Just wet-tapped a lady...

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cchoukal

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On call for OB tonight and a 27 yo G7P1142 comes in at 19 0/7 wks with PPROM. The OBs want to let her deliver, and she wants an epidural (she'd had them before with good success) for her cramping. Most of our attendings wont do an elective epidural from a case like this, but we did one tonight. Sort of. Took a while to find the space, lots of extra local. Good LOR to air, but as I start to thread the catheter, she moved. Still no CSF, but once the catheter is threaded, it starts to return CSF. We kept it in and are using it, but of course she got a headache and started vomiting. This is only my second WT, and even though she basically did it to herself, I'm kinda bummed. On the other hand, there was just that big paper in Anesthesiology about IT analgesia for labor, but of course those were much smaller catheter... anyway...
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cchoukal said:
On call for OB tonight and a 27 yo G7P1142 comes in at 19 0/7 wks with PPROM. The OBs want to let her deliver, and she wants an epidural (she'd had them before with good success) for her cramping. Most of our attendings wont do an elective epidural from a case like this, but we did one tonight. Sort of. Took a while to find the space, lots of extra local. Good LOR to air, but as I start to thread the catheter, she moved. Still no CSF, but once the catheter is threaded, it starts to return CSF. We kept it in and are using it, but of course she got a headache and started vomiting. This is only my second WT, and even though she basically did it to herself, I'm kinda bummed. On the other hand, there was just that big paper in Anesthesiology about IT analgesia for labor, but of course those were much smaller catheter... anyway...
Click to expand...

It's OK, It happens to the best :)
And it will happen again.
 
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2 schools of thought:

1) take it out and start over 1 level up or down (seems up would be safer; might be less likely to "find" the previous dural puncture with the 2nd catheter).

2) Leave it in. There're data to suggest leaving the catheter in (whether or not you use it) reduces the incidence of PDPH. The theory is leaving it in either "plugs the hole" or creates an inflammatory response that plugs the hole, or both

We left it in and used it at 1 mL/hr of dilute bupivicaine. Worked well for her. So far the HA isn't too bad and is responding to conservative measures. For MMD, those measures usually involve supine position (although the evidence behind this is dubious), fluids, caffeine, and fioricet.
 
How about the biggest wet tap?

I was placing an SCS lead and got a 14G through the Dura. Pulled it out into the epidural space and threaded the lead up in the epidural space from T12 to T9. I can not explain why the patient did not get a PDPH. I had him go home, lay flat, drink caffiene and plenty of fluids (all anecdotally appropriate and without good literature to support it). I told him he should develop a HA that will last 2-4 days and may require a blood patch.

Also had a lady pee the table. But my contrast was epidural. Maybe I pinholed the dura. 4cc 2% lido mixed with 2cc NSS and 2cc Celestone, sensory block, no motor block, and bladder went woosh. She had FBSS and I think her nerves lacked reserve.
 
Then there's the "leave it in for 24hr" school of thought. I've never wet-tapped anyone yet either, but I realize that I've done far fewer epidurals than a lot of you guys (probably close to 300 at this point). But, I have followed wet-tap patients and, in some of them, they leave the catheter in to minimize PDPH risk. Don't know if this really works. Have seen it both ways (i.e., no headache vs. got a headache in spite of leaving it in).

-copro
 
lobelsteve said:
How about the biggest wet tap?

I was placing an SCS lead and got a 14G through the Dura. Pulled it out into the epidural space and threaded the lead up in the epidural space from T12 to T9. I can not explain why the patient did not get a PDPH. I had him go home, lay flat, drink caffiene and plenty of fluids (all anecdotally appropriate and without good literature to support it). I told him he should develop a HA that will last 2-4 days and may require a blood patch.

Also had a lady pee the table. But my contrast was epidural. Maybe I pinholed the dura. 4cc 2% lido mixed with 2cc NSS and 2cc Celestone, sensory block, no motor block, and bladder went woosh. She had FBSS and I think her nerves lacked reserve.
Click to expand...

Lob, if your guy had developed a PDPH with phtophobia and tinitus would you have performed an EBP with the SCS leads in place?

As far as the the local used in ESI, I stopped using it b/c nearly all complications reported from ESI's were from the local. If your contrast shows epidural spread then you should be golden. The local has some immediate benefits but it is not necessary and a little fentanyl can achieve the same short term relief.
 
cchoukal said:
I definitely think this is what happened.
Click to expand...


