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Noyac

Noyac

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  1. Attending Physician
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Young female s/p L4/5 microdisc 4 weeks out. Pt has a fluid collection at the surgical site with no other symptoms. Spine guy draws off 30cc of clear fluid. He calls you regarding an epidural blood patch. What do you do?
 
Pt is 4 weeks out with no other symptoms. I don't see the point in doing a blood patch now since she is asymptomatic. The leak should close by itself. Sometime it takes a while. If she becomes symptomatic then I think it would be warranted. How long do you wait to do it in an asymptomatic patient? I don't know but I think if she continues to have to have fluid drained eventually you may have to do it.

Pd4
 
Are you sure that fliud is CSF? Shouldn't she be having headaches? 4 weeks post surgery seems like a long time, thus probably a big hole. Shouldn't a big hole be closed surgically? Assuming it is CSF.
 
My answer would be:
A blood patch is a symptomatic treatment for post dural puncture headache, If the patient does not have headache then a blood patch is not indicated.
A blood patch is not intended to repair a dural tear and adding blood to a fluid collection (assumed to be CSF without evidence) is asking for an infection.
 
Seems like operative repair of her dural injury would be about as prudent as a blood patch.

I mean, theres no way shes slowly leaking 1cc/day, and if she acutely leaked 30cc out of a 4 week old operative site, Id think the ball is in their court.
 
very odd request


sounds more like a post op seroma...i dont see how a blood patch is indicated here.
 
is this a resident making this request?
 
Yes it could be a seroma. What if I told you that the glucose of this fluid was 126 in a nondiabetic pt? Would that help?

Would anyone do a patch with platelet jel? Thats what is used in the OR when a dural tear occurs.
 
Noyac said:
What if I told you that the glucose of this fluid was 126 in a nondiabetic pt? Would that help?
Click to expand...

I haven't messed around with CSF chem for a few years, but doesn't CSF have 2/3 of serum glucose? That would mean that the serum glucose of this pt is around 180. She is not diabetic, so that is probably not right. A seroma would have the same glucose as serum. 126 makes more sense in a non diabetic pt. That would steer me towards seroma more. Anyone have a different opinion?

I wonder if the old thiopental trick would help you differentiate between the 2 of them. I guess it would.
 
i'd tell him to go shove it... unless she had a whopping headache...
 
seems like the surgery attending should have better things to do then drawing glucose measurements on a seroma (which this is)


i have never heard of anyone even considering a blood patch in the absence of headache....even if it is CSF, a headache may not occur..


i just dont understand what this surgeon is thinking....
 
urge said:
I haven't messed around with CSF chem for a few years, but doesn't CSF have 2/3 of serum glucose? That would mean that the serum glucose of this pt is around 180. She is not diabetic, so that is probably not right. A seroma would have the same glucose as serum. 126 makes more sense in a non diabetic pt. That would steer me towards seroma more. Anyone have a different opinion?

I wonder if the old thiopental trick would help you differentiate between the 2 of them. I guess it would.
Click to expand...



yes 40-70% of serum
 
I still think you follow it or a few weeks to see if it stops spontaneously or if the patient develops symptoms. I think a blood patch is worth a try if the leak continues. I would much rather give the blood patch a try than to speculate that the leak is too big and force the patient to have an operation. Even if the odds were 50/50 or less if it were me I'd try it as opposed to the alternative. As for the tissue seal, I just don't know much about putting that through a touhy. Anybody got any good case reports?

Pd4
 
no headache...no patch
 
this leak ain't gonna get fixed w/ a patch

if there is CSF, the surgeon needs to go in and clean up his tear...
 
If it is CSF, then it's a gray zone for me. Could it help? Maybe. Could it be of harm? Probably not. I don't think anybody can fault you for trying or for not trying.

Question for the pain guys: Is Epidural Fibrosis a "big deal" in a pt getting a microdiscectomy? Could the blood patch cause this? Should this be a concern?
 
Here's a few case reports. There are all sorts of reports of persistent leaks that were helped with a blood patch. What would you do if it was your back and you were looking at a laminectomy to find a small hole and hopefully close it. How many infections have you seen due to a blood patch? It may not work but if it saved you an operation I think it is still worth trying. Sure the risk of infection is there but it is always there. I wonder what the risk for another back operation is? Probably the same or more than the blood patch.


http://Reg Anesth Pain Med. 2001 Jul-Aug;26(4):363-7
http://www.anesthesia-analgesia.org/cgi/reprint/98/3/629.pdf

pd4
 
Well I went ahead and did the patch with plt jel. So far so good.
 
Noyac said:
Well I went ahead and did the patch with plt jel. So far so good.
Click to expand...

In PP land, you do it. You make a collegial bond stronger.

In Academia land, you don't. Nothing to gain, much to lose.

Sad, but true.

-copro
 
Noyac said:
Well I went ahead and did the patch with plt jel. So far so good.
Click to expand...

Noy, I've seen it been used but not in this fashion. Is this your first time? Any potential problems? ie. what happens if it gets in the wrong space? I would have never thought of using platelet jel. It's unfamiliar to me and the way we do things in non-PP. I appreciate the lack of blood born organisms.
 
Noyac said:
Well I went ahead and did the patch with plt jel. So far so good.
Click to expand...



i am glad that your patient is doing well....however, if something want wrong (meningitis, bleeding, etc) I do not feel that you could defend your actions........
 
joshmir said:
i applaud you for your courage to help this pt out.

how much volum of platelet gel did you use? was it prepared from the pt's serum? did you use only platelet gel?
Click to expand...

10cc of plt gel from pts own serum. It is thicker than blood and 10cc was a bit more noticeable for the pt.

By the way, She is still doing better but the csf leak still remains although much less leak. May or may not be due to the patches. Interesting though.
 
Noyac said:
10cc of plt gel from pts own serum. It is thicker than blood and 10cc was a bit more noticeable for the pt.

By the way, She is still doing better but the csf leak still remains although much less leak. May or may not be due to the patches. Interesting though.
Click to expand...


Great case thanks for posting. I hope the leak stops for her.

Pd4
 
Hey Noy, how is the platelet gel prepared? How much blood do you need? How long does it take?
 
urge said:
Hey Noy, how is the platelet gel prepared? How much blood do you need? How long does it take?
Click to expand...

Dude, you didn't learn to make plt gel in residency. WTF.😱




Of course I'm kidding. I have no idea. We have a perfusion, cell saver, heme tech that does this for all the spine cases. I know you spin it down to 10cc but I'm not sure if you start with 20 or 40cc.
 
thanks again for posting the case.... i wonder what the surgeon is going to suggest... if I were the patient, i think that I would wait it out especially since there are not symptoms....i am interested to find out what happens....keep us updated....
 
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