Go to Spinal Needle

[Dawkter]

I wanted to poll the group with a few questions to see practice patterns:

-What is your go to spinal needle?
-If the placement is difficult what needle do you use for back up? If this is a 22G needle how often do you have cases of PDPH?
-Opioid or no opioid in your spinal cocktail for joint cases?
-Anyone still using hyperbaric bupivacaine?

I know there are some threads on this but wanted to have a targeted discussion. Thanks!

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[Southpaw]

1. 25 whitacre
2. I do spinal largely on joints and OB. For joints I don’t have a backup. If I can’t get the spinal, which is rare these days, patient goes to sleep. On OB if I struggle with a spinal I move to CSE technique Bc I can feel considerably more w the 17 touhy than 25 whitacre.
3. No spinal opioids in joints. Yes on OB
4. Use heavy bupi all day every day

 

[Dawkter]

1. 25 whitacre
2. I do spinal largely on joints and OB. For joints I don’t have a backup. If I can’t get the spinal, which is rare these days, patient goes to sleep. On OB if I struggle with a spinal I move to CSE technique Bc I can feel considerably more w the 17 touhy than 25 whitacre.
3. No spinal opioids in joints. Yes on OB
4. Use heavy bupi all day every day

Why avoid opioid in the spinal, is it duration related?

 

[drmwvr]

1. 24 sprotte
2. paramedian with a 24 sprotte
3. not for ortho
4. yes but moving to mepivicaine recently

 

[DocMcCoy]

I wanted to poll the group with a few questions to see practice patterns:

-What is your go to spinal needle?
-If the placement is difficult what needle do you use for back up? If this is a 22G needle how often do you have cases of PDPH?
-Opioid or no opioid in your spinal cocktail for joint cases?
-Anyone still using hyperbaric bupivacaine?

I know there are some threads on this but wanted to have a targeted discussion. Thanks!

Don’t do OB but do a lot of joints.

25 gauge W because it’s in the kit

22 gauge Q for the elderly joints when unsuccessful with above

No opioids in spinal. Don’t personally think they are necessary for most joints

Hyperbaric because it’s in the kit

 

[GassYous]

25 pencan

If it doesn't work, I just lma them but I'm thinking about starting to use 22 whitacres. blade is a fan of 22s he has a low incidence of pdph from what I remember

I use 1.5-1.8 of hyperbaric bupi also because it comes in the kit. Used to put 15 of fentanyl but I stopped because I didn't think it was giving me anything and caused side effects.

For long cases or patients that I want to be hemodynamically stable I use 2-3 of bupi 0.5. I am thinking about switching to mepivacaine as well for the shorter ones.

 

[Mman]

I use the 25 g needle in the kit. If it's a struggle because of obesity or being 100 years old, I will switch to a 22 g. Incidence of PDPH clearly relatively higher the bigger the needle is, but pretty low for old and/or fat people. Hyperbaric bupivacaine works well though occasionally I use isobaric.

Basically just hand me a needle and some local and I will make it work.

 

[okayplayer]

I am a huge fan of the 22g Whitacre for difficult SAB. As a matter of fact it is my first choice needle for total joints. Knock on wood, but I can think of zero PDPH that I’m aware of that I have caused using that needle.

 

[deleted875186]

I am a huge fan of the 22g Whitacre for difficult SAB. As a matter of fact it is my first choice needle for total joints. Knock on wood, but I can think of zero PDPH that I’m aware of that I have caused using that needle.

I have seen some patients come to the hosptial or pain clinic with relatively delayed PDPH from a spinal, I wonder how many we actually miss.

 

[dhb]

1. 27g Whitacre
2. 25G
3.no opiods if i need more duration i'll put clonidine in first
4. Iso mostly, heavy for saddle blocks

 

[Velefunt]

I wanted to poll the group with a few questions to see practice patterns:

-What is your go to spinal needle?
-If the placement is difficult what needle do you use for back up? If this is a 22G needle how often do you have cases of PDPH?
-Opioid or no opioid in your spinal cocktail for joint cases?
-Anyone still using hyperbaric bupivacaine?

I know there are some threads on this but wanted to have a targeted discussion. Thanks!

