I caused my first wet tap today

[G0S2]

MS4 here going into anesthesia.

Currently on OB anesthesia and have placed about 5 epidurals, 2xCSE's and 6 straight spinals. I lost saline resistance as the pt jumped and I knew what I did. I feel like crap. We placed an epidural one level up but still a 30% chance of a raging HA coming her way.

Any other MS4's out there who feel my pain?

For senior residents, how many have you caused in your CA2 year? Candor appreciated.

I am a little spooked now but I know I have to get back on the horse.

I also know that there are worse things that can happen in anesthesia.

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[DO4lifer]

i spoke with anesthesiologists that say that they get 1 wet tap a year...so 1 for 5 aint bad.

it hasn't happened to me. in fact i was setting up an epidural and was ready but my anesthesiologist said i was not deep enough, and of course, went forward and she caused a wet tap. it happens because its somewhat blind, so get back on that horse bucko, youre only a 4th year med student! 👍

think of it as kobe bryant as a rookie. he air balled 3 pointers in the playoffs, but he kept throwing them up...look at him now!

 

[docdoc]

next time just thread the catheter, manage the continuous spinal, leave it in for 24hrs, have less chance of spinal headache when you pull it and a patient that is very happy with the pain relief they received.

 

[cchoukal]

agreed

 

[ssmallz]

if you haven't caused at least 1 wet tap you haven't done enough epidurals. No worries, just give her a blood patch if necessary.

Do any of you guys ever just thread the catheter and use it as a spinal catheter rather than pull it and retry? One of my attendings mentioned that it decreased the incidence of pdph. Thoughts...

 

[G0S2]

next time just thread the catheter, manage the continuous spinal, leave it in for 24hrs, have less chance of spinal headache when you pull it and a patient that is very happy with the pain relief they received.

Wouldn't thread at wet tap level but that is what we do.

My attending said that either threading the cath at the level wet tapped for a spinal or going to a different level to thread for an epidural both decrease the risk of pdph to 30%. If you wet tap and do noting, around 70%.

 

[Hockeyguy]

I wet tapped someone after my 50th plus epidural, then I had another one in the same week. Have done many since that time without incidence. As far as management we just thread the catheter into the intrathecal space and dose accordingly - then d/c it no sooner than 24 hours. In the two I mentioned previously thats how I managed them and no PDH (at least that I know of).

 

[cchoukal]

Wouldn't thread at wet tap level but that is what we do.

My attending said that either threading the cath at the level wet tapped for a spinal or going to a different level to thread for an epidural both decrease the risk of pdph to 30%. If you wet tap and do noting, around 70%.

yes, my understanding is leaving the catheter in the intrathecal space at the level you wet-tapped decreases PDPH whether you use it or not, but it's there; why not use it? it's a GREAT block.

 

[jennyboo]

My first epidural ever (for abdominal surgery) was a wet tap.

I did two more wet taps during my first week of OB anesthesia.

Don't feel too bad.

 

[Jalopycat]

I wet tapped a young lady (early 20's) putting in an epidural several months ago. I threaded the catheter and used it as a spinal block. The patient loved it and could have cared less when I apologized and explained to her about the possibility of a PDPH. We took it out after 24 hours, I check on her twice during the rest of her hospitalization, and no headache.

Funny though, half the people I tell this story to think it was neat to use it as a spinal block and the other half think it was stupid.

 

[USAnesthesiaDoc]

For those of you using intrathecal catheters after wet-tap epidural attempts in LDRP for labor analgesia, what are you using for a continuous infusion? Anyone see any mishaps/overdoses?

 

[cchoukal]

I've used our epidural solution (0.125% bupiv +/- fentanyl) at 1 mL/hr or, alternatively, personally bolused 1 to 1.5 mL of something every hour or so. I think I prefer the latter approach because it 'forces' me to see and continuously evaluate the patient.

 

[rsgillmd]

For those of you using intrathecal catheters after wet-tap epidural attempts in LDRP for labor analgesia, what are you using for a continuous infusion? Anyone see any mishaps/overdoses?

