Definition of champagne tap

[CoolWhipp]

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I'm in an argument I need the hive to way in.

Is it a champagne tap if the first tube analyzed had 300 rbcs, but the 4th tube had no rbcs?

 

[Jabbed]

I'm in an argument I need the hive to way in.

Is it a champagne tap if the first tube analyzed had 300 rbcs, but the 4th tube had no rbcs?

Never run the cell count on the first tube if you’re doing it for bragging rights.

Enjoy your wine.

 

[DeadCactus]

No

 

[pkwraith]

It's only a champagne tap if the CSF is sourced from the champagne region of France.

 

[watermanMD]

I'm in an argument I need the hive to way in.

Is it a champagne tap if the first tube analyzed had 300 rbcs, but the 4th tube had no rbcs?

No

 

[DrDrummer]

Call the lab and tell them to un-report Tube 1.

 

[Tiger26]

I'm in an argument I need the hive to way in.

Is it a champagne tap if the first tube analyzed had 300 rbcs, but the 4th tube had no rbcs?

Not in my mind--0 RBCs in all tubes for me to call it that, but nobody is getting champagne for it since it's doable on every one of them if you're methodical about your technique.

It would be like celebrating an aspiration-free intubation or receiving praise for placing a central line without inducing a pneumothorax.

 

[Mount Asclepius]

It’s rare to do an emergent LP in the ED anymore. The incidence of meningitis and CT negative SAH is rare. In doing a LP it’s unusual to do a cell count on more than one tube (typically pick tube 3 or 4). I suspect you did for CT negative SAH to check for RBCs changing from tube to tube in the absence of xanthocromia. This is rare. Either way, you need 0 RBCs to deserve champagne. It sounds like not the case based upon your post, but despite the rules if you picked up the ever elusive CT negative SAH and saved a life then of course champagne is on me! 🍾 🥂

 

[BoardingDoc]

I'm in an argument I need the hive to way in.

Is it a champagne tap if the first tube analyzed had 300 rbcs, but the 4th tube had no rbcs?

No. 1st tube, no reds. The whole point is that it's supposed to be hard. Getting no rbcs in tube 4 isn't a challenge.

 

[BoardingDoc]

it's doable on every one of them if you're methodical about your technique.

It would be like celebrating an aspiration-free intubation or receiving praise for placing a central line without inducing a pneumothorax.

Lol what? There is no technique which will guarantee zero RBCs coming back through your needle. It's luck. The random coursing of the vertebral venous plexus means that hitting or not hitting a small vein is left to chance. This doesn't even account for random capillary bleeding from miniscule soft tissue damage which is also sometimes unavoidable, even if you have a perfectly bulls-eye shot with a small gauge needle.

The entire point is that it's an unlikely outcome. It should not be expected that if you poke someone with something sharp that they won't bleed.

 

[Tiger26]

Lol what? There is no technique which will guarantee zero RBCs coming back through your needle. It's luck. The random coursing of the vertebral venous plexus means that hitting or not hitting a small vein is left to chance. This doesn't even account for random capillary bleeding from miniscule soft tissue damage which is also sometimes unavoidable, even if you have a perfectly bulls-eye shot with a small gauge needle.

The entire point is that it's an unlikely outcome. It should not be expected that if you poke someone with something sharp that they won't bleed.

No guarantees, of course—but it’s absolutely doable on a regular basis. I don’t perform as many LPs as I used to, mostly because of the head CT literature around SAH and the ease of getting a CTA when needed. That said, I still get champagne taps more often than not. Honestly, I’m genuinely annoyed if there’s even a single RBC.

The biggest game changer for me was switching to lidocaine with epinephrine and being generous with anesthesia. Most patients don’t feel anything beyond the initial skin stick, which makes my job easier—they stay relaxed and still.

I also spend real time on positioning, mark the skin meticulously with a Sharpie in multiple planes before draping, and always use the smallest needle I can—ideally a 25g, though often it’s a 22g.

 

[valianteffort]

No guarantees, of course—but it’s absolutely doable on a regular basis. I don’t perform as many LPs as I used to, mostly because of the head CT literature around SAH and the ease of getting a CTA when needed. That said, I still get champagne taps more often than not. Honestly, I’m genuinely annoyed if there’s even a single RBC.

The biggest game changer for me was switching to lidocaine with epinephrine and being generous with anesthesia. Most patients don’t feel anything beyond the initial skin stick, which makes my job easier—they stay relaxed and still.

I also spend real time on positioning, mark the skin meticulously with a Sharpie in multiple planes before draping, and always use the smallest needle I can—ideally a 25g, though often it’s a 22g.

 

[AlmostAnMD]

mostly because of the head CT literature around SAH and the ease of getting a CTA when needed.

