Intrathecal cath, going to c/s

[caligas]

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cath has been running for hours. Now going for non stat section. Comfy with block to t-10.

How do you dose?

 

[facted]

Slowly. I would use maybe 0.5-1 ml of 0.5% bupi to start and go from there.

Could also use lidocaine, but I'm not too familiar with intrathecal lidocaine so I'd stick to what I know.

 

[Arch Guillotti]

Carefully.

 

[Noyac]

Is one main reason not to place intrathecal catheters. Unless your department is very familiar with them, which would mean that they suck at epidurals, then I would recommend not placing them.

 

[Arch Guillotti]

Is one main reason not to place intrathecal catheters. Unless your department is very familiar with them, which would mean that they suck at epidurals, then I would recommend not placing them.

Pretty harsh.

So if you wet tap an enormous patient with a crappy airway what do you do? What if the epidural has been a struggle?

I realize you and pretty much everybody else on SDN is a wizard at procedures and never struggles with anything🙄

 

[caligas]

Slowly. I would use maybe 0.5-1 ml of 0.5% bupi to start and go from there.

Could also use lidocaine, but I'm not too familiar with intrathecal lidocaine so I'd stick to what I know.

Exactly what I was thinking. Maybe wait 5 minutes between doses. Throw a bit of fent in there too. Stat section would be trickier, have to be bolder with first dose or just go GA.

 

[Noyac]

Pretty harsh.

So if you wet tap an enormous patient with a crappy airway what do you do? What if the epidural has been a struggle?

I realize you and pretty much everybody else on SDN is a wizard at procedures and never struggles with anything🙄

Well I have wet tap’d a pt before. Why are you lobbing insults my way? Aren’t you supposed to be the referee here, not instigator?

And when I do get a wet tap I “do not” thread a catheter. I inject the 10cc of sterile NS that comes with the kit into the CSF and remove my touhy. Then I place the catheter at another level. This has worked for me every time. I have mentioned the PDPH avoidance technique on this site before. Look it up. It works. I had a morbidly obese pt last year with hardware in her back from an MVA as a teenager. I got CSF on the first pass and injected the NS then moved to another level and I knew how deep to go now. It worked like a charm.

The reason I don’t use IT cath’s Is not because they don’t work but because we rarely ever place them, maybe three in 15yrs at my efore, nursing is not familiar with them. And if the pt were to need a c/s and someone else were to do that case then there is more concern. I know it is easy to dose slowly but you have introduced a possible chance of mishap. Even if well labeled. **** happens. I’d rather avoid it though.

Please try to keep the insults at bay.

 

[facted]

The fear of an intrathecal catheter is somewhat irrational. You place spinals ALL THE TIME. You know what dosing works for those spinals. Why the sudden fear because the pt is pregnant?

I do understand the issue with labelling and such, and while I'm not keen on handing such a catheter over to the next team, I certaintly would if it was a difficult placement to start with. If it's a thin pt I could re-do without much trouble, I'd just replace.

As for the saline into the intrathecal space, IceI never heard of that. What's the evidence behind that? I assume you're putting in more volume than would leak out over the time it takes for the whole to patch up. On the other hand, you're also increasing intrathecal pressure which would place more tension on the sac and delay site closure.

 

[d9sccr]

However you choose to dose it, don't forget the dead space of the catheter (0.2mL I believe)

 

[deleted875186]

Never actually thought of this because I’ve never seen an IT catheter.

For those that have used them, could you comment on how the level usually rises? If you use plain bupi rather than hyperbaric like a typical CS spinal, does the level rise predictably? How much are yoj usually running in the labor room and how much more does it typically take to get up to T5. Do laboring patients with these already have a significant motor block?

 

[Arch Guillotti]

Please try to keep the insults at bay.

OK, sure😵

Unless your department is very familiar with them, which would mean that they suck at epidurals,

 

[Gas]

Well I have wet tap’d a pt before. Why are you lobbing insults my way? Aren’t you supposed to be the referee here, not instigator?

