csf drips but you can't aspirate...

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stephenpatrickd

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Hi all,
I'm sure we've all had this. You feel the dural puncture, you get csf dripping, but you can't aspirate.
What do you do?
1) inject medicine
2) manipulate needle (turn, advance, etc)
3) withdraw and redirect
4) something else
Thanks!
 
stephenpatrickd said:
Hi all,
I'm sure we've all had this. You feel the dural puncture, you get csf dripping, but you can't aspirate.
What do you do?
1) inject medicine
2) manipulate needle (turn, advance, etc)
3) withdraw and redirect
4) something else
Thanks!
Click to expand...
In the obstetric population I manipulate and generally do what it takes to get aspiration because their CSF volume should be such that I could aspirate without creating a vacuum against the Dural wall. So I feel less inclined to take a non-aspirating spinal for them as in my experience they do not work as well or at all.

In the Ortho geriatric population their CSF volume is lower and I feel that oftentimes the needle opening is up against the Dural wall and creating a vacuum when I aspirate so I do not get CSF but I'm actually in the intrathecal space. So I take those more readily even if they do not aspirate well after a manipulation.

So I don't have any real trick to answer your question but essentially I'm saying I worry more about getting aspiration in the young obstetric population and care less about aspiration in the geriatric ortho due to anatomy differences.

Also people who don't want to cover OB are weaker anesthesiologists. Just to fire a shot across the bow per usual.
 
stephenpatrickd said:
Hi all,
I'm sure we've all had this. You feel the dural puncture, you get csf dripping, but you can't aspirate.
What do you do?
1) inject medicine
2) manipulate needle (turn, advance, etc)
3) withdraw and redirect
4) something else
Thanks!
Click to expand...
Some of 2. If it doesn't work, some of 3. Keep doing until I get frustrated and then 1. The amount of 2 and 3 depends on my aversion to having a failed spinal in this particular patient.
 
I do as Dr. Rude does. I am more willing to mess around to get a good spinal on OB. If my spinal fails for a total joint (which is not common even if you can't aspirate), its really not that big of a deal to just do a general.
 
1. Rotate needle
2. Insert and remove stylet (clear debris)
3. Insert another mm
4. If still drips, then inject. If no drip, insert farther
 
If you are referring to spinals on OB:

If there is dripping, and then can’t aspirate after attaching syringe, good chance you have moved the needle out from the intrathecal space.
But otherwise, I’d probably inject, and if unsatisfactory levels, I’d sit pt back up and do an epidural.
 
Lecithin5 said:
If you are referring to spinals on OB:

If there is dripping, and then can’t aspirate after attaching syringe, good chance you have moved the needle out from the intrathecal space.
But otherwise, I’d probably inject, and if unsatisfactory levels, I’d sit pt back up and do an epidural.
Click to expand...

Would any of you just repeat the spinal in this situation with a reduced dose, such as 1 ml of heavy bup? I have done that and have not gotten burned with high spinal, but interested to hear others thoughts.
 
What gauge needle is the OP using? I find the 26 and 27 gauge needles are less likely to aspirate even with good flow, and I just inject these. Can’t say I’ve noticed more failures.
 
medicine2wallstreet said:
In the obstetric population I manipulate and generally do what it takes to get aspiration because their CSF volume should be such that I could aspirate without creating a vacuum against the Dural wall. So I feel less inclined to take a non-aspirating spinal for them as in my experience they do not work as well or at all.

Also people who don't want to cover OB are weaker anesthesiologists. Just to fire a shot across the bow per ususual.
Click to expand...
You said OB was easy... how have you had experience with spinals not aspirating in OB if OB was so easy? You should have 0 issues...

And why would you think weak anesthesia opt out of OB if as you say OB is so facile?

Something doesn't add up, could you be lying about your experience and ability? Surely not
 
medicine2wallstreet said:
In the obstetric population I manipulate and generally do what it takes to get aspiration because their CSF volume should be such that I could aspirate without creating a vacuum against the Dural wall. So I feel less inclined to take a non-aspirating spinal for them as in my experience they do not work as well or at all.

In the Ortho geriatric population their CSF volume is lower and I feel that oftentimes the needle opening is up against the Dural wall and creating a vacuum when I aspirate so I do not get CSF but I'm actually in the intrathecal space. So I take those more readily even if they do not aspirate well after a manipulation.

So I don't have any real trick to answer your question but essentially I'm saying I worry more about getting aspiration in the young obstetric population and care less about aspiration in the geriatric ortho due to anatomy differences.