I had this happen to me as well. The pt. immediately said "I have a headache". Kind of scary actually, but it went away soon enough. I did learn a lesson with her though. Somehow I had gotten some blood in the syringe which dried up pretty quickly. In hindsight when I punctured the flavum I got a very equivocal soft change in resistance. Stupid me as a CA-1 thought that there was no way I could be in the epidural space. So I pushed on of course and of course got CSF after that. I think the partially dried blood in the syringe made the plunger hang a little bit. And now I treat funny or weird changes in restsitance more cautiously.
 
Arch Guillotti said:
I had this happen to me as well. The pt. immediately said "I have a headache". Kind of scary actually, but it went away soon enough. I did learn a lesson with her though. Somehow I had gotten some blood in the syringe which dried up pretty quickly. In hindsight when I punctured the flavum I got a very equivocal soft change in resistance. Stupid me as a CA-1 thought that there was no way I could be in the epidural space. So I pushed on of course and of course got CSF after that. I think the partially dried blood in the syringe made the plunger hang a little bit. And now I treat funny or weird changes in restsitance more cautiously.
Click to expand...

Hey, man. **** happens. If they were all easy, anyone could do it. Known and expected complication of this procedure, and why we tell all our patients it might happen.

I know what you mean about the clot in the syringe/Tuohy, though. If I'm not sure, I pull the whole thing out and repeatedly flush with saline before re-inserting the stylet and retrying. But, I have found in follow-up that the more pokes you do the more back pain at the insertion site you get, so I try to be as slick as possible on the first try when going in. Fatties get a double-dose of the forewarning before I attempt them, too.

-copro
 
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militarymd said:
I guess I must be second rate....I've never had one.
Click to expand...

That is interesting. Possible explanations:

a)refuse to admit ever having had a complication
b)haven't done very many epidurals
c)didn't recognize when it happened
d)luckiest SOB on the planet

I trained with a guy like (a) who never had a wet tap. Ironically, he would sometimes feel the need to give a few patients prophylactic blood patches the next day. Incidentally, this type of person should never be trusted.
To the original poster, it is not too uncommon early in training. Hopefully the frequency will approach zero as you gain more experience.
 
Gern Blansten said:
That is interesting. Possible explanations:

a)refuse to admit ever having had a complication
b)haven't done very many epidurals
c)didn't recognize when it happened
d)luckiest SOB on the planet

I trained with a guy like (a) who never had a wet tap. Ironically, he would sometimes feel the need to give a few patients prophylactic blood patches the next day. Incidentally, this type of person should never be trusted.
To the original poster, it is not too uncommon early in training. Hopefully the frequency will approach zero as you gain more experience.
Click to expand...

Even I know that prophylactic blood patches have been proven NOT to be efficacious.

So this guy is obviously e) un - Educated.

I'm just f) & g) that F uckin G ood
bouncingkx3.gif
 
Arch Guillotti said:
I had this happen to me as well. The pt. immediately said "I have a headache". Kind of scary actually, but it went away soon enough. I did learn a lesson with her though. Somehow I had gotten some blood in the syringe which dried up pretty quickly. In hindsight when I punctured the flavum I got a very equivocal soft change in resistance. Stupid me as a CA-1 thought that there was no way I could be in the epidural space. So I pushed on of course and of course got CSF after that. I think the partially dried blood in the syringe made the plunger hang a little bit. And now I treat funny or weird changes in restsitance more cautiously.
Click to expand...

I pretty much treat any CHANGE in resistance as a LOSS of resistance. If I notice a slight change, i will attempt to thread the catheter. 9 times out of 10, I'm in the space and it threads in nicely. If it doesn't, I put the syringe back on and soldier on. This probably applies a lot more to the elderly pts that I'm putting thoracic epidruals in than to the lumbar epidurals in young gravid patients.
 
militarymd said:
Even I know that prophylactic blood patches have been proven NOT to be efficacious.

So this guy is obviously e) un - Educated.

I'm just f) & g) that F uckin G ood
bouncingkx3.gif
Click to expand...

and of course I have wet taps
 
VentdependenT said:
Air or saline bitches?

I'm a saline dude.
Click to expand...

Saline in lumbars. Air in thoracics. It all has to do with the stakes.