OB:
- 24/25G (whatever's in the kit)
- 22G whitacre > 22G Pencan, but whatever's available (just not a quinke/cutting needle)
- opioid
- hyperbaric in the kit

Joints:
- 22G whitacre > 22G pencan
- no backup necessary since I've already started with Plan B
- no opioid in my current practice culture
- isobaric > hyperbaric; mepivicaine for particular surgeons

Here's a thought - despite injecting local subq either with a 30G or 25G (whatever's in the kit), patients still often flinch w/ the insertion/repositioning of a 20G introducer. They never seem to feel a 22G after local and going in the same insertion site/repositioning. I've tried using the 25G alone and it's just too flimsy w/o the introducer. It's enough to make me want to consider a 22G to start in OB, but I don't want to see a "rash" of PDPH's if that's the case.

 

[Southpaw]

Why avoid opioid in the spinal, is it duration related?

hips typically go home day 0 or morning pod1. knees generally go home pod1. none of them get a foley. I could use IT fentanyl but I don't think they need it. we don't do duramorph bc the goal is early ambulation, early dispo, along with no foley.

 

[deleted126335]

24g Pencan for almost everything. 22g Quincke as back up. Virtually no headaches in the total joint population.
Only use the Quincke about once every third year in the OB population and only because I am trying to shave a few seconds off the time for an urgent, but not quite STAT C-Section.

 

[Southpaw]

I've tried using the 25G alone and it's just too flimsy w/o the introducer. It's enough to make me want to consider a 22G to start in OB, but I don't want to see a "rash" of PDPH's if that's the case.

wouldn't use a 22g in the OB population. asking for trouble. you can use the 25g Whitacre without the introducer. it takes some getting used to, but you need to stabilize the proximal end of the needle and push through skin quickly, then stabilize proximally as you advance. doesn't always work, but I'll do it on skinny Moms with good landmarks when I don't think the spinal will be tough.

 

[DrZzZz]

Standard - 25ga Pencan
Backup - 22ga Quincke (Zero PDPH to my knowledge, usually only need/use it in old patients)
Joints - No opioids (only use for C/S)
Hyperbaric - probably 95% of the time. Use isobaric only for more hemodynamic stability in select patients or for the slowest of surgeons

 

[Southpaw]

Backup - 22ga Quincke (Zero PDPH to my knowledge, usually only need/use it in old patients)

I've done blood patches for patients when my partners have used 25ga or 22ga quincke for patients getting a new joint. I'm not telling you to not use what you think you need, but I'm disagreeing with any statement saying 22ga doesn't lead to increased incidence of PDPH.

 

[DrZzZz]

I've done blood patches for patients when my partners have used 25ga or 22ga quincke for patients getting a new joint. I'm not telling you to not use what you think you need, but I'm disagreeing with any statement saying 22ga doesn't lead to increased incidence of PDPH.

I wouldn't argue there isn't a greater risk with a 22Ga Quincke vs. a 25Ga non-cutting needle. But my group has done zero blood patches outside of OB or after the ED did an LP on someone. So none for any of our joint population. I'll ignore LPs in the argument given 1) they intentionally drained a bunch of csf for study and 2) performed by a non-anesthesiologist. Vast majority of the OB patches were done for wet taps during epidural placement. Of the rare ones done for PDPH after spinal, I'm not sure how many, if any, were caused by a 22Ga needle (since we almost never use them on OB). So, I wouldn't argue the difference doesn't exist. Just that it's a small enough difference to be clinically irrelevant in our setting.

 

[coffeebythelake]

Why avoid opioid in the spinal, is it duration related?

Urinary retention

 

[AdmiralChz]

Anyone use the Gertie-Marx?

 

[deleted162650]

Anyone use the Gertie-Marx?

Admit it, you just like the feel of those little balls.


Joking aside, I really like the Gerties. Unfortunately my shop doesn’t stock them in any relevant sizes.

 

[Arch Guillotti]

Never done a blood patch post spinal total joint.

 

[Beeftenderloin]

1) 25g pencan
2) 25g pencan through a 17g Tuohy
3) GA

 

[coffeebythelake]

Anyone use the Gertie-Marx?

Then I would do an epidural

 

[Southpaw]

Never done a blood patch post spinal total joint.

Curious - does your group exclusively use non-cutting needles? We have some partners who simply will not stop using cutting needles no matter what is said. They say it makes the spinals easier/faster and keeps the rooms moving/surgeons happy. We do a handful of blood patches yearly in the joint population.