Also people who don't want to cover OB are weaker anesthesiologists. Just to fire a shot across the bow per usual.
Click to expand...

Loved this. Hilarious shade throwing.
 
I’m
PpfSuxTube said:
You said OB was easy... how have you had experience with spinals not aspirating in OB if OB was so easy? You should have 0 issues...

And why would you think weak anesthesia opt out of OB if as you say OB is so facile?

Something doesn't add up, could you be lying about your experience and ability? Surely not
Click to expand...
He’s a resident. A textbook example of the Dunning-Kruger effect. Just scroll on by.
 
Medicine2wallstreet is on to something; namely, patient population matters. Like him, in the OB population, I will not dose until I can aspirate csf. I will even perform a second dural puncture before dosing on + egress but no aspiration. If after the second dural puncture the poor aspiration continues (after turning needle in 45 degree increments and ensuring continued flow in multiple quadrants), I'd probably dose it and cross my fingers. In the ortho population, + egress means my local is getting dosed. Like another poster mentioned, GA is no big deal in the ortho world.

Great question though; it's cool seeing other approaches to a not-uncommon problem.
 
rick roller pump said:
Would any of you just repeat the spinal in this situation with a reduced dose, such as 1 ml of heavy bup? I have done that and have not gotten burned with high spinal, but interested to hear others thoughts.
Click to expand...

with no block, I'd probably consider a reduced dose SAB
with a partial block, I'd place and dose an epidural
 
cchoukal said:
What gauge needle is the OP using? I find the 26 and 27 gauge needles are less likely to aspirate even with good flow, and I just inject these. Can’t say I’ve noticed more failures.
Click to expand...

27g is a great needle for CSE on the floor; wouldn't even bother to aspirate that needle
I personally would not use less than a 25G for a SAB for surgical anesthesia; stakes are kinda high
 
PpfSuxTube said:
You said OB was easy... how have you had experience with spinals not aspirating in OB if OB was so easy? You should have 0 issues...

And why would you think weak anesthesia opt out of OB if as you say OB is so facile?

Something doesn't add up, could you be lying about your experience and ability? Surely not
Click to expand...
I never said Ob spinals were hard. They're actually easy compared to Ortho patients with 65 years of bad habits and no exercise. I just said I prefer good aspiration with OB spinals. It is particularly important for the spinal to work well and be dense as hell because I don't want that patient to go to sleep because the risk is much higher of something going bad. If a spinal doesn't work on an ortho patient who cares just go to sleep they're NPO and their airway is likely not hostile. Keep belittling me all you want but I know more than you think.
 
medicine2wallstreet said:
I never said Ob spinals were hard. They're actually easy compared to Ortho patients with 65 years of bad habits and no exercise. I just said I prefer good aspiration with OB spinals. It is particularly important for the spinal to work well and be dense as hell because I don't want that patient to go to sleep because the risk is much higher of something going bad. If a spinal doesn't work on an ortho patient who cares just go to sleep they're NPO and their airway is likely not hostile. Keep belittling me all you want but I know more than you think.
Click to expand...
OB patient going to sleep wouldn’t be high risk in your hands though right? Only for other people.
 
patriot6 said:
yeah, i'm not "afraid" of it.
but i'd prefer to not steal those first moments from a new mom because i yolo'ed an SAB that didn't aspirate well.
Click to expand...
1718206498345.gif
 
patriot6 said:
27g is a great needle for CSE on the floor; wouldn't even bother to aspirate that needle
I personally would not use less than a 25G for a SAB for surgical anesthesia; stakes are kinda high
Click to expand...
That’s fair. In residency, we used 25 gauge hundred percent of the time. Last decade or so as an attending, 90% of time I use a 27 gauge while on OB for C-sections, and it works great!
 
Lecithin5 said:
That’s fair. In residency, we used 25 gauge hundred percent of the time. Last decade or so as an attending, 90% of time I use a 27 gauge while on OB for C-sections, and it works great!
Click to expand...
I’m sorry if that’s obvious for you guys, but are you talking about Whitacre needles?
 
OB Anesthesiologist for over 18 months here, I have encountered dozens of these, my trick as long there is no blood - inject and pray and most of the time it works!
I had one that didn't work, and I repeated the procedure with the same amount 2.5 ml hyperbaric bupivacaine (the patient was asthmatic and PROM emergency), thanks God it works well.
 
What are the advantages people find with the sprotte or Gertie Marx? I’ve used both but realistically don’t appreciate a big difference, if you really prefer one of these needles why so?
 
