Doing blood patches alone

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castafari

castafari

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Is anyone out there doing blood patches alone? What is your technique? Draw blood first? Place epidural catheter and then draw the blood?
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castafari said:
Is anyone out there doing blood patches alone? What is your technique? Draw blood first? Place epidural catheter and then draw the blood?
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Have done about three in my career. All in training or first year out. Now I say No F'N way.
Pt lateral. Down Arm for phlebotomy extended, tourniquet, and prepped. Needle in epidural space. Leave it there with stylet back in. Walk around draw blood. Walk back and inject.
 
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castafari said:
Is anyone out there doing blood patches alone? What is your technique? Draw blood first? Place epidural catheter and then draw the blood?
Click to expand...
Sterile prep the site you want to draw blood and have that equipment ready; do the epidural first and get loss, then draw the blood, then inject. If it looks like it’s going to be a slamdunk epidural, then get the blood first. Otherwise you’d hate to draw the blood first, only to fiddle around with the epidural as the blood is clotting.
 
I prep out the arm and draw the blood first. Then I sit them up for the epidural and do the patch. The hardest part for me is the blood draw - usually a puffy, but intravascularly dry post partum patient. I’d rather do this than get loss, then struggle for 10 min trying to get the blood while they’re sitting there with a needle in their back.
 
Noyac said:
Place a-line then move to epidural. Then draw blood and inject.
Remove epidural then remove a-line.
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I typically use the U/S to place the arterial line to guarantee success on the 1st or 2nd attempt. Typically, some of these patients are obese and difficult IV sticks. I do them in the PACU so I'm never "alone" but that said I don't trust most of the PACU nurses to get the blood. I've had to leave the epidural needle in place while going to get the blood required to do the patch. That's not my preference.

These days unless the IV stick is super-easy I'll scan the antecubital area and SHOW the vein to the nurse (plus make sure the nurse can palpate the vein). Any doubt at all and I'll place the arterial line before doing the Epidural.

Arterial Line Placement:Safety First | Anesthesiology | ASA Publications
 
Never considered an A-line w/ US but given some of the reasoning on this thread may actually consider it.
 
I sit them hunched over one of those rolling desks with a pillow on top. I put a tourniquet on an arm and scope out a nice fat vein to draw the blood. Then I take the tourniquet off and go around the back to put the tuohy in. Come around the front to draw the blood and inject it. We do it in pacu too so I always have a nurse helping us. But the Aline sounds like a better idea.
 
I don't see the need for an a-line. Start an IV in sterile fashion and keep it all clean. Get your epidural and draw back from the IV. A healthy 16G will draw back without issue and none of the complications associated with an arterial puncture.
 
Twiggidy said:
Never considered an A-line w/ US but given some of the reasoning on this thread may actually consider it.
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You get all your a lines by feel? that makes me wanna work on my A line skills.
 
I admit resorting to a radial stick multiple times during residency for a blood patch. Usually it was in very obese patients who had terrible veins.

I never actually put in an aline though; I would use a butterfly needle. With a little lidocaine it seemed minimally painfully and traumatic.
 
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dchz said:
You get all your a lines by feel? that makes me wanna work on my A line skills.
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I have never used US for an A-line. It’s all in the approach. You must train your fingers to feel the rope and pulse then as you get better at that you can even place one in pts without a pulse in an emergency.
 
SaltyDog said:
Just connect a-line tubing straight to the tuohy with a 3-way stopcock and 20cc syringe inline. Aspirate 20cc, flip the stopcock, inject, done.
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I totally thought about that after I posted. Was too lazy to go back and edit. I have never done it obviously. And I understand that you are halfway joking. But it would be awesome.
 
Noyac said:
you can even place one in pts without a pulse in an emergency.
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OK so question about this. I agree you can feel the "rope" and stab the artery in a pulseless patient, but how do you know when you're in and can thread when you aren't getting any blood return??
 
SaltyDog said:
OK so question about this. I agree you can feel the "rope" and stab the artery in a pulseless patient, but how do you know when you're in and can thread when you aren't getting any blood return??
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You still get blood return. Just like when place a central line in a code etc.
Plus it is tremendously helpful when assessing the effectiveness of chest compressions.
 
Noyac said:
I have never used US for an A-line. It’s all in the approach. You must train your fingers to feel the rope and pulse then as you get better at that you can even place one in pts without a pulse in an emergency.
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Are you willing to concede that some patients just don’t have a “rope”? I’ve had many. Or my fingers are defective.
 
dchz said:
You get all your a lines by feel? that makes me wanna work on my A line skills.
Click to expand...

i referring to doing an A-line for a blood patch, whether with U/S or not. It just never occurred to me to place an A-line for quick blood draw and then do the epidural portion. To me it seems darn brilliant.

Side note, all my awake patients get an A-line with U/S because I don't want to stick an awake person a bunch of times. If asleep I'm 50/50. Depends on the feel of the artery, wrist "girth", etc.
 
Noyac said:
I totally thought about that after I posted. Was too lazy to go back and edit. I have never done it obviously. And I understand that you are halfway joking. But it would be awesome.
Click to expand...
This may be overkill, but i'm thinking, you could have an entire "normal" A-line setup with transducer and all on a IV pole next to where you're working. You place the A-line and attach it as if a regular A-line. The you do the epidural next to the IV pole and when you have loss, draw the blood straight from the Transducer and inject. Seems like overkill but also seems very streamlined at the same time. Of course after you're finished someone has to hold pressure on the wrist.
 
I wonder if you would even need the stopcock and syringe. I bet there's enough pressure to just hook up the tubing straight to the tuohy. Let it pump in until they get that uncomfortable pressure.
 
