CRAP......A wet tap

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turnupthevapor

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CRAP my resident just has a wet tap on a B/L knee during a CSE placement (L3-4). Been doing this for 6 years now and it is my first!


I took over and did a CSE a a level lower (4-5)


My colleagues are telling me not to use the catheter for post pain relief for the risk of high spinal occurring. Some of the senior partners feel it is ok to use the catheter.

does any one have any input for me?


I want to be safe as possible so if the risk of high spinal is there I would prefer not to do it


Thanks for your insight and experience
 
I'm sure it can be used as intrathecal pressure is higher than epidural pressure and the catheter will not be at the level of the dural puncture.... so you should be good.

However, I wouldn't sleep well at night with the above scenerio in mind. I'd just give .2mg of IT duramorph + LA and call it a day. This may be a conservative approach, but it is what I would do. No harm done and the patient will still get analgesia.... and I get to go to sleep with a clear mind.
 
Plenty of wet taps happen every day on the L&D floor throughout the nation. Most of those ladies go on to get a properly placed epidural without any problems. I would view the risk of a high spinal from a post op epidural to be extremely remote. If you want to be conservative, skip the PCEA and just go with continuous infusion. What were you planning, 6cc/hour? You might be able to program the PCEA to deliver the bolus dose over 20 minutes if you want the pt controlled bolus. I don't see how you could really get a high spinal from low dose, low pressure infusions. If you bolus him 10cc over 1 minute, maybe.
 
you shouldnt get a high block with isobaric bupivacaine even if delivered intrathecally at reasonable doses, much less epidurally. probably should have threaded a catheter with the initial wet tap and used that for the case. continuous spinal here is perfectly reasonable and would have provided very stable analgesia
 
sevoflurane said:
I'm sure it can be used as intrathecal pressure is higher than epidural pressure and the catheter will not be at the level of the dural puncture.... so you should be good.

However, I wouldn't sleep well at night with the above scenerio in mind. I'd just give .2mg of IT duramorph + LA and call it a day. This may be a conservative approach, but it is what I would do. No harm done and the patient will still get analgesia.... and I get to go to sleep with a clear mind.
Click to expand...

what do you mean you wouldnt sleep well? wet taps happen frequently and the answer is either IT catheter or go another level and place a catheter and never seen any high spinal from either technique, really. isnt this what you would do with your epidural patients on L+D?
 
I'm a firm believer in verbal abuse and physical harassment.

Virtually guarantees it won't happen again. 😀

At least it was a resident MD and not some militant CRNA...
 
Idiopathic said:
what do you mean you wouldnt sleep well? wet taps happen frequently and the answer is either IT catheter or go another level and place a catheter and never seen any high spinal from either technique, really. isnt this what you would do with your epidural patients on L+D?
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The OP did not put in the epidural at another level. He left it at the same level as the dural puncture. I know it would be hard for the catheter to migrate near the puncture site, but it's possible, especially if you leave the catheter in 4cm into the space (less likelyhood of one sided blocks). Imagine the night resident giving a 10cc bolus for inadequate analgesia... Low chances of anyting happening, but I don't like leaving anything up to chance.

In OB land, we always go to another level.

As I said, it's a conservative approach but one that eliminates any possibility of anything funky going on + the patient still gets analgesia. I think using an IT catheter for the case is a good idea... bolus duramorph at the end. The patient will still benefit from good analgesia.
 
sevoflurane said:
The OP did not put in the epidural at another level. He left it at the same level as the dural puncture. I know it would be hard for the catheter to migrate near the puncture site, but it's possible, especially if you leave the catheter in 4cm into the space (less likelyhood of one sided blocks). Imagine the night resident giving a 10cc bolus for inadequate analgesia... Low chances of anyting happening, but I don't like leaving anything up to chance.

In OB land, we always go to another level.

As I said, it's a conservative approach but one that eliminates any possibility of anything funky going on + the patient still gets analgesia. I think using an IT catheter for the case is a good idea... bolus duramorph at the end. The patient will still benefit from good analgesia.
Click to expand...

Oh... wait... yes he did. My bad. But at what level did the catheter end up at????
 
It's really not that big of a deal either way... just another way of doing things.
 
I'd have just inserted a spinal catheter with the initial wet tap and been done with it. But since you went ahead and put a new epidural in, I'd just use it like an epidural. If you are feeling particularly cautious, you could omit opioids from the epidural out of concern that they may have an easier time getting into the CSF. Wouldn't really worry about the local. I mean if it's acting like a spinal cath, you'll know pretty darn soon.
 
My attending had a wet tap the other day, so we went to another epidural space and threaded the catheter. When he used the test dose, the patient had a profound sensory block in minutes so maybe some solution gets displaced in the dural sac. I am still a firm believer that the increased ICP keeps solution from migrating into the SA space but I still think its best to be a little conservative and use a slower rate with a smaller bolus. If it gives inadequate post op pain, you can always increase the rate.