I run our standard infusion bag (Bupi 0.1% + Fentanyl 2 mcg/ml) at 2 ml/hr. I used to run it at 1 ml hr (classic 1/10) but many patients didn't get adequate pain relief. If they need a bolus, I'll give 1-2 ml of Bupiv. 0.25% (I usually give 1 ml, but I'll stick arround and on occasion I'll have to give another 1 ml).

No mishaps so far, that I know of, due to this regimen. The patients are happy with it.

Just keep in mind the deadspace in your catheter -- in our's it's approximately 0.3 ml.

 

[G0S2]

Just an update:

The pt was DC'd on 1/31 w/o a HA. I called today for a follow up and she has a horrible postural HA. She is coming in tonight and we will first start 2L NS and Toradol, which in my attending's experience, kills the HA over 90% of the time. If this doesn't work, blood patch.

 

[maceo]

Just an update:

The pt was DC'd on 1/31 w/o a HA. I called today for a follow up and she has a horrible postural HA. She is coming in tonight and we will first start 2L NS and Toradol, which in my attending's experience, kills the HA over 90% of the time. If this doesn't work, blood patch.

just blood patch her alreay.. enough with the conservative approach

 

[G0S2]

just blood patch her alreay.. enough with the conservative approach

We have yet to try a conservative measure.

Resident wanted BP but attending wants fluids and Toradol.

 

[Bertelman]

You gonna send her home with a couple extra bags of NS and some toradol?

I would have assumed that part of the patient education for PDPH was fluids and NSAIDs. Did she do this at home?

 

[G0S2]

You gonna send her home with a couple extra bags of NS and some toradol?

I would have assumed that part of the patient education for PDPH was fluids and NSAIDs. Did she do this at home?

Inpatient tx for a few hours.

Also, she started to have the HA this afternoon and can't take care of her newborn. Once she can fnx, we will of course send her home with instructions to drink fluids and take NSAIDS.

 

[lobelsteve]

Inpatient tx for a few hours.

Also, she started to have the HA this afternoon and can't take care of her newborn. Once she can fnx, we will of course send her home with instructions to drink fluids and take NSAIDS.

She has to come in to the hospital? So you bring her in from home for fluids and Toradol? And this is better than drinking 2liters of water and taking Motrin?

If you drag her in to the hospital, you should at least make a concerted effort to fix the problem. Blood patch so she can get back to the baby and be the new mom, not having to lay flat for the next few days.

 

[penghill]

infact if you spinal or epidural or CSE enter in center&#65292; the jumpe will <10%. i have 2000 case in epidural and spinal

 

[huktonfonix]

infact if you spinal or epidural or cse enter in center&#65292; the jumpe will <10%. I have 2000 case in epidural and spinal

huh?!?

 

[G0S2]

She has to come in to the hospital? So you bring her in from home for fluids and Toradol? And this is better than drinking 2liters of water and taking Motrin?

If you drag her in to the hospital, you should at least make a concerted effort to fix the problem. Blood patch so she can get back to the baby and be the new mom, not having to lay flat for the next few days.

Gave her 2L NS and Toradol. HA resolved and pt sent home. She returned 1 hr later with HA and BP was performed. Pt pain free today.

And, yes, I would think that 2L NS iv and Toradol is a bit better than drinking 2L and taking Motrin.

 

[OB1🤙]

And, yes, I would think that 2L NS iv and Toradol is a bit better than drinking 2L and taking Motrin.

I'm sure accounts receivable agrees with you.

infact if you spinal or epidural or CSE enter in center&#65292; the jumpe will <10%. i have 2000 case in epidural and spinal

Is that you, Michael Phelps?

 

[Bertelman]

Gave her 2L NS and Toradol. HA resolved and pt sent home. She returned 1 hr later with HA and BP was performed. Pt pain free today.

And, yes, I would think that 2L NS iv and Toradol is a bit better than drinking 2L and taking Motrin.

Bottom line, she came back with a headache, what we all expected. Fluids and NSAIDs can buy you time, and may allow some to ride the wave until the hole resolves on it's own, but if a post-partum is so concerned about her headache that she is coming in to the hospital, you should just give her the patch.

