Champagne Tap?

Started by EM_Rebuilder
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EM_Rebuilder

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So.. I have done probably 25 or so LPs total in my short medical career and have gotten just one with RBCs of 1..the rest more than that. I am in the PICU this month and did a tap on a 5 month old today squirming all over the place and finally got a Champagne Tap (RBC = 0)!!

So, my question is, how often do you get these? I always hear talk about it, and was happy to join the club....
 
I just got my first the other day... I read something that said <30% are champagne taps in experienced hands. Assuming they meant just less than 30% that seems astronomically high. Otherwise i don't know.

Still waiting for my bottle of champagne however.
 
i've only done a handful of unsupervised taps, but on my second to last one i could have sworn it was a champagne tap but there were 5 RBC's... i can't wait for my first one, congrats on coming close!
 
I would say it is way more rare than 30% in experienced hands. I've done my share. I have received a bottle of champaigne. But even the most perfect tap sometimes has a red or two. Kids are easier for me, even the squirmy ones, because money is right beneath the skin. There isn't much room to pick up a stray red.
 
Here is how to increase your chances

1. Use Lido with Epi for anesthesia
2. One stick, one pass.
3. 22 Gauge needle
4. Keep the stylet in at all times when advancing.
 
The June 2007 issue of Annals has a study looking at the risk factors for traumatic or unsuccessful tap. One of them is advancing with the stylet in. It doesn't make since in my head, but apparently advancing with stylet out is the way to go.
 
uncwalley said:
The June 2007 issue of Annals has a study looking at the risk factors for traumatic or unsuccessful tap. One of them is advancing with the stylet in. It doesn't make since in my head, but apparently advancing with stylet out is the way to go.
Click to expand...
NEVER advance without the stylette in. You can create an epidermoid cyst if you advance without it.
 
That is a risk, but I would like to see the a head-to-head study showing that advancing without increases risk of iatrogenic epidermoid cyst. In reality, iatrogenic epidermoid cysts are very rare, especially with improved spinal needles. The incidence of missed LP is not as low, and in a setting where radiology isn't available to do LP under fluoro if I miss, I want the best chance I can get.
 
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I don't know if there is any way to say which opinion is "right" regarding advancement with the stylet in or out, but I read that same article in whichever journal it was in.

On people with poor landmarks due to redundant SQ tissue (that is the way I tell patients they are fat, isnt it great?) who do still have distinguishable processes I will chloraprep the skin and numb with bupivicaine with epi some time before the procedure, let the nurse get the tray set up, go see somebody else, etc). When I come back the area is numb and the there is no distortion of landmarks. This is only in that subset of rather portly yet not oozing off the gurney patients.

Another trick for bigguns is to use an 18 ga. needle to enter the skin as sort of an introducer and then a much smaller pencil point needle through it. Sounds odd but works in folks that it would otherwise be hard to get that pencil point through all the fat.
 
can someone explain the mechanism for getting an epidermoid cyst? thanks!

my first tap ever was a champagne tap (i think either the lab messed up or it was true beginner's luck)...hasn't ever happened again.
 
jojo14 said:
can someone explain the mechanism for getting an epidermoid cyst? thanks!

my first tap ever was a champagne tap (i think either the lab messed up or it was true beginner's luck)...hasn't ever happened again.
Click to expand...

Presumably, pushing epidermal tissue deep into the dermal or even subdermal spaces (read, intradural, which means badness). They still are viable, produce sebum, etc. Thus, a cyst forms.
 
southerndoc said:
NEVER advance without the stylette in. You can create an epidermoid cyst if you advance without it.
Click to expand...

No, you can create an epidermoid cyst if you enter the skin without it, after that it's at the operators discretion.
 
I only commented because my frontal lobes arent very good, but I think the stylet vs. no stylet is a hairsplitting argument. I think either is acceptable as cyst formation is case reportable complication. Perhaps this will change if we all start advancing without the stylet, but I doubt it. I tend to leave the stylet in out of habit - pull it out when I get to the depth I like, but I dont think there is anything wrong with pulling it out earlier.

heh heh "pull out" heh heh
 
kungfufishing said:
I only commented because my frontal lobes arent very good, but I think the stylet vs. no stylet is a hairsplitting argument. I think either is acceptable as cyst formation is case reportable complication. Perhaps this will change if we all start advancing without the stylet, but I doubt it. I tend to leave the stylet in out of habit - pull it out when I get to the depth I like, but I dont think there is anything wrong with pulling it out earlier.

heh heh "pull out" heh heh
Click to expand...
Case reportable? Do a PubMed search. There are plenty of cases reported, so it's not a case reportable (i.e., rare, uncommon) condition. It's been reported plenty of times.
 
Just because you can find lots of case reports does not make it uncommon. Over history there have been lots of instances of very rare stuff (luxatio erecta, lemiere's syndrome). There are certainly a lot of case reports of these things, but they are still exceedingly rare.