Related tangent, don't know what others think about this (and keep in mind I'm not longer in practice so I'm "out of the loop.")

A neurosurgeon told me on a NSGY rotation that if a CTA is done and no aneurysm is found or bleed is found in a comparatively acute timeline, no further workup is merited because the bleed source would be so small (ie, sub mm aneurysm) it would have no viable treatment anyway (ie, too small to coil).

So if their headache was treatable at all with IV cocktails I would just discharge and not even think about LP with a negative CTA. I don't think I ever once did an LP for SAH after this convo and I worked in a high acuity, high volume shop for 5 years where I dx many, many SAH.

Good practice? Dunno. Statute of limitations for giving me a 180 day letter is coming up and no litigation about this yet! Maybe I just got lucky.

EDIT for clarity: I did do some LPs, but for meningitis. Found two cases of legit bacterial meningitis, which even in retrospect felt unnecessary because biofire assays can detect DNA for days after starting abx, so I could have easily punted this to floor work/IR. But I was a partner and wanted the revenue/it was somewhat indicated.

 

[TooMuchResearch]

Related tangent, don't know what others think about this (and keep in mind I'm not longer in practice so I'm "out of the loop.")

A neurosurgeon told me on a NSGY rotation that if a CTA is done and no aneurysm is found or bleed is found in a comparatively acute timeline, no further workup is merited because the bleed source would be so small (ie, sub mm aneurysm) it would have no viable treatment anyway (ie, too small to coil).

So if their headache was treatable at all with IV cocktails I would just discharge and not even think about LP with a negative CTA. I don't think I ever once did an LP for SAH after this convo and I worked in a high acuity, high volume shop for 5 years where I dx many, many SAH.

Good practice? Dunno. Statute of limitations for giving me a 180 day letter is coming up and no litigation about this yet! Maybe I just got lucky.

EDIT for clarity: I did do some LPs, but for meningitis. Found two cases of legit bacterial meningitis, which even in retrospect felt unnecessary because biofire assays can detect DNA for days after starting abx, so I could have easily punted this to floor work/IR. But I was a partner and wanted the revenue/it was somewhat indicated.

My average patient that I consider LP on these days is 70+ with a BMI of 40+ and surgical scars on their backs suggesting they might not even have bones to squeak around anymore thus defer to radiology.

 

[Jabbed]

Related tangent, don't know what others think about this (and keep in mind I'm not longer in practice so I'm "out of the loop.")

A neurosurgeon told me on a NSGY rotation that if a CTA is done and no aneurysm is found or bleed is found in a comparatively acute timeline, no further workup is merited because the bleed source would be so small (ie, sub mm aneurysm) it would have no viable treatment anyway (ie, too small to coil).

So if their headache was treatable at all with IV cocktails I would just discharge and not even think about LP with a negative CTA. I don't think I ever once did an LP for SAH after this convo and I worked in a high acuity, high volume shop for 5 years where I dx many, many SAH.

Good practice? Dunno. Statute of limitations for giving me a 180 day letter is coming up and no litigation about this yet! Maybe I just got lucky.

EDIT for clarity: I did do some LPs, but for meningitis. Found two cases of legit bacterial meningitis, which even in retrospect felt unnecessary because biofire assays can detect DNA for days after starting abx, so I could have easily punted this to floor work/IR. But I was a partner and wanted the revenue/it was somewhat indicated.

So ACEP has official policy recommendations that CTA in isolation is no longer adequate to rule out SAH if symptoms ongoing for more than 6 hours. So this does not meet the standard of care according to our governing body.

If a DSA with IR is negative for aneurysm, then yes you’re done and they don’t need coiling. These are frequently perimesencephalic SAHs that have excellent prognoses. BUT you can’t make that determination from CTA as aneurysms frequently spasm acutely and can be negative on early imaging.

 

[RustedFox]

So ACEP has official policy recommendations that CTA in isolation is no longer adequate to rule out SAH if symptoms ongoing for more than 6 hours. So this does not meet the standard of care according to our governing body.

If a DSA with IR is negative for aneurysm, then yes you’re done and they don’t need coiling. These are frequently perimesencephalic SAHs that have excellent prognoses. BUT you can’t make that determination from CTA as aneurysms frequently spasm acutely and can be negative on early imaging.

We can't win in this situation.

 

[Jabbed]

We can't win in this situation.

If low/moderate probability and >6 hours and CTA is negative and they feel better I’ll put a shared decision-making blurb about risks/benefits of LP. Nobody seems to want a needle in their spine after this conversation for some reason. BUT I can document that patient verbalized their understanding and acceptance of the low but non-zero risk of potentially life-threatening/disabling intracranial bleeding and I’ll put a direct quote from the patient to that effect.