 

[Dawkter]

Curious - does your group exclusively use non-cutting needles? We have some partners who simply will not stop using cutting needles no matter what is said. They say it makes the spinals easier/faster and keeps the rooms moving/surgeons happy. We do a handful of blood patches yearly in the joint population.

I have been using the 22 gauge Q needle as my back up needle for several years. The tactile feel, loss, and aspiration of CSF are much better than the 25 gauge. We call all of our patients after surgery and I personally have yet to see a case of PDPH, though the literature says it is around 6x more likely with a cutting needle compared to pencil point.

 

[Southpaw]

I have been using the 22 gauge Q needle as my back up needle for several years. The tactile feel, loss, and aspiration of CSF are much better than the 25 gauge. We call all of our patients after surgery and I personally have yet to see a case of PDPH, though the literature says it is around 6x more likely with a cutting needle compared to pencil point.

22g quincke? I’ve personally done blood patches for those patients. Same for 25 quincke. Is the incidence high? No, not in the joint population. But it exists. I’m not sure what your volume is. We do thousands of joints a year. I couldn’t even give you an exact number. But regardless, we do a small handful of blood patches yearly and they’re all in patients where a cutting needle was used. The incidence would be significantly higher if we used cutting needles on OB (which we don’t ....).

6x higher may be accurate. I think it’s exceedingly rare to get a PDPH in a joint patient when a 25g pencil point was used.

No question though - you get better/more feel w a 22g compared to 25g.

Honestly if you want to spare your patient a 22g cutting needle, which I think is worth it, do a CSE technique and use a 27g long whitacre through the tuohy. You’ll get even better feel with a 17g tuohy than a 22g spinal needle. But since you’re not seeing headaches I can’t make a strong argument against your technique. I can only speak to what I see in my practice.

 

[GassYous]

Curious - does your group exclusively use non-cutting needles? We have some partners who simply will not stop using cutting needles no matter what is said. They say it makes the spinals easier/faster and keeps the rooms moving/surgeons happy. We do a handful of blood patches yearly in the joint population.

Spinal and blocks can be done within 10 minutes with a 25g needle. Quinckes are the devil.

 

[okayplayer]

If you want a 22g, try the Whitacre vs a Quincke. It’s really a fantastic needle. I will try to find the paper I read looking at pdph incidence with 22g Whitacre (been a few years since I read it), but it is very low (especially in non OB population).

I also use it in tough OB spinals (obese, etc) and can think of 1 PDPH in >100 uses personally for me (that I know of).

 

[deleted162650]

I will try to find the paper I read looking at pdph incidence with 22g Whitacre (been a few years since I read it), but it is very low (especially in non OB population).

There’s a post from Blade with all the percentages for the various needle types/gauges.

 

[MirrorTodd]

I don't have access to the articles at home but I am coincidentally presenting my grand rounds tomorrow on PDPH. The general consensus was the traumatic needles significantly increase the chances of a pt developing a PDPH and the larger the needle the higher the chance, although that isn't true for atraumatic needles. So, if you did need to go to a larger bore needle for a spinal, you are still better off going to a larger atraumatic needle vs a cutting needle.

 

[GassYous]

OB:
- 24/25G (whatever's in the kit)
- 22G whitacre > 22G Pencan, but whatever's available (just not a quinke/cutting needle)
- opioid
- hyperbaric in the kit

Joints:
- 22G whitacre > 22G pencan
- no backup necessary since I've already started with Plan B
- no opioid in my current practice culture
- isobaric > hyperbaric; mepivicaine for particular surgeons

Here's a thought - despite injecting local subq either with a 30G or 25G (whatever's in the kit), patients still often flinch w/ the insertion/repositioning of a 20G introducer. They never seem to feel a 22G after local and going in the same insertion site/repositioning. I've tried using the 25G alone and it's just too flimsy w/o the introducer. It's enough to make me want to consider a 22G to start in OB, but I don't want to see a "rash" of PDPH's if that's the case.

I've noticed the same thing. It's amazing that there are people here who advocate for placing a tuohy with no local because they claim the back has few pain receptors but patients seem to really hate that intro.

 

[okayplayer]

There’s a post from Blade with all the percentages for the various needle types/gauges.

There’s always a Blade post...