On another note, do these case reports state whether stylet was in or out?

I also think you would be surprised how common a practice it is to advance without the stylet. In the study I mentioned above, it was up to the operators discretion, and a significant percentage did so without stylet. When I've been observed doing LP's early on, on more than one occasion the attending encouraged me to go stylet out.
 
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Just did some quick checking. Between 1977 and 1995, 28 cases reported. That's really rare given the number of LP's and spinal procedures that are done.
 
uncwalley said:
Just did some quick checking. Between 1977 and 1995, 28 cases reported. That's really rare given the number of LP's and spinal procedures that are done.
Click to expand...
28 cases in 30 years does not make it a reportable case. Reportable cases are for very rare instances, peculiar presentations, etc. If there had been 3 in 30 years, then it would still be reportable.

Still uncommon, yes. Reportable, no.
 
Also, taught long ago to NOT advance with stylette in place for LP's. Only risk is for going through skin for epidermoid cysts. Once through skin take out stylette.

then you can just watch for CSF as you advance instead of pulling stylette in and then out and in and then out over and over.

I've had much greater success with this technique.

i think the review in 2007 supports this and most at my program do NOT use the stylette after they're through skin/sub-q.

later
 
There are a lot of little journals that would love to print an article on an iatrogenic epidermoid cyst, as evidenced by the recent case reports printed in various journals. These are so rare that the only way they make it into academia is through case reports. There will never be enough numbers to do trials. Despite the fact that one might find 20 case reports already, I will encourage any med student or resident that encounters one of these to write it up. Of course, I haven't seen any case reports in the EM lit. Annals is calling.
 
The last 2 I've done have had RBC=1. I think the lab does it to spite me. I've never procured a truly champagne tap.

And I always insert with the stylet in to a point, but advance without it. I also use a 25g needle. (Which is a PITA - I think the 24s are better, but my department came up with 25s. Better than the 20g harpoons in the kits, IMHO.)
 
Aloha Kid said:
Here is how to increase your chances

1. Use Lido with Epi for anesthesia
2. One stick, one pass.
3. 22 Gauge needle
4. Keep the stylet in at all times when advancing.
Click to expand...

For the littler kids (neonatal, NICU rats, and young sepsis w/u kids): Try not using a drape over the child. Lots use it just because it comes in the kit, but one of the keys to my successes was "getting" the three dimensional planes in which the back and spine lie...I just did a very wide swath of (whichever sterilizing agent) which allowed me to use both hands to find landmarks and get the sense of where everthing was. The other was a really good holder.
 
got my 2nd Champagne Tap today! Thats 2/8 taps so far, guess ive just been very lucky.
 
dchristismi said:
The last 2 I've done have had RBC=1. I think the lab does it to spite me. I've never procured a truly champagne tap.
Click to expand...

I'm with you in the RBC = 1 club. No champagne for me. Perhaps we can start a "really, really light beer" club?

And how is it that the only patients of mine that ever seem to need a tap are 200 years old, 300 pounds and have had at least 400 lumbar surgeries?

Take care,
Jeff
 
And since I am into pot stirring today. If you get a bloody tap, does anyone use clearing from tube 1 to 4 r/o sah? If so what percentage do you use?

I was just looking at an article "clearing of rbcs in lumbar puncture does not rule out ruptured aneurysm in patients with suspected subarachnoid hemorrhage" in am j neuroradiol apr 2005. Small pt size and they used >25% clearing....

So if a true champagne taps occurs in less than one-third of all LPs even in experienced hands are we all just being set up for a missed sah?

(oh my first ever tap was champagne but none since - so I guess I am getting worse)

Anyone have a good article that justifies sending home our two rbc pts that is not all doom and gloom?
 
well, I think in this case the anecdotal experience shared by physicians over the history of the procedure may speak for itself to some degree, in that if your RBCs markedly dissipate from tube one to four, your patient has a much lower chance of suffering a significant bleed than if they dont - I do not know the answer, but how commonly do we come across patients with a hemorrhage who have RBCs that incompletely clear from tube 1 to 4? Especially if you take a population of CT negative people within an appropriate time frame, you are probably talking about a pretty small number. Perhaps CTA is the appropriate next step if your RBCs do not quite clear? I heard about the article on emrap but have not read it.
 
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My first tap was also a champagne tap, and like everyone else, I have never had another one since then.
Quick question about the stylette in vs. out... In theory it seems like you may have a small amount of tissue "plug" the lumen of the needle without the stylette. anyone ever have something like this happen? I was taught to leave the stylette in and that just has been my practice since graduating.
 
Strangely enough, I had a guy with a great story for SAH last night (worst HA of his life, sudden onset during sex, yada yada). Neg CT. Symptoms resolved with my cocktail.