If concerning story/encephalopathic/lots of pain I’ll admit for IR LP so I don’t have to perseverate on the inevitable RBCs that contaminate my bedside LP.

I also hate LPs.

 

[RustedFox]

If low/moderate probability and >6 hours and CTA is negative and they feel better I’ll put a shared decision-making blurb about risks/benefits of LP. Nobody seems to want a needle in their spine after this conversation for some reason. BUT I can document that patient verbalized their understanding and acceptance of the low but non-zero risk of potentially life-threatening/disabling intracranial bleeding and I’ll put a direct quote from the patient to that effect.

If concerning story/encephalopathic/lots of pain I’ll admit for IR LP so I don’t have to perseverate on the inevitable RBCs that contaminate my bedside LP.

I also hate LPs.

Yeah.
My average patient is 900 years old with calcified ligaments, discs, and probably calcified CSF.

 

[TooMuchResearch]

So ACEP has official policy recommendations that CTA in isolation is no longer adequate to rule out SAH if symptoms ongoing for more than 6 hours. So this does not meet the standard of care according to our governing body.

If a DSA with IR is negative for aneurysm, then yes you’re done and they don’t need coiling. These are frequently perimesencephalic SAHs that have excellent prognoses. BUT you can’t make that determination from CTA as aneurysms frequently spasm acutely and can be negative on early imaging.

ACEP is not my governing body.

 

[valianteffort]

ACEP is not my governing body.

My governing body is typically the middle opinion between @RustedFox , @southerndoc, @DocEspana and @Groove

 

[Apollyon]

Yeah.
My average patient is 900 years old with calcified ligaments, discs, and probably calcified CSF.

But they're also playing tennis or Picklerick or whatever, or skateboarding or rollerblading around!

 

[Jabbed]

ACEP is not my governing body.

Sure, but at least you’ll have a great platform during the deposition to expound upon that.

At the end of the day we will always have >0% uncertainty in any of our dispos, particularly discharges. It stands to reason that if you discharge enough negative CTAs you’ll eventually have someone with a bad outcome and you’ll be hung out to dry if what you’re doing is ‘below the standard of care’ as defined by a national organization of ED docs. Does my strategy mitigate that risk? Maybe? Maybe not?

 

[DocEspana]

My governing body is typically the middle opinion between @RustedFox , @southerndoc, @DocEspana and @Groove

I'm on a spectrum!

No, not that one.

But also, maybe.

 

[RustedFox]

But they're also playing tennis or Picklerick or whatever, or skateboarding or rollerblading around!

"Picklerick" sent me.

 

[thegenius]

We can't win in this situation.

Roll the dice. It's a 100 sided die where you lose on 1 side and win on the other 99.

 

[RustedFox]

Roll the dice. It's a 100 sided die where you lose on 1 side and win on the other 99.

Yeah, you're right - my reply really didn't capture what I was trying to convey. I'll try again.

This is us:

"Ah-HA! With THIS method, we can obviate doing LPs so long as THESE conditions are met. Our organizations are behind this!"

... several years later:

"Well, we really can't do THAT, either. Our organizations aren't behind that."

It seems like we get hit with that trap again and again.

 

[thegenius]

Yeah, you're right - my reply really didn't capture what I was trying to convey. I'll try again.

This is us:

"Ah-HA! With THIS method, we can obviate doing LPs so long as THESE conditions are met. Our organizations are behind this!"

... several years later:

"Well, we really can't do THAT, either. Our organizations aren't behind that."

It seems like we get hit with that trap again and again.

The problem is someone has decided (maybe at ACEP?) that we zero tolerance for missing SAH.
Yet we regularly discharge low risk chest pain with a 1% or less chance of 30 day MACE
and we discharge low risk syncope
and low risk dissection
and low risk <NAME YOUR DANGEROUS DIAGNOSIS>

how many post dural headaches are we willing to get to save one person's life?
250 to 1?
500 to 1?

The real question is how many people with a neg CT Head die within 30 days of a massive SAH
it's a tiny amount, gotta be tiny

 

[AlmostAnMD]

This reminds me of one of my favorite med mal cases where an anesthesiologist lost a suit because he did a tap and patient got bacterial meningitis and one of the reasons the suit was successful is that apparently the prep included in the kit wasn't up to some kind of code. But you always use what's in the kit to soap up the back so clearly he had no chance to win.

The tap itself isnt a risk-free procedure, people forget.

Ultimately, you can be sued for anything. That's the joy of em

 

[Jabbed]

The problem is someone has decided (maybe at ACEP?) that we zero tolerance for missing SAH.
Yet we regularly discharge low risk chest pain with a 1% or less chance of 30 day MACE
and we discharge low risk syncope
and low risk dissection
and low risk <NAME YOUR DANGEROUS DIAGNOSIS>

how many post dural headaches are we willing to get to save one person's life?
250 to 1?
500 to 1?