 

[Dawkter]

Slightly off topic but anyone notice a clinically significant difference in spinal duration with epi wash vs. 100 mcg dose of epi?

 

[GassYous]

Slightly off topic but anyone notice a clinically significant difference in spinal duration with epi wash vs. 100 mcg dose of epi?

Don't waste your time with epi. For any half decent surgeon you don't need more than straight local. If you really need extra time just do the cse. Or tetracaine. The less crap you put in the back the better.

 

[okayplayer]

If you want a 22g, try the Whitacre vs a Quincke. It’s really a fantastic needle. I will try to find the paper I read looking at pdph incidence with 22g Whitacre (been a few years since I read it), but it is very low (especially in non OB population).

I also use it in tough OB spinals (obese, etc) and can think of 1 PDPH in >100 uses personally for me (that I know of).

Found a few studies that quote incidence of PDPH with 22g pencil point needle of 0.6%-2% (in OB population). Anecdotally, that seems about right to me.

https://bjanaesthesia.org/article/S0007-0912(17)45974-5/pdf

The frequency of postdural puncture headache in obstetric patients: A prospective study comparing the 24-gauge versus the 22-gauge sprotte needle

Study Objective: To compare the frequency of postdural puncture headache (PDPH) in obstetric patients when using the 24 gauge or the larger 22 gauge S…

www.sciencedirect.com

https://www.researchgate.net/publication/231586049_Post-dural_puncture_headache_Pathogenesis_prevention_treatment

 

[kmurp]

25 Pencan or 25 Whitacre (varies with where I'm working). REALLY like the Pencan. I will use 27 whitacre for patients under 40 unless they are obese. Only use 22 cutting for the elderly as a backup. Occasionally will use 24 ga long sprotte which is what we have for a long needle. Never use narcotics. Rarely use hyperbaric these days. Isobaric, chloro, mepiv or ropiv only as indicated by length of procedure.

 

[Arch Guillotti]

Never done a blood patch post spinal total join

Curious - does your group exclusively use non-cutting needles? We have some partners who simply will not stop using cutting needles no matter what is said. They say it makes the spinals easier/faster and keeps the rooms moving/surgeons happy. We do a handful of blood patches yearly in the joint population.

No, we have a few "cutters" also.

 

[nimbus]

My buddy who did a few mission trips to Vietnam told me their go to was a 29g cutting needle. Obviously they have a different patient population.

 

[okayplayer]

Never done a blood patch post spinal total join

No, we have a few "cutters" also.

Not only have I never done a blood patch for a total joint patient, I’ve never heard of a partner ever doing one.

I also don’t think any of my partners use cutting needles for these patients (some do for hip fracture 90 year olds).

 

[26B]

Slightly off topic but anyone notice a clinically significant difference in spinal duration with epi wash vs. 100 mcg dose of epi?

The Effect of Adding Subarachnoid Epinephrine to Hyperbaric Bupivacaine and Morphine for Repeat Cesarean Delivery: A Double-Blind Prospective Randomized Control Trial - PubMed

In this single center, prospective, double-blind, randomized control trial, the addition of epinephrine 200 µg to hyperbaric bupivacaine and preservative-free morphine for repeat cesarean delivery prolonged the duration of the sensory blockade. Motor blockade was similarly prolonged and block...

pubmed.ncbi.nlm.nih.gov

The short version is they found a statistically significant difference with 200 mcg epi but not with 100 mcg.

The Effect of Adding Subarachnoid Epinephrine to Hyperbaric Bupivacaine and Morphine for Repeat Cesarean Delivery: A Double-Blind Prospective Randomized Control Trial​

Background: Spinal anesthesia has become the most common type of anesthetic for cesarean delivery. The major limitation to spinal anesthesia is that the duration of the anesthetic may not be adequate in the event of a prolonged surgery. Some practitioners add epinephrine to hyperbaric bupivacaine to increase the duration, although its effect has not been fully studied. We therefore aimed to evaluate whether adding epinephrine to the spinal medication prolongs the duration of action of the resultant block in women presenting for repeat cesarean delivery.