Saline equals potentially less patchy blocks in laboring patients. Air equals knowing you're intrathecal if you're doing a thoracic.

-copro
 
coprolalia said:
Saline in lumbars. Air in thoracics. It all has to do with the stakes.

Saline equals potentially less patchy blocks in laboring patients. Air equals knowing you're intrathecal if you're doing a thoracic.

-copro
Click to expand...

I'm not sure I follow any of this.

BTW: Air always. Just b/c you use air doesn't mean you are injecting air into the space. Its all about the feel.
 
coprolalia said:
Saline in lumbars. Air in thoracics. It all has to do with the stakes.

Saline equals potentially less patchy blocks in laboring patients. Air equals knowing you're intrathecal if you're doing a thoracic.

-copro
Click to expand...
Excuse my ignorance but why would using saline make a block less patchy?
The only reason for a patchy block is a crappy operator in my opinion.
 
Use 1cc of air and 2ccs of saline--so a combination of the 2. --Zip
 
Planktonmd said:
Excuse my ignorance but why would using saline make a block less patchy?
Click to expand...

Air trapping. An air bubble takes time to dissipate and resorb in the epidural space. The air bubble acts as a dam that prevents the spread of local into that area. When you have a laboring patient who's already in pain, it's better to avoid missing a dermatome while you're waiting for that bubble to dissipate.

I've seen/done it both ways. The only times I've witnessed laboring patients experience a patchy block is when air was used for LOR. Maybe doesn't happen every time, but it definitely happens. Just avoid air in these patients. (I know I'm only a Jedi in training, but it doesn't mean I don't know anything.)

I'm not making this **** up.

http://www.cja-jca.org/cgi/reprint/36/5/603.pdf

And, here's more reason not to do it your way...

http://www.sciencedirect.com/scienc...serid=10&md5=aed044ba03906e55de5e6aa8e306e2e8

http://www.greenjournal.org/cgi/content/abstract/108/3/795

http://www.ncbi.nlm.nih.gov/pubmed/9010941

http://www.ncbi.nlm.nih.gov/pubmed/...bmed_ResultsPanel.Pubmed_RVAbstractPlusDrugs1

http://www.anesthesia-analgesia.org/cgi/content/citation/105/4/1173

Planktonmd said:
The only reason for a patchy block is a crappy operator in my opinion.
Click to expand...

:laugh: Cute. I know this is a controversial subject, Plankton. But, come on. Why so snarky?

-copro
 
coprolalia said:
Air trapping. An air bubble takes time to dissipate and resorb in the epidural space. The air bubble acts as a dam that prevents the spread of local into that area. When you have a laboring patient who's already in pain, it's better to avoid missing a dermatome while you're waiting for that bubble to dissipate.

I've seen/done it both ways. The only times I've witnessed laboring patients experience a patchy block is when air was used for LOR.

And, here's more reason not to do it your way...

http://www.sciencedirect.com/scienc...serid=10&md5=aed044ba03906e55de5e6aa8e306e2e8

http://www.greenjournal.org/cgi/content/abstract/108/3/795

http://www.ncbi.nlm.nih.gov/pubmed/9010941

http://www.ncbi.nlm.nih.gov/pubmed/...bmed_ResultsPanel.Pubmed_RVAbstractPlusDrugs1

http://www.anesthesia-analgesia.org/cgi/content/citation/105/4/1173



:laugh: Cute. I know this is a controversial subject, Plankton. But, come on. Why so snarky?

-copro
Click to expand...
Well,

All these examples you mentioned can go under the category of crappy operator.
Can you believe that someone was able to cause subcutaneous emphysema or retroperitoneal air while injecting air in the epidural space??
How much air are these people using?
I think the rule should be: If you are a rookie then use what they tell you to use, if you know what you are doing then you can use whatever you want and whatever feels right in your hands.
It's unfortunate that people keep publishing papers about insignificant minutia in this specialty for the only purpose of publishing something.
 
Did you read that article you mentioned first?
http://www.cja-jca.org/cgi/reprint/36/5/603.pdf

These people got confirmed CSF from the catheter but kept calling it an epidural catheter and want to convince us that CSF aspiration was because they used air for LOR!!
I don't know about you but that definitely fits my definition of CRAPPY OPERATORS!
 