The real question is how many people with a neg CT Head die within 30 days of a massive SAH
it's a tiny amount, gotta be tiny

In this cohort, incidence of aneurysmal SAH with negative non-contrast CT (<24 hours) was 0.1%. That has to at least approximate the risk of serious complication from LP like epidural hematoma, meningitis, herniation, or (ironically) SAH.

SAH - Is CT Out to 24 Hours Enough to Rule-Out? - JournalFeed

 

[gro2001]

Related tangent, don't know what others think about this (and keep in mind I'm not longer in practice so I'm "out of the loop.")

A neurosurgeon told me on a NSGY rotation that if a CTA is done and no aneurysm is found or bleed is found in a comparatively acute timeline, no further workup is merited because the bleed source would be so small (ie, sub mm aneurysm) it would have no viable treatment anyway (ie, too small to coil).

So if their headache was treatable at all with IV cocktails I would just discharge and not even think about LP with a negative CTA. I don't think I ever once did an LP for SAH after this convo and I worked in a high acuity, high volume shop for 5 years where I dx many, many SAH.

Good practice? Dunno. Statute of limitations for giving me a 180 day letter is coming up and no litigation about this yet! Maybe I just got lucky.

EDIT for clarity: I did do some LPs, but for meningitis. Found two cases of legit bacterial meningitis, which even in retrospect felt unnecessary because biofire assays can detect DNA for days after starting abx, so I could have easily punted this to floor work/IR. But I was a partner and wanted the revenue/it was somewhat indicated.

Neurointensivist here.

That is a ridiculously bad (or perhaps just outdated) opinion. Was this an endovascular neurosurgeon speaking recently? Sounds like a generalist who was commenting off the cuff about something too far outside his area of expertise.

An aneurysm not being visible on CTA does not mean it won't be visible on DSA. It is quite common to not identify an aneurysm on a CTA and then identify it on DSA. And just because the spacing on CTA slices is < 1 mm does not mean that an aneurysm to be missed has to be < 1mm. Missed aneurysms do tend to be small, typically < 3 mm (at that size the sensitivity of CTA for aneurysms drops dramatically) but are definitely not all sub mm. Unfortunately, while the rate of initial rupture correlates with size (among other features), the risk of re-rupture of these very small aneurysms does not seem to be particularly low. And re-rupture doubles the expected mortality.

Even if it is not identified on the initial DSA, standard practice for these "angio negative" SAHs is to repeat a DSA some time later, typically about a week. A little less than 10% of the time an aneurysm is identified on the repeat DSA. This might be due to it initially having clotted off on the initial DSA (which is why we give it some time to allow the clot to resorb, otherwise its likely the repeat DSA will be false negative again) or due to some hyper acute spasm, even apart from limitations in technique. Until the repeat DSA is also negative, we treat the SAH as if it were from a ruptured but unsecured aneurysm (ICU, q1h neuro checks, SBP <140, nimodipine, TCDs, keppra).

As for the treatment of very small aneurysms: while more challenging, it's not like there are no treatment options. They may not be amenable to clipping or coiling, but they may very well be amenable to a flow diverter. There are untreatable aneurysms, or aneurysms where the treatment is too risky to try, but that's something that's decided at the very least after a DSA and likely conferring with a couple of other endovascular neurosurgeons.

 

[thegenius]

The problem is someone has decided (maybe at ACEP?) that we zero tolerance for missing SAH.
Yet we regularly discharge low risk chest pain with a 1% or less chance of 30 day MACE
and we discharge low risk syncope
and low risk dissection
and low risk <NAME YOUR DANGEROUS DIAGNOSIS>

how many post dural headaches are we willing to get to save one person's life?
250 to 1?
500 to 1?

The real question is how many people with a neg CT Head die within 30 days of a massive SAH, and comparing that the harm we are infliciting on dozens, if not hundreds of patients working it up
it's a tiny amount, gotta be tiny

 

[Zebra Hunter]

So ACEP has official policy recommendations that CTA in isolation is no longer adequate to rule out SAH if symptoms ongoing for more than 6 hours. So this does not meet the standard of care according to our governing body.

If a DSA with IR is negative for aneurysm, then yes you’re done and they don’t need coiling. These are frequently perimesencephalic SAHs that have excellent prognoses. BUT you can’t make that determination from CTA as aneurysms frequently spasm acutely and can be negative on early imaging.

Did they put out a new policy statement because that is literally the opposite of what they say?

https://www.acep.org/siteassets/sites/acep/media/clinical-policies/cp-headache.pdf

 

[AlmostAnMD]

Neurointensivist here.

