Cutting (Quincke) Needles in OB

[foshizzo]

Anybody out there still use beveled spinal needles in OB instead of pencil-point? I visited a hospital where their standard spinal kit has a 24g Quincke - made me cringe. They claim their postdural puncture headache rate is negligible, and that the Quincke is a better needle to use in a pinch (i.e. urgent/stat c-section).

Is my reaction off base or is this common practice out there?

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[VentdependenT]

I think I'd rather use a 22g pencil point versus a 24g cutter if I was "in a pinch." Not sure what that pinchy incorporates. Only time we use a 22g is on the, uh, large patients.

We only use sprotte and whitacre's but, for some reason, there are diamond points and cutters laying around too. Never seen anyone use them though.

 

[BLADEMDA]

I think I'd rather use a 22g pencil point versus a 24g cutter if I was "in a pinch." Not sure what that pinchy incorporates. Only time we use a 22g is on the, uh, large patients.

We only use sprotte and whitacre's but, for some reason, there are diamond points and cutters laying around too. Never seen anyone use them though.

Venty,

You are correct. A 22G Whitacre has the same incidence of PDPH as a 25 G Q. Anyone can get CSF with a 22G needle.

I have performed more than 200 Spinals for C-Sections on the extreme morbidly obese using 22G whitacre needles with ZERO blood patches.

Blade

 

[Intubate]

You could probably do your spinal with a 17G touhy on a patient who is "extremely morbidly obese" and not get a PDPH.

Our kits have a quinke in them too. Its apparently cheaper for us to throw it away and open a sprotte then to buy a kit with the sprotte already in it. Some of our kits come with lidocaine or tetracaine too-- who the hell orders this crap?

 

[CremeSickle]

There was a trial at my hospial with an n=20 (not huge) where the Q needle was used and of the 20, 13 had PDPH. They have never used the Q needle since.

 

[BLADEMDA]

You could probably do your spinal with a 17G touhy on a patient who is "extremely morbidly obese" and not get a PDPH.


Not true. I have blood patched patients that weigh as much as 450 pounds after a "wet tap" with a 17 G needle. The incidence of headach is reduced but not eliminated with cutting needles.

Blade

 

[2ndyear]

You could probably do your spinal with a 17G touhy on a patient who is "extremely morbidly obese" and not get a PDPH.

Our kits have a quinke in them too. Its apparently cheaper for us to throw it away and open a sprotte then to buy a kit with the sprotte already in it. Some of our kits come with lidocaine or tetracaine too-- who the hell orders this crap?

Our old kits (until this summer) had heavy lidocaine in them too. Tetracaine is at least mildly useful, but lido much less so. Not to get into a debate about TNS, but even for cerclages most people avoid the lido.

 

[Mman]

You could probably do your spinal with a 17G touhy on a patient who is "extremely morbidly obese" and not get a PDPH.


Not true. I have blood patched patients that weigh as much as 450 pounds after a "wet tap" with a 17 G needle. The incidence of headach is reduced but not eliminated with cutting needles.

Blade

It's not 100% true, but it's not far from the truth. In several case series, morbidly obese females (think BMI > 40 or > 50) with wet taps with a touhy had a very low incidence of PDPH.

 

[deleted126335]

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[BLADEMDA]

It's not 100% true, but it's not far from the truth. In several case series, morbidly obese females (think BMI > 40 or > 50) with wet taps with a touhy had a very low incidence of PDPH.

I agree that with increasing Obesity the incidence of PDPH drops regardless of needle size. But, that does not make 20% an acceptable number does it?

A 22G whitacre needle is EASY To place even in the LARGEST patients and the incidence of PDPH is less than 1% in the BMI greater than 40.

Blade

 

[Mman]

I agree that with increasing Obesity the incidence of PDPH drops regardless of needle size. But, that does not make 20% an acceptable number does it?

A 22G whitacre needle is EASY To place even in the LARGEST patients and the incidence of PDPH is less than 1% in the BMI greater than 40.

Blade

20%? It's lower than that. One case series at SOAP a few years ago had nobody with a headache with BMI > 50.

 

[foshizzo]

I'm with Blade - don't really see why it would be appreciably easier to do a spinal with a 22g Quincke than a 22g pencil-point. The headache rate with cutting needles is at least twice as high, and of those who get headaches, the necessity for blood patch is many multitudes higher in the cutting needle group (i.e. the headaches are more severe):

Postdural puncture headache: a randomized comparison of five spinal needles in obstetric patients.Vallejo MC, Mandell GL, Sabo DP, Ramanathan S.
Magee-Womens Hospital, University of Pittsburgh School of Medicine, Department of Anesthesiology, Pittsburgh, Pennsylvania 15213, USA. vallejomc@anes.upmc.edu

This prospective, blinded, randomized study compares the incidence of postdural puncture headache (PDPH) and the epidural blood patch (EBP) rate for five spinal needles when used in obstetric patients. One thousand two women undergoing elective cesarean delivery under spinal anesthesia were recruited. We used two cutting needles: 26-gauge Atraucan and 25-gauge Quincke, and three pencil-point needles: 24-gauge Gertie Marx (GM), 24-gauge Sprotte, and 25-gauge Whitacre. The needle for each weekday was chosen randomly. Cutting needles were inserted parallel to the dural fibers. The incidences of PDPH were, respectively, 5%, 8.7%, 4%, 2.8%, and 3.1% for Atraucan, Quincke, GM, Sprotte, and Whitacre needles (P = 0.04, chi(2) analysis), and the corresponding EBP rates in those with PDPH were 55%, 66%, 12.5%, 0%, and 0% (P = 0.000). The Quincke needle had a more frequent PDPH rate than the Sprotte or the Whitacre needle (P = 0.02) and a more frequent EBP rate than the GM, Sprotte, or the Whitacre needle (P = 0.01). The Atraucan needle had a more frequent EBP rate than the Sprotte or Whitacre needle (P = 0.05). Neither the PDPH rate nor the EBP rates differed among the pencil-point needles. The cost of EBP must be taken into consideration when choosing a spinal needle. We conclude that pencil-point spinal needles should be used for subarachnoid anesthesia in obstetric patients.

 

[foshizzo]

From Turnbull, BJA 2003:

Table 1 Relationship between needle size and incidence of post-dural puncture headacheNeedle tip design Needle gauge Incidence of post-dural puncture headache (%)
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Quincke 22 36%
Quincke 25 3–25%
Quincke 26 0.3–20%
Quincke 27 1.5–5.6%
Quincke 29 0–2%
Quincke 32 0.4%
Sprotte 24 0–9.6%
Whitacre 20 2–5%
Whitacre 22 0.63–4%
Whitacre 25 0–14.5%
Whitacre 27 0%
Atraucan 26 2.5–4%
Tuohy 16 70%

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