Maverikk said:
What are the advantages people find with the sprotte or Gertie Marx? I’ve used both but realistically don’t appreciate a big difference, if you really prefer one of these needles why so?
Click to expand...
I like the sprotte, generally speaking, because the interface between the needle and the introducer just feels very smooth. I also like that the introducer has a Leur fitting, so I can inject local with it (the needle for the local in our kits is quite short). In contrast, the Gertie-Mark has no such Leur fitting, but I find the tactile sensations during needle insertion to be very pronounced, which I like.
 
This happened to me on a couple ortho patients this year. If im pretty convinced im in the right spot I'll give a small dose of the spinal (like 0.5ml). Wait 20 seconds and ask the patient if they feel any different. Every time theyve said their feet/legs are starting to tingle, then i give the rest and have had successful surgical blocks.
 
0doc21 said:
This happened to me on a couple ortho patients this year. If im pretty convinced im in the right spot I'll give a small dose of the spinal (like 0.5ml). Wait 20 seconds and ask the patient if they feel any different. Every time theyve said their feet/legs are starting to tingle, then i give the rest and have had successful surgical blocks.
Click to expand...
This is a very cool trick, 0.5 ml and wait, I bet you are using isobaric right? This will be a challenge if you use hyperbaric as it sinks down and starts create saddle so here we are talking about S3 - S5 numbness and although it would be determined by the speed of injection too. I am just myself thinking loudly.
 
DrAmir0078 said:
This is a very cool trick, 0.5 ml and wait, I bet you are using isobaric right? This will be a challenge if you use hyperbaric as it sinks down and starts create saddle so here we are talking about S3 - S5 numbness and although it would be determined by the speed of injection too. I am just myself thinking loudly.
Click to expand...
yes i am using isobaric. it really only takes about 10 seconds or so for onset of some tingling (mepivacaine). I've heard of some places that keep the OB patients sitting for a minute or two after the hyperbaric spinal is in to reduce hypotension. Heres a study talking about it. They left the patients sitting upright for 2 minutes after administration of a hyperbaric spinal.

Comparison of 1- and 2-Minute Sitting Positions Versus Immediately Lying Down on Hemodynamic Variables After Spinal Anesthesia with Hyperbaric Bupivacaine in Elective Cesarean Section - PMC

Hypotension is one of the most common complications of spinal anesthesia in parturients undergoing cesarean section. In this regard, the patient’s position may affect the incidence of hypotension. In this clinical trial, we evaluated the effects of ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov
 
0doc21 said:
yes i am using isobaric. it really only takes about 10 seconds or so for onset of some tingling (mepivacaine). I've heard of some places that keep the OB patients sitting for a minute or two after the hyperbaric spinal is in to reduce hypotension. Heres a study talking about it. They left the patients sitting upright for 2 minutes after administration of a hyperbaric spinal.

Comparison of 1- and 2-Minute Sitting Positions Versus Immediately Lying Down on Hemodynamic Variables After Spinal Anesthesia with Hyperbaric Bupivacaine in Elective Cesarean Section - PMC

Hypotension is one of the most common complications of spinal anesthesia in parturients undergoing cesarean section. In this regard, the patient’s position may affect the incidence of hypotension. In this clinical trial, we evaluated the effects of ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov
Click to expand...
no thanks, i'll just give some neo
 
0doc21 said:
yes i am using isobaric. it really only takes about 10 seconds or so for onset of some tingling (mepivacaine). I've heard of some places that keep the OB patients sitting for a minute or two after the hyperbaric spinal is in to reduce hypotension. Heres a study talking about it. They left the patients sitting upright for 2 minutes after administration of a hyperbaric spinal.

Comparison of 1- and 2-Minute Sitting Positions Versus Immediately Lying Down on Hemodynamic Variables After Spinal Anesthesia with Hyperbaric Bupivacaine in Elective Cesarean Section - PMC