That is a ridiculously bad (or perhaps just outdated) opinion. Was this an endovascular neurosurgeon speaking recently? Sounds like a generalist who was commenting off the cuff about something too far outside his area of expertise.

An aneurysm not being visible on CTA does not mean it won't be visible on DSA. It is quite common to not identify an aneurysm on a CTA and then identify it on DSA. And just because the spacing on CTA slices is < 1 mm does not mean that an aneurysm to be missed has to be < 1mm. Missed aneurysms do tend to be small, typically < 3 mm (at that size the sensitivity of CTA for aneurysms drops dramatically) but are definitely not all sub mm. Unfortunately, while the rate of initial rupture correlates with size (among other features), the risk of re-rupture of these very small aneurysms does not seem to be particularly low. And re-rupture doubles the expected mortality.

Even if it is not identified on the initial DSA, standard practice for these "angio negative" SAHs is to repeat a DSA some time later, typically about a week. A little less than 10% of the time an aneurysm is identified on the repeat DSA. This might be due to it initially having clotted off on the initial DSA (which is why we give it some time to allow the clot to resorb, otherwise its likely the repeat DSA will be false negative again) or due to some hyper acute spasm, even apart from limitations in technique. Until the repeat DSA is also negative, we treat the SAH as if it were from a ruptured but unsecured aneurysm (ICU, q1h neuro checks, SBP <140, nimodipine, TCDs, keppra).

As for the treatment of very small aneurysms: while more challenging, it's not like there are no treatment options. They may not be amenable to clipping or coiling, but they may very well be amenable to a flow diverter. There are untreatable aneurysms, or aneurysms where the treatment is too risky to try, but that's something that's decided at the very least after a DSA and likely conferring with a couple of other endovascular neurosurgeons.

It was an old man neurosurgeon I can tell you that

Good news is I'm no longer in practice anyway so I can't infect people with misinformation beyond you correcting me lol

I'm somewhat glad I did it that way though.....hosptialists would roll their eyes if I admitted someone with a negative ct and HA that is mild just to rule all this out......glad I'm no longer dealing with this

I do wonder how many bleeds I sent home. Probably at least one. Fortunately I'm close to statue of limitations so hopefully I got lucky lol

 

[Radetzky]

I’ve never seen a SAH turn up to the icu with a history of having been seen previously with headache, having a negative CT, then being sent home, and I’ve seen a lot of SAH.

I’m sure it’s happened to someone, but so has paralysis after an LP

 

[Zebra Hunter]

I’ve never seen a SAH turn up to the icu with a history of having been seen previously with headache, having a negative CT, then being sent home, and I’ve seen a lot of SAH.

I’m sure it’s happened to someone, but so has paralysis after an LP

There was a single center study out of New Zealand a few years ago that demonstrated in a 10 year time span at their facility, a negative CT head had a near 100% sensitivity at ruling out SAH I believe up to 2-3 days out from symptom onset.

 

[Zebra Hunter]

Found the paper

Sensitivity of modern multislice CT for subarachnoid haemorrhage at incremental timepoints after headache onset: a 10-year analysis - PubMed

These data suggest that it may be possible to extend the timeframe from headache onset within which modern MSCT can be used to rule out aneurysmal SAH.

pubmed.ncbi.nlm.nih.gov

 

[gro2001]

There was a single center study out of New Zealand a few years ago that demonstrated in a 10 year time span at their facility, a negative CT head had a near 100% sensitivity at ruling out SAH I believe up to 2-3 days out from symptom onset.

Seems like they are reporting a 99% at 24 hours and closer to 96% 2-3 days out. Which is good, but not sure I would bet my life on it.

Similar to the Canadian paper it somehow assumes that if there was a SAH complication, they would find it in their records. Instead of:

-missing it because the patient was a visitor from another part of the country (the Canadian paper looked at a national database but this one did not)
-missing it because the patient was a tourist from the big neighbor (some Americans may be lost to follow up in the Canadian study, some Australians in the Kiwi study)
-missing it because the patient was misdiagnosed on the repeat visit a week later (and instead of realizing it's a DCI they just go huh, weird this person has a stroke)

I think the sensitivity is high, like in the high 90s, and maybe close to 100% in the first 24 hours, but depending on the pretest probability (and accuracy of the history, and quality of radiologists) not sure I would be willing to bet on it quite so blindly.

 

[gro2001]

I’ve never seen a SAH turn up to the icu with a history of having been seen previously with headache, having a negative CT, then being sent home, and I’ve seen a lot of SAH.

I’m sure it’s happened to someone, but so has paralysis after an LP

Anecdotes are not data, but I see this with some regularity. Not every day, but often enough that it's not an entirely surprising phenomenon to me or most practicing neurointensivists. People tend to go to other systems if they had their headache misdiagnosed. Or just suffer complications (not all re-rupture immediately; some just get DCI).

