the few wet taps I've had, the most common scenario was similar to yours when I thought I had LOR and the catheter wouldn't thread so I advanced a little more.

My current line of thinking is if I get LOR and the catheter won't thread I just back out and start over (same interspace).