Tube 1: RBC = 0

Yeah! My first champagne tap. Exit Jeff from "RBC = 1" club!

Tube 4: RBC = 1. "Argh. Back in the club, with ye Jeff."

Dammit. I liked the first tube better.

Take care,
Jeff
 
Hail other Charter Member of the light, light beer tap club! I had one the other night (and he was a biggun) with an RBC = 3. That's still pretty light beer, I'd say.

One day...
 
I had 5 taps the month of November. I decided to look back when I saw this post. 2 with RBC's = 0 !!! 1 with RBC's =1 darn it! and 2 with RBCs 13 and 16.

The one with 1 RBC was with a patient that I tried 3 times while lying down, the attending tried 3 times while lying down, and then I got it on the first attempt with him sitting up. The same needle the entire time. I couldn't believe it!
 
I'm at 50% so far. Done 6 LPs this year and had 3 champagne taps (RBC =0). Most recent one was last night.

I still have yet to get any champagne though. 🙁
 
I let the first few cc's drip onto the sterile field.... Not only does that help increase the number of champagne taps, but also makes your usual tube#4 your tube #1
 
Heh to the necrobump.

That being said, in the 4 years since the original discussion, have any of the prior people heard negative studies from the "stylet out" club? I haven't, but then again, I'm not xaelia, getting paid to read literature. I know quite a few people who do it, but I haven't started not because I'm scared, but because I learned another way, and after doing it enough times, learning a new way is somewhat challenging.

I did get a champagne tap during residency, while in the PICU. One of the intensivist attendings was looking at the results and simply said, "you did an ok job with that LP." Gee, thanks.
 
sylvanthus said:
Still generally accepted that your preceptor buy ya a bottle of bubbly? Just did my first LP and it was a champagne tap. Prob wont get one again from the sounds of it!
Click to expand...

Probably not...it seems like the tradition is dead but I'll certainly try to revive it if I have the opportunity one day--sounds like a nice gesture. What classifies a champagne tap anyway? I've never not seen clear fluid return on adults. Even the ones that come back with a few hundred RBCs looked clear when they were sent.
 
Jeff698 said:
I'm with you in the RBC = 1 club. No champagne for me. Perhaps we can start a "really, really light beer" club?

And how is it that the only patients of mine that ever seem to need a tap are 200 years old, 300 pounds and have had at least 400 lumbar surgeries?

Take care,
Jeff
Click to expand...

What happened to Jeff? He kind of just fell off the SDN radar.
 
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ensuii said:
Probably not...it seems like the tradition is dead but I'll certainly try to revive it if I have the opportunity one day--sounds like a nice gesture. What classifies a champagne tap anyway? I've never not seen clear fluid return on adults. Even the ones that come back with a few hundred RBCs looked clear when they were sent.
Click to expand...

Champagne tap is one that has 0 RBCs.

Apollyon said:
What happened to Jeff? He kind of just fell off the SDN radar.
Click to expand...

I was wondering the same thing recently.
 
RustedFox said:
I have two champagne taps to my credit. One attending bought me a cheap bottle of pinot grigio.
Click to expand...

I have two also, one being on someone I stuck 3 times. I also vividly remember walking out of a tap in residency holding the tubes and the attending asking "Is that a type&screen?" She introduced me to the "letting it drip before collecting tube 1" approach.
 
I've had a couple but it's been a while. I remember a journal club we had in residency speaking of the stylet issue. It is rare to form a dermoid cyst and it supposed to come from epidermoid tissue. With that, they said it is safe to remove the stylet once past the epidermis which doesmake sense...

I've tried both ways and it doesn't seem to make too big of a difference on my success rate and does seem to increase my chance of getting blood back. Just from my experience.
 
Our attendings don't count it as champagne unless 0 WBCs and 0 RBCs. I think the lab knows this is the goal...there is always 1 WBC every time I do one.
 
EM2BE said:
Our attendings don't count it as champagne unless 0 WBCs and 0 RBCs. I think the lab knows this is the goal...there is always 1 WBC every time I do one.
Click to expand...

Concur. Though I have an "intern rule" - I look at tube #4 for them. All else = tube #1.

Bubbly for all my peeps that pull it off.

But, for my fellow attendings, who buys for *us* when we champagne a rescued failed LP? d;-)

Cheers!
-d

Sent from my DROID BIONIC using Tapatalk
 
southerndoc said:
That is contradictory to what I've been taught. Perhaps you are correct, but one could reason that even subcutaneous tissue introduced into the epidural space is not a good thing.
Click to expand...

I did read that advancing only with the stylet in place - whether protective of epidermoid cyst or not - helps reduce post LP headache. Another thing to consider!
 
I've done 4 LPs. All during fourth year EM rotations. 2 of them were champagne taps. The first one, and the most recent one.

The attending on my first LP/champagne tap was a buddy who had just begun the month before as an attending. He promised me a bottle...never came through.
 
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