Hypotension is one of the most common complications of spinal anesthesia in parturients undergoing cesarean section. In this regard, the patient’s position may affect the incidence of hypotension. In this clinical trial, we evaluated the effects of ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov
Click to expand...
Thank you for sharing the research, I read it fast, but stopped at "Therefore, allowing the patient to remain in the sitting position, instead of immediately lying down, could delay the onset of anesthesia and reduce the incidence of hypotension". This could delay onset of anesthesia, I myself want no delay (although there is always delay in regard of Glass Spine phenomenon), but looking at the results in the research is promising, and myself will be a bit worried about the onset of block, and I am not sure did they examine the S2-S5? Then after 2 minutes, what should I do? Change position, de-lordosis (my usual technique but not for OB) and lower head - bed down in order to reach T6. In Glass spine we got a tricky issue, the uneven spread of LA (somehow) and it will be divided cephalic vs caudal spread. Well diving deep in glass spine, you may consider that even hyperbaric Bupivacaine will be changed into isobaric - hypobaric like activity and spreading up. Spinal anesthesia is mixed complexity for me, I had changed my perspective many times over the past 5 years. Thanks to Dr. SaltyDog who brought up the Video of Glass Spine in my post about my first case of combined spinal - epidural anesthesia. I miss this Anesthesiologist so much Dr. SaltyDog !

By the way see : Modifying the Baricity of Local Anesthetics for Spinal Anesthesia by Temperature Adjustment: Model Calculations

Glass Spine video (check the minute 08:43 after injecting isobaric and might be changed to hypobaric by temperature and other factors - but in case of hyperbaric the research above might mention the change of hyperbaric into isobaric - hypobaric due to temperature)

 
DrAmir0078 said:
This is a very cool trick, 0.5 ml and wait, I bet you are using isobaric right? This will be a challenge if you use hyperbaric as it sinks down and starts create saddle so here we are talking about S3 - S5 numbness and although it would be determined by the speed of injection too. I am just myself thinking loudly.
Click to expand...
*injects* waits 20 seconds. “Is your anus tingling?” Ok good. *continues injection*
 
0doc21 said:
I've heard of some places that keep the OB patients sitting for a minute or two after the hyperbaric spinal is in to reduce hypotension. Heres a study talking about it. They left the patients sitting upright for 2 minutes after administration of a hyperbaric spinal.

Comparison of 1- and 2-Minute Sitting Positions Versus Immediately Lying Down on Hemodynamic Variables After Spinal Anesthesia with Hyperbaric Bupivacaine in Elective Cesarean Section - PMC

Hypotension is one of the most common complications of spinal anesthesia in parturients undergoing cesarean section. In this regard, the patient’s position may affect the incidence of hypotension. In this clinical trial, we evaluated the effects of ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov
Click to expand...
What in the wide wide world of sports is this pseudo saddle block for c-section nonsense?

You need a level approaching the upper thoracic area to reliably cover the uterus and all the viscera that get yanked or poked during a section.

A T4ish level is the point. Just give some phenylephrine. That study notes less hypotension (duh) but doesn't comment on block efficacy (hmm).
 
pgg said:
What in the wide wide world of sports is this pseudo saddle block for c-section nonsense?

You need a level approaching the upper thoracic area to reliably cover the uterus and all the viscera that get yanked or poked during a section.

A T4ish level is the point. Just give some phenylephrine. That study notes less hypotension (duh) but doesn't comment on block efficacy (hmm).
Click to expand...
That is the bold talk I can't myself comment like you Dr. Pgg.

For a reference - Page 215 in the book titled Obstetric Anesthesia by Oxford University Press 1st edition, there is a wonderful image about the spread of LA.
Stating that putting a pillow only under the head will make LA travel up to T2 and by placing another pillow under the mid thoracic curve will give more controllable spread - means less than T2...

This image collaborates in my mind with the knowledge of Glass Spine phenomenon to get the full picture of the spread of LA.

Indeed, some phenylephrine will solve any hypotension and it is not a big deal to worry about. When I grew up here I told you one day I had NO Ephedrine and you guys said "try epinephrine instead" which is available. Because of you guys the epinephrine is always handy as a substitute beside Ephedrine, norepinephrine and phenylephrine. In resistant cases epinephrine works like a charm 5 - 7 mcg couple times boluses and that is it. By you guys here the Anesthesiologists I terminated the fear of using epinephrine and passed to my colleagues and we have circle of discussions, they all love epinephrine. Lots of Anesthsiologists still skeptical about giving epinephrine even in bronchospasm, and myself it is my leg and hand in every day practice.
 
Get rid of ALL the air in the 5cc syringe with meds that you are drawing from. When you do that you the see the volume increase in syringe.
If that doesn’t work, grab the little 1cc syringe and pull back on it see if you see it fill up 0.10cc at a time. All you need is that initial 0.10cc and you know for sure you are in.
We are often in but the air gets in the way and the larger syringe with air can trick your eyes.
And yeah I need to get the hell out of OB. That place is draining.
 
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