Why not just stick the artery with a butterfly and syringe? What's all this nonsense about putting in an a line

Or just pull from a vein like ronin suggested
 
If a nurse isn’t available to help I’m not doing the blood patch. I can’t imagine a scenario where someone capable of drawing sterile blood wouldn’t be available to help
 
Psai said:
Why not just stick the artery with a butterfly and syringe? What's all this nonsense about putting in an a line

Or just pull from a vein like ronin suggested
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That works but I like the hands free draw that the a-line affords.
 
ZzzPlz said:
If a nurse isn’t available to help I’m not doing the blood patch. I can’t imagine a scenario where someone capable of drawing sterile blood wouldn’t be available to help
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That's our practice, too. However, I am in a busy academic center so this literally never happens.

That said, interesting thought experiment to read through for those that have had to do this alone.

Sent from my XT1710-02 using Tapatalk
 
If you see a vein, go for it. If you don’t, go for the artery. I think most would take this approach
 
Twiggidy said:
i referring to doing an A-line for a blood patch, whether with U/S or not. It just never occurred to me to place an A-line for quick blood draw and then do the epidural portion. To me it seems darn brilliant.

Side note, all my awake patients get an A-line with U/S because I don't want to stick an awake person a bunch of times. If asleep I'm 50/50. Depends on the feel of the artery, wrist "girth", etc.
Click to expand...
I will say, I think I got so much better at arterial lines when I practiced doing them on awake patients with their family in the room. Puts the pressure on. (I know you can kick them out, but where's the fun in that?)
 
This thread is sad. In a week someone will ask how to operate a sterilizer and how long should they sterilize their laryngoscopy blades. Followed by where’s the mop.
 
For Blood Patch: Sterile prep, place the IV with a short catheter and a saline flush. Release the tourniquet and slap a tegaderm on the site. Leave the saline flush hanging on the catheter. Do the epidural, leave the needle in place. Tighten the IV tourniquet and draw the blood from the catheter, discarding a small portion. Inject the blood.
 
Ronin786 said:
I will say, I think I got so much better at arterial lines when I practiced doing them on awake patients with their family in the room. Puts the pressure on. (I know you can kick them out, but where's the fun in that?)
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Ha ha, 🙂 make sure you put the family (or the med student) in the proper positioning for the blood spurting across the room.
 
skypilot said:
Ha ha, 🙂 make sure you put the family (or the med student) in the proper positioning for the blood spurting across the room.
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I know you're only (semi)joking, but people too frequently try to occlude the arterial flow by pushing with one finger distal to the catheter. If you four fingers instead and push down broadly, blood spurting is rarely an issue.
 
SaltyDog said:
WTF is the point of this???

So everyone can all stand around and be in agreement that you just did the wrong procedure to the wrong person?
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In on example it’s to make sure that the ovary specimen for a lap oophorectomy has actually been removed from the patient before they’ve emerged and the surgeon has left the room.

In another, it’s to document that a piece of equipment was not working properly so that it can be taken out of service.
 
Newtwo said:
Sphenopalatine ganglion block anyone?
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Very easy to do. Limited data for PDPH.
I prefer to treat the cause rather than the symptoms. Also not sure about duration of a SPB even with .5% marcaine.
 
sevoflurane said:
Very easy to do. Limited data for PDPH.
I prefer to treat the cause rather than the symptoms. Also not sure about duration of a SPB even with .5% marcaine.
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The data from a small trial said even with 2% lido it worked as well as a patch for up to a week.

Why not try it first before the blood patch? I see literally no downside to it
 
Newtwo said:
The data from a small trial said even with 2% lido it worked as well as a patch for up to a week.

Why not try it first before the blood patch? I see literally no downside to it
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What's the upside?? If I'm gonna do a procedure for a PDPH, then I'm doing the gold standard one that's actually curative.

I would like to see you consent the patient though:

"Okay ma'am, to treat your headache we have 2 options. I can either inject some of your own blood into you lower back very similar to how the epidural was done in the first place

Ooorrrrr

I can stick this long needle into the center of your skull"
 
Newtwo said:
The data from a small trial said even with 2% lido it worked as well as a patch for up to a week.

Why not try it first before the blood patch? I see literally no downside to it
Click to expand...

I've tried it a few times. It does help but not as reliable as a blood patch. The "downside" is the patient still has a mild headache and must return to the hospital for a blood patch with a newborn baby at home.

For those patients with a contraindication to a blood patch or a mild headache I'd consider the Sphenopalatine block.

Sphenopalatine ganglion block for relieving postdural puncture headache: technique and mechanism of action of block with a narrative review of efficacy
 
SaltyDog said:
What's the upside?? If I'm gonna do a procedure for a PDPH, then I'm doing the gold standard one that's actually curative.

I would like to see you consent the patient though:

"Okay ma'am, to treat your headache we have 2 options. I can either inject some of your own blood into you lower back very similar to how the epidural was done in the first place

Ooorrrrr

I can stick this long needle into the center of your skull"
Click to expand...
You don't need to use a needle, we do them routinely using the MRSA swabs. They're definitely great temporizing measures with very little risk associated. No way they work just as well as blood patch though, very short lived duration (anywhere from 1-24 hours in my experience).

I think there value is in the early stages of PDPH. A lot of PDPH is short lived (25% if I'm not mistaken), so this is a great temporizing measure the first day to let the mom get some sleep. Then if it's still there at 48 hours do the blood patch before they go home.
 
Nice alternative for a Jehovah's witness



SaltyDog said:
What's the upside?? If I'm gonna do a procedure for a PDPH, then I'm doing the gold standard one that's actually curative.

I would like to see you consent the patient though:

"Okay ma'am, to treat your headache we have 2 options. I can either inject some of your own blood into you lower back very similar to how the epidural was done in the first place

Ooorrrrr

I can stick this long needle into the center of your skull"
Click to expand...
 
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