Methods: Sixty-eight patients were randomized to receive no epinephrine (NE group), epinephrine 100 µg (low-dose [LD] group), or epinephrine 200 µg (high-dose [HD] group) with a standardized spinal mixture (1.5 mL 0.75% hyperbaric bupivacaine with 0.25 mg morphine). Sixty-five patients were included for primary analysis. Our primary outcome was time to intraoperative activation of the epidural catheter or postoperative regression of sensory blockade to T-10 dermatome level as measured by pinprick sensation; motor recovery was a secondary outcome, and graded via a Modified Bromage scale.

Results: Block onset time, vital sign changes, and the incidence of hypotension; nausea, and vomiting were similar among groups. Median difference in time to T-10 regression was greatest in the HD group compared to the NE group (median difference [min] [95% confidence interval]: 40 [15-60]; P = .007), followed by the HD group to the LD group (30 [15-45]; P = .007). Comparisons of LD to NE were not significant, but trended to an increase in T-10 regression time (10 [-15 to 30]; P = .76). Median difference in time to knee extension (Bromage 3) was also greatest in the HD group when compared to both the LD and NE group (median difference [min] [95% confidence interval]: 30 [0-60]; P = .034, 60 [0-93]; P = .007). Median difference time to knee extension (min) between the LD and NE group was also significant (37.5 [15-60]; P = .001]. Pain scores during the procedure were higher in the NE group (median [interquartile range] HD: 0 [0-0], LD: 0 [0-0], NE: 0 [0-3]; P = .02) during uterine closure and were otherwise not significantly different from the other groups.

Conclusions: In this single center, prospective, double-blind, randomized control trial, the addition of epinephrine 200 µg to hyperbaric bupivacaine and preservative-free morphine for repeat cesarean delivery prolonged the duration of the sensory blockade. Motor blockade was similarly prolonged and block quality may have been enhanced.

 

[Mman]

Never done a blood patch post spinal total join

We probably get about 1 or 2 a year out of the 1000+ that we do. It is really rare but can happen. I feel like it is usually in the < 50 years old that it tends to happen to. Don't recall anybody over 65 ever needing one.

 

[kmurp]

Slightly off topic but anyone notice a clinically significant difference in spinal duration with epi wash vs. 100 mcg dose of epi?

Your urinary retention incidence may increase if you use epi.

 

[GassYous]

If you want a 22g, try the Whitacre vs a Quincke. It’s really a fantastic needle. I will try to find the paper I read looking at pdph incidence with 22g Whitacre (been a few years since I read it), but it is very low (especially in non OB population).

I also use it in tough OB spinals (obese, etc) and can think of 1 PDPH in >100 uses personally for me (that I know of).

I just tried the whitacre 22 after failing once with a 25. Obese scoliotic septugenarian. The 22 gave me great tactile feedback for readjusting the trajectory and very satisfying csf backflow.

 

[Drwine]

25 Pencan for OB and young ortho
22 for older joint placements
18 or 20 for elderly hip fractures
heavy bupivicaine but moving to mepivicaine for same day discharge joints
isobaric bupivicaine for hip fractures

 

[OneFellSwoop]

95% of the time (including OB), 24g 3.5” sprotte because it’s in the kit
22g Sprotte 5” for difficult elderly or large patients usually after 24g has failed.
25g whitacre if h/o PDPH or young non-OB female

I can’t remember the last time I did a blood patch for a post c section patient and the 24g is what all of my partners use as well, and we do a fair amount if OB. I have placed a blood patch on a few post op young females however, obese patients included.

 

[Velefunt]

25 Pencan for OB and young ortho
22 for older joint placements
18 or 20 for elderly hip fractures
heavy bupivicaine but moving to mepivicaine for same day discharge joints
isobaric bupivicaine for hip fractures

Wow! 18 or 20G spinal needles!?!? Are those the steel cutting needles the ER uses for LP’s?

 

[BloodySurgeon]

CSE for difficult OB spinal
22G Quicke for difficult hip cases

I never had an OB patient i couldnt place a spinal with a CSE approach but had trouble handful of time for hip cases with severe arthritis.

The 17G toughy can cut through tissue without bending but usually gets stuck on osteophytes or spinous process. The 22G needles has the ability to sheer through tissue with a smaller guage to fit through tight spaces.

Any thoughts on spinal under ultrasound guidance. Ive had good success with thinner patients but cant see well with obese patients. Do you use ultrasound to make landmarks or live guidance?

Lastly, im always a little worried with paramedian approach for large patients using a 7'' needle. Thoughts?