And missed SAH is way more common than paralysis after LP. If you scan people before LP and don't LP within 2 days of being on anticoagulation then the incidence has got to be approaching zero. Certainly less common than missed SAH.

 

[thegenius]

Seems like they are reporting a 99% at 24 hours and closer to 96% 2-3 days out. Which is good, but not sure I would bet my life on it.

Similar to the Canadian paper it somehow assumes that if there was a SAH complication, they would find it in their records. Instead of:

-missing it because the patient was a visitor from another part of the country (the Canadian paper looked at a national database but this one did not)
-missing it because the patient was a tourist from the big neighbor (some Americans may be lost to follow up in the Canadian study, some Australians in the Kiwi study)
-missing it because the patient was misdiagnosed on the repeat visit a week later (and instead of realizing it's a DCI they just go huh, weird this person has a stroke)

I think the sensitivity is high, like in the high 90s, and maybe close to 100% in the first 24 hours, but depending on the pretest probability (and accuracy of the history, and quality of radiologists) not sure I would be willing to bet on it quite so blindly.

Seems like you want 100% sensitivity and that just can't happen due to the random stochastic nature of human fallibility.

Knowing you, I'd ask you to prove that doing all those LP's to improve the sensitivity from 99.x to 99.y where x>y is actually not harming more patients than helping.

Anecdotes are not data, but I see this with some regularity. Not every day, but often enough that it's not an entirely surprising phenomenon to me or most practicing neurointensivists. People tend to go to other systems if they had their headache misdiagnosed. Or just suffer complications (not all re-rupture immediately; some just get DCI).

C'mon man I just don't believe this. I don't think you see this "with some regularity"

 

[Mount Asclepius]

Anecdotes are hard to determine if whether it’s 1 out of 100 or 1 out of 1,000 for something that we see 1 out of every 1,000 patient encounters.

We are going to miss CT negative SAH, troponin negative 30-day MACE, or discharged crazies that are hit by cars. We can’t stop everything. Society should stop pretending we can, but value us for what we can. I won’t hold my breath, but I’ll support those who don’t LP headaches to rule out SAH. If the story is worrisome, I still think you need to chart defensively with shared decision making given the ACEP recommendation and ‘standards of care’ that often aren’t the standard.

 

[Zebra Hunter]

Anecdotes are hard to determine if whether it’s 1 out of 100 or 1 out of 1,000 for something that we see 1 out of every 1,000 patient encounters.

We are going to miss CT negative SAH, troponin negative 30-day MACE, or discharged crazies that are hit by cars. We can’t stop everything. Society should stop pretending we can, but value us for what we can. I won’t hold my breath, but I’ll support those who don’t LP headaches to rule out SAH. If the story is worrisome, I still think you need to chart defensively with shared decision making given the ACEP recommendation and ‘standards of care’ that often aren’t the standard.

Again, ACEP is actually on the side of CTA is an appropriate alternative to LP. Read the policy statement I posted above.

And agreed, of course a neurointensivist is going to have significant referral bias regarding CT negative SAH. We have a ton of literature on this. The incidence is relatively rare, actually quite similar to the incidence 30 day MACE in a low risk chest pain patient with negative hsTrop. There was the 2015 prospective trial by Perry et al. That found evidence of SAH by LP in 15 of 1700 patients with a negative head CT. Of those 15, only 6 required NSGY intervention. So a NNT of 290. They also had a traumatic tap rate of 36% which likely lead to additional interventions, cost of care, prolonged hospitalizations in otherwise healthy patients. Also, we know NNH for post LP headache is somewhere around 10 which only complicates the clinical picture.

Meanwhile, while I understand clot and vasospasms can lead to false negatives for CTA in the setting of aSAH, I haven’t seen any literature to demonstrate this to be a particularly common occurrence, in fact, if using DSA as the gold standard, the incidence is quite rare. The 2007 prospective trials by El Khalid demonstrated 1 single false negative CTA out of 134 patients with confirmed SAH by non-con CT head. In 2011 Menke et al demonstrated a sensitivity of 97% for CTA to diagnose aSAH.

 

[gro2001]

Again, ACEP is actually on the side of CTA is an appropriate alternative to LP. Read the policy statement I posted above.

And agreed, of course a neurointensivist is going to have significant referral bias regarding CT negative SAH. We have a ton of literature on this. The incidence is relatively rare, actually quite similar to the incidence 30 day MACE in a low risk chest pain patient with negative hsTrop. There was the 2015 prospective trial by Perry et al. That found evidence of SAH by LP in 15 of 1700 patients with a negative head CT. Of those 15, only 6 required NSGY intervention. So a NNT of 290. They also had a traumatic tap rate of 36% which likely lead to additional interventions, cost of care, prolonged hospitalizations in otherwise healthy patients. Also, we know NNH for post LP headache is somewhere around 10 which only complicates the clinical picture.