Wet taps suck. I did over 100 epidurals in the last 3 months and had one wet tap which made me feel like crap. It was on the OB floor and the moment I got the wet tap, the OB resident came in and said the patient needs a urgent c/s. I threaded the catheter intrathecally and when I got to the OR I used 20 mg bupivacaine and 300 mcg of astromorph through the catheter for spinal anesthesia not knowing how much extra volume the catheter could hold. It worked great (in retrospect, if this situation ever happened again I would of pushed the usually dose of 12-15 mg, then aspirated csf and bolused it back in). I taped the catheter cap and labeled it DO NOT USE INTRATHECAL. I removed it 24 hours later and luckily the patient never developed a PDPH.

I would however, never thread an interathecal catheter in any other situation for fear that another resident/CRNA would bolus the catheter with an epidural dose even if properly marked. That would be a nightmare situation.
 
Last edited:
RxBoy said:
It was on the OB floor and the moment I got the wet tap, the OB resident came in and said the patient needs a urgent c/s. I threaded the catheter intrathecally and when I got to the OR I used 20 mg bupivacaine and 300 mcg of astromorph through the catheter for spinal anesthesia not knowing how much extra volume the catheter could hold. It worked great (in retrospect, if this situation ever happened again I would of pushed the usually dose of 12-15 mg, then aspirated csf and bolused it back in). I taped the catheter cap and labeled it DO NOT USE INTRATHECAL. I removed it 24 hours later and luckily the patient never developed a PDPH.

I would however, never thread an interathecal catheter in any other situation for fear that another resident/CRNA would bolus the catheter with an epidural dose even if properly marked. That would be a nightmare situation.
Click to expand...

We do IT catheters whenever there is a wet tap. Probably 2 or 3 a month on OB. Label it carefully and sign it off appropriately and it wont be a problem, plus you may prevent a headache. Im not personally a fan however.

Your story above is weird, like why did they decide right at that minute when you are doing a procedure that you have an urgent need for CS? I probably would have pulled the Touhy and done a spinal in the room, but I can get behind your way too, not sure I would ever give someone that much marcaine though, and 0.3 of duramorph is about 3 times what I give also.
 
Great responses, I appreciate the input

I like the idea of conservative flow rate but I did choose to remove the catheter.

I feel if the risk is increased even if remotley, it is beter to have some pain than be dead.

Patient was headed to a floor with mediocare RN's that I dont trust and since I will be home I wouldn't be there to check up and manage any issues. I am generally a conservative guy in these situations!

I gave b/l single shot femoral blocks brought his pain from a 8 to a 3 which should get him through until tomorrow'

thanks again

You are all a great resource to get some outside input in a pinch. I posted the question and had responses with in an hour which helped me critically think about the situation and react

two thumbs up SDN🙄
 
turnupthevapor said:
I feel if the risk is increased even if remotley, it is beter to have some pain than be dead.
Click to expand...

Uhhhh....show me one case where this happened (high spinal after a wet tap from an epidural placed at the same or different level from an infusion pump at 6-10cc/hr with or without boluses).

I think it would be impossible and at this point it is unheard of.

I would say that it is important to remember everything we do has consequences. And by the way, I commend you for trying to be conservative and wanting to protect the patient. But I would argue that the chances of you giving the patient a femoral nerve injury (I have seen it a few times - and we are are not novices at our institution) doing your femoral nerve blocks is MUCH greater than the feared complication that made you change management.

We do things like this all the time. For some reason all my residents draw up atropine and place on the top of the anesthesia cart (despite the fact it is in the drawer already prepared). Yet I can't remember a time I gave atropine during anesthesia in a non-code situation - it is a rare event. But what is probably less rare - is grabbing a syringe in a moment of intensity and maybe giving atropine inadvertently. We do stuff like this all the time. My pain clinic is a prime example (npo before procedures, iv's in all the patients...). Pure silliness.
 
Idiopathic said:
i disagree, sometimes its appropriate. with that said, i never drew it up either except for kids, obviously
Click to expand...

I'm confused...

You disagree I haven't used it much, or you disagree that I don't remember. How do you know these things?

Are you stalking me?
 
Idiopathic said:
Your story above is weird, like why did they decide right at that minute when you are doing a procedure that you have an urgent need for CS?
Click to expand...

Yeah it is kind of weird. We have an OB attending that c/s happy. If the patient coughs she sends for c/s. They were considering doing the c/s beforehand for questionable late decels but decided not to when they stabilized. Apparently she was having late decels again during the procedure, so the resident came in to give the call for c/s.

If you're already in the intrathecal space, why subject them to another procedure? Specially one that might be difficult (patient was 300+).

We for the most part use 200 mcg astromorph. Its night and day for post op pain, aside of course of the pruritis (which usually responds well to nubain). The L&D RNs love it when I tell them we used AM for the section, it makes there job so much easier.
 
a little follow up:

he never got a headache

He did have a lot of pain after the fem blocks wore off though

thanks again
 
oh great... had to come across this thread the night before I take overnight call on OB for the first time. wish me luck...
 
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