 

[BColorado]

Totally agree with above, when the deed is done and they actually do have the stereotypical headache, go ahead and bp. As for the management of the wet tap, we go ahead and thread the cath, run at 2-3 cc/hr of 0.08 bup with 2ucg/cc fent. Provides an excellent labor analgesic (way better than epiural). Then leave the cath in for 24 hrs and +/- bolus with ns 10cc when you pull it. I personally have tapped 3 and only 1 had a headache after this regimen. I know N is not great but personal experience seems to count for a lot in determining future practice.

 

[G0S2]

As for the management of the wet tap, we go ahead and thread the cath, run at 2-3 cc/hr of 0.08 bup with 2ucg/cc fent. Provides an excellent labor analgesic (way better than epiural). Then leave the cath in for 24 hrs and +/- bolus with ns 10cc when you pull it. I personally have tapped 3 and only 1 had a headache after this regimen. I know N is not great but personal experience seems to count for a lot in determining future practice.

That is our approach as well, however, we could not thread the cath at the level of the tap ( I have seen this more than once and have no idea why this happens given you are subdural) and had to start a new epidural one level above. What can I say/do? Some attending like the conservative approach with fluids and NSAIDS before BP and others prefer to perform a BP straight off if a pt presents to the hospital with a PDPH. As an MSIV, I have little power, if you can believe it.

Back on the horse...last night I placed 2 that were smooth as silk and pts had great pain control throughout labor.

 

[bne_12mne]

I've done probably 100 epidurals thus far. So far (crossing my fingers) no wet taps. I do mostly an intermittent loss technique, at least when I get to flavum, I do. The wet taps that I have seen or been aware of a my place mostly happened to people doing a continuous loss technique.

I don't think the literature supports a different rate of wet tap for the technique, but anecdotally, I would think that there is a difference.

So for you guys with wet tap stories -- How did you do it?

BNE

 

[huktonfonix]

That is our approach as well, however, we could not thread the cath at the level of the tap ( I have seen this more than once and have no idea why this happens given you are subdural) and had to start a new epidural one level above. What can I say/do? Some attending like the conservative approach with fluids and NSAIDS before BP and others prefer to perform a BP straight off if a pt presents to the hospital with a PDPH. As an MSIV, I have little power, if you can believe it.

Back on the horse...last night I placed 2 that were smooth as silk and pts had great pain control throughout labor.

You are intrathecal not subdural.

 

[G0S2]

You are intrathecal not subdural.

Correct. My bad. But I still do not know why the cath didn't insert.


During the two I got last night I knew and felt that I was up against flavum and just moved one mm at a time until loss of resistance was obvious so I do believe that getting a wet tap as an MSIV has more to do with getting used to the "feel" of how the interspinous and flavum feel as you advance.

Like anything, its the #'s.

 

[tracheatoedoc]

2 wet taps in a row as a CA2.
None in the 11 years since.
What's great is when someone you work with has one everymonth and asks you to do the bloodpatch. That is aggravating.

 

[dhb]

The wet taps that I have seen or been aware of a my place mostly happened to people doing a continuous loss technique.

So for you guys with wet tap stories -- How did you do it?

BNE

200 epidurals continuous technique no wet tap. I did think that a had my first las week but it ended up being ok.

 

[coprolalia]

What's great is when someone you work with has one everymonth and asks you to do the bloodpatch. That is aggravating.

I know someone like that (attending)... I saw him get two wet taps in the space of four hours. Continuous technique.

I use continuous until I hit flavum, and then advance/stop/test technique. This adds maybe an extra minute to the total time it takes... maybe. Soup to nuts, I can put a labor epidural in and have it dosed-up in less than 15 minutes. That includes setting up the pump.

The only wet tap I've had (probably in the neighborhood of 750-800 epidurals at this point) is when I was doing a CSE in the lateral position on a beached whale at 9cm with 1 minute contractions after a late call by the L&D nurse. After I'd injected the spinal, I re-tested the Tuohy and got a "bounce". I advance the needle ever-so-slightly right into the intrathecal space. Patient got a PDPH.

-copro