Meanwhile, while I understand clot and vasospasms can lead to false negatives for CTA in the setting of aSAH, I haven’t seen any literature to demonstrate this to be a particularly common occurrence, in fact, if using DSA as the gold standard, the incidence is quite rare. The 2007 prospective trials by El Khalid demonstrated 1 single false negative CTA out of 134 patients with confirmed SAH by non-con CT head. In 2011 Menke et al demonstrated a sensitivity of 97% for CTA to diagnose aSAH.

The Perry paper (while an excellent effort, don't mean to criticize this very meaningful contribution to the field that I do think moved the needle (heh)) had several hundred patients with incomplete follow up data. A lot of DCI could be hiding in there.

 

[gro2001]

Seems like you want 100% sensitivity and that just can't happen due to the random stochastic nature of human fallibility.

Knowing you, I'd ask you to prove that doing all those LP's to improve the sensitivity from 99.x to 99.y where x>y is actually not harming more patients than helping.



C'mon man I just don't believe this. I don't think you see this "with some regularity"

I think my risk tolerance for missing this is quite low, but I would argue that's the correct view to take on a disease process that is very treatable if diagnosed, very morbid if missed. So I would be interested in a miss rate that is lower than MACE. So if 2% is "acceptable" (by who?) in MACE, I would argue that the acceptable miss rate in SAH should be lower.

To a certain extent we are somewhat spared by the relatively low incidence of the disease in the first place. A busyish center may see 100 aneurysmal SAH a year. So if we had 99% sensitivity in diagnosing them, we would miss about 1 a year. On the one hand, that's pretty good. On the other hand, that's a fair amount of morbidity (and law suits).

It's a good point about the LPs though: I agree, I don't actually have the data that LPs increase sensitivity of diagnosing SAH. Seems intuitive to me, but I can't think of a paper I would point to. I must admit though, as I think most of us, I also look at things through the lens of what my peers/expert witnesses would say if/when things are missed, and I would find it hard to defend not doing an LP in a case with a high enough pretest probability based on a negative CTH and a timeline.

 

[gro2001]

Anecdotes are hard to determine if whether it’s 1 out of 100 or 1 out of 1,000 for something that we see 1 out of every 1,000 patient encounters.

We are going to miss CT negative SAH, troponin negative 30-day MACE, or discharged crazies that are hit by cars. We can’t stop everything. Society should stop pretending we can, but value us for what we can. I won’t hold my breath, but I’ll support those who don’t LP headaches to rule out SAH. If the story is worrisome, I still think you need to chart defensively with shared decision making given the ACEP recommendation and ‘standards of care’ that often aren’t the standard.

I agree with you: we should have an acceptable miss rate. Two problems:

1) There is no currently accepted miss rate for any condition. The 2018 ACEP clinical policy says that: "the committee based its recommendations on the assumption that the majority of patients and providers would agree that a missed diagnosis rate of 1% to 2% for 30-day MACE in NSTE ACS is acceptable." It's a great policy, and I agree with that statement. That doesn't actually mean this is societally accepted. If I am wrong, please educate me. But I don't think if I am defending a missed event in court, that a valid defense would be to look at what my miss rate is? I wouldn't be able to pull up charts of all the ACS patients I diagnosed correctly to show that this unfortunate miss is a rare event for me, would I?

2) If there is an acceptable miss rate for MACE, the acceptable miss rate for SAH should be lower. Being a composite end point, MACE has some very bad things in it (ie death) it has some less bad things (MI, varies in severity) and fairly subjective things (need for revascularization). Aneurysmal SAH is a highly morbid condition and not a composite end point. Also, brain is more important than heart (would you rather take a 10% hit to your heart function or 10% hit to your brain function?). So if 1-2% is an acceptable miss rate for MACE, then the sensitivity we should ask and expect for aSAH should be >99%.

But if there was some societal acceptance of a miss rate, maybe that would change my practice. Perhaps some sort of tort reform that allows the introduction of outcomes of all the patients a physician has seen over his career as a defense. Until then, we don't actually have an accepted miss rate.

 

[thegenius]

I agree with you: we should have an acceptable miss rate. Two problems:

1) There is no currently accepted miss rate for any condition. The 2018 ACEP clinical policy says that: "the committee based its recommendations on the assumption that the majority of patients and providers would agree that a missed diagnosis rate of 1% to 2% for 30-day MACE in NSTE ACS is acceptable." It's a great policy, and I agree with that statement. That doesn't actually mean this is societally accepted. If I am wrong, please educate me. But I don't think if I am defending a missed event in court, that a valid defense would be to look at what my miss rate is? I wouldn't be able to pull up charts of all the ACS patients I diagnosed correctly to show that this unfortunate miss is a rare event for me, would I?