Hmmm... you are starting to sound like someone else who posts a lot here... ;)

-copro
 
Planktonmd said:
Did you read that article you mentioned first?
http://www.cja-jca.org/cgi/reprint/36/5/603.pdf

These people got confirmed CSF from the catheter but kept calling it an epidural catheter and want to convince us that CSF aspiration was because they used air for LOR!!
I don't know about you but that definitely fits my definition of CRAPPY OPERATORS!
Click to expand...


I agree.

I've been using air for 11 years. Works for me. Saves at least 30 seconds....no popping open the saline, drawing it up, etc

Like Noy said, its all feel.
 
militarymd said:
Even I know that prophylactic blood patches have been proven NOT to be efficacious.

So this guy is obviously e) un - Educated.
Click to expand...

I think you missed the point. They were not REALLY prophylactic. They were necessary, but this is how he portrayed it so that he could carry out his farce of never having had a wet tap. It never really made sense to anyone but him. I don't think it was a matter of being uneducated. He was, plain and simple, a narcissist. As I mentioned, this type should never be trusted.
 
I like NSS in a plastic 10cc syringe. No EPilor or glass for me.

I use air for SCS (14g Tuohy) and once gave some nice lady a pneumoepidurogram. She had a lot of irritation and pain and it took 2 weeks for the air to resorb. Saline would have disappeared much quicker. I'm just glad I didn't stick her in the cord. That was my concern when I ordered the MRI post-op because of the pain she was having. NVI but just being cautious.
 
lobelsteve said:
I like NSS in a plastic 10cc syringe. No EPilor or glass for me.

I use air for SCS (14g Tuohy) and once gave some nice lady a pneumoepidurogram. She had a lot of irritation and pain and it took 2 weeks for the air to resorb. Saline would have disappeared much quicker. I'm just glad I didn't stick her in the cord. That was my concern when I ordered the MRI post-op because of the pain she was having. NVI but just being cautious.
Click to expand...

I use 2mL air with a constant pumping technique while continuously advancing the Tuohy.....once I hit the epidural space my thumb automatically comes off the plunger.

I use the same amount (2mL) not because its a magic number, but it provides a consistent feel since I use the same every time.

This is a tactile procedure, ladies and gentlemen. Its all feel.

.5mL or less I guess may enter the space.

Like Plank said in post #32, its all in the operator. Not whats in the syringe.
 
jetproppilot said:
I use 2mL air with a constant pumping technique while continuously advancing the Tuohy.....once I hit the epidural space my thumb automatically comes off the plunger.

I use the same amount (2mL) not because its a magic number, but it provides a consistent feel since I use the same every time.

This is a tactile procedure, ladies and gentlemen. Its all feel.

.5mL or less I guess may enter the space.

Like Plank said in post #32, its all in the operator. Not whats in the syringe.
Click to expand...

I use 2 ml as well. I use it b/c that is the best volume that fits in my hand (length of syringe) while constant pressure is being held on the plunger. 1ml feels too small and 3 is too big. When i am done there is still 2 ml in the syringe. I do the pumping thing sort of but mostly I hold constant pressure on the end of the syringe. I begin to feel the resistance increase as I approach the ligamentum flavum and I stop pumping and just continue constant pressure. With slow steady advancement I can tell to the split second when I am about to poke through the LF and everything stops at this point, I stop advancing, I stop putting pressure on the plunger, etc. Disconnect the syringe and I usually hear the sucking like sound (best I can describe) of the epidural space and I know I am golden. 2mls still in the syringe.
 
Noyac said:
I use 2 ml as well. I use it b/c that is the best volume that fits in my hand (length of syringe) while constant pressure is being held on the plunger. 1ml feels too small and 3 is too big. When i am done there is still 2 ml in the syringe. I do the pumping thing sort of but mostly I hold constant pressure on the end of the syringe. I begin to feel the resistance increase as I approach the ligamentum flavum and I stop pumping and just continue constant pressure. With slow steady advancement I can tell to the split second when I am about to poke through the LF and everything stops at this point, I stop advancing, I stop putting pressure on the plunger, etc. Disconnect the syringe and I usually hear the sucking like sound (best I can describe) of the epidural space and I know I am golden. 2mls still in the syringe.
Click to expand...

Is that like the "hanging drop technique" you slick bastard?

I use 2ML Saline with a lil' bubble (about .33 of a ML).
 
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