2) If there is an acceptable miss rate for MACE, the acceptable miss rate for SAH should be lower. Being a composite end point, MACE has some very bad things in it (ie death) it has some less bad things (MI, varies in severity) and fairly subjective things (need for revascularization). Aneurysmal SAH is a highly morbid condition and not a composite end point. Also, brain is more important than heart (would you rather take a 10% hit to your heart function or 10% hit to your brain function?). So if 1-2% is an acceptable miss rate for MACE, then the sensitivity we should ask and expect for aSAH should be >99%.

But if there was some societal acceptance of a miss rate, maybe that would change my practice. Perhaps some sort of tort reform that allows the introduction of outcomes of all the patients a physician has seen over his career as a defense. Until then, we don't actually have an accepted miss rate.

WUT?
Have you ever had a conversation about the benefits and risks of working up a condition or performing a test?
EVER?

Of course society has an accepted miss rate. It might be different for different people. It's called shared decision making. That's why you talk to the patient, learn their value system, present the pros and cons as best as you can, and let the patient decide.

Are you over here in American now? Or are you still practicing in Dubai (or was it Qatar?)

 

[TooMuchResearch]

WUT?
Have you ever had a conversation about the benefits and risks of working up a condition or performing a test?
EVER?

Of course society has an accepted miss rate. It might be different for different people. It's called shared decision making. That's why you talk to the patient, learn their value system, present the pros and cons as best as you can, and let the patient decide.

Are you over here in American now? Or are you still practicing in Dubai (or was it Qatar?)

One of my retired partners was...older than shared decision making. Instead, he used "do everything I say or sign ama paperwork" decision making.
20th lifetime ureteral stone?
CT to confirm or AMA.
Pain in chest?
Admit or AMA.

 

[Mount Asclepius]

WUT?
Have you ever had a conversation about the benefits and risks of working up a condition or performing a test?
EVER?

Of course society has an accepted miss rate. It might be different for different people. It's called shared decision making. That's why you talk to the patient, learn their value system, present the pros and cons as best as you can, and let the patient decide.

Are you over here in American now? Or are you still practicing in Dubai (or was it Qatar?)

I think they are just suggesting that the medical legal side won't care that there is an acceptable miss rate. If you miss it and you are sued, good luck.

 

[thegenius]

I think they are just suggesting that the medical legal side won't care that there is an acceptable miss rate. If you miss it and you are sued, good luck.

As an esteemed member of this board once wrote that a lawyer told him: "If there was a bad outcome, I will find negligence whether it occurred or not."

Treat the patient, not the lawyer sitting next to them (most of the time)

 

[Brigade4Radiant]

Yeah you can be sure but let’s not act like doctors who are sued have a 90 percent chance of winning if it goes to trial


Even strong evidence the odds are 50/50. So I’m not sure where all these arguments are coming from. Also diagnosing isn’t treating coiling and clipping have morbidity and mortality as well

 

[gro2001]

WUT?
Have you ever had a conversation about the benefits and risks of working up a condition or performing a test?
EVER?

Of course society has an accepted miss rate. It might be different for different people. It's called shared decision making. That's why you talk to the patient, learn their value system, present the pros and cons as best as you can, and let the patient decide.

Are you over here in American now? Or are you still practicing in Dubai (or was it Qatar?)

Yeah, I practice state side. I also seem to have a roughly similar practice pattern in most things to a typical EM physician (except for a few key areas).

I have a lot of shared decision making conversations. I am just not under the false impression that they will somehow protect me in case of a bad outcome.

Say you see and discharge 200 patients with chest pain last year. Then you find out that 3 of them came back with a bad outcome related to a missed heart attack. Say all three are angry and want to sue. How many of those law suits would be successfully defended by the argument that 3/200 is < 2%? How many of the lay people will be dissuaded by that? How many of the lawyers will not take the case because your miss rate is acceptably low?

I think bringing that argument would get you laughed out of the room. I think you would be defending each of those cases exclusively on their own merits.

That doesn't mean that we should practice purely with an eye on how it will look in court (my arguments about how far I would pursue a diagnosis of SAH are based primarily on my medical opinions about the disease, not my legal ones). I just find the claim that there is an acceptable miss rate ludicrous. But again, I am open to admitting I was wrong if you show me a case where a physician won by showing all the cases of the disease that they did not miss (ie the denominator). Surely, if there is a societally acceptable miss rate, cases like that would not be hard to find.