And when I do get a wet tap I “do not” thread a catheter. I inject the 10cc of sterile NS that comes with the kit into the CSF and remove my touhy. Then I place the catheter at another level. This has worked for me every time. I have mentioned the PDPH avoidance technique on this site before. Look it up. It works. I had a morbidly obese pt last year with hardware in her back from an MVA as a teenager. I got CSF on the first pass and injected the NS then moved to another level and I knew how deep to go now. It worked like a charm.

The reason I don’t use IT cath’s Is not because they don’t work but because we rarely ever place them, maybe three in 15yrs at my efore, nursing is not familiar with them. And if the pt were to need a c/s and someone else were to do that case then there is more concern. I know it is easy to dose slowly but you have introduced a possible chance of mishap. Even if well labeled. **** happens. I’d rather avoid it though.

Please try to keep the insults at bay.

This sounds interesting. Do you always have the sterile NS drawn up? What I mean by this is let's say you get a wet tap, and CSF is pouring out of the Tuohy. By the time you crack open the vial, draw up the NS, and then inject it, I bet quite a bit of CSF has come out of the Tuohy.

Personally, before I start the procedure, I mix 5cc of NS with 5cc 0.25% bupivacaine for 10cc of 0.125% bupivacaine. When I get loss, I inject about 7-10cc of this mixture through the Tuohy, thread the catheter, and then administer the test dose of 5cc of 1.5% lido with epi. Haven't administered ephedrine in years. Patients get comfortable rather quickly, so no need for CSE either.

I realize it's risky dosing through the needle, because you can't be 100% sure your catheter works. But I feel like 0.125% bupiv is less likely to confound your diagnosis compared to 0.25% through the needle, which is what some of my partners do. One of my attendings did it this way in residency and it stuck.

 

[deleted162650]

This sounds interesting. Do you always have the sterile NS drawn up? What I mean by this is let's say you get a wet tap, and CSF is pouring out of the Tuohy. By the time you crack open the vial, draw up the NS, and then inject it, I bet quite a bit of CSF has come out of the Tuohy.

Put the stylet back in the Tuohy

Or do like this guy:

 

[IMGASMD]

Put the stylet back in the Tuohy

Or do like this guy:

Looks about right.

 

[AdmiralChz]

However you choose to dose it, don't forget the dead space of the catheter (0.2mL I believe)

I haven’t done much IT catheters, but this is important from the few I did in training. We would place a stock cock at the end, pull back ~ 3 mL CSF and use it to flush in the med (~ 0.5 mL). A pretty nifty technique for trainees out there.

 

[narcotics999]

Well I have wet tap’d a pt before. Why are you lobbing insults my way? Aren’t you supposed to be the referee here, not instigator?

And when I do get a wet tap I “do not” thread a catheter. I inject the 10cc of sterile NS that comes with the kit into the CSF and remove my touhy. Then I place the catheter at another level. This has worked for me every time. I have mentioned the PDPH avoidance technique on this site before. Look it up. It works. I had a morbidly obese pt last year with hardware in her back from an MVA as a teenager. I got CSF on the first pass and injected the NS then moved to another level and I knew how deep to go now. It worked like a charm.

The reason I don’t use IT cath’s Is not because they don’t work but because we rarely ever place them, maybe three in 15yrs at my efore, nursing is not familiar with them. And if the pt were to need a c/s and someone else were to do that case then there is more concern. I know it is easy to dose slowly but you have introduced a possible chance of mishap. Even if well labeled. **** happens. I’d rather avoid it though.

Please try to keep the insults at bay.

Maybe she did not have pdph because of obesity?

Sent from my moto g(6) using SDN mobile

 

[Mman]

on the rare occasion I get a wet tap, I thread a catheter. If they are at risk for a PDPH, why not give them the rolls royce labor analgesia plus have the instant perfect anesthetic for a c-section waiting to go instead of pulling it and then redoing an epidural catheter which may or may not work great and then still have them at risk for PDPH.

My colleagues are about 50/50 in terms of who puts in a catheter vs who pulls out and does epidural instead. The nurses are well educated about how we treat a spinal catheter and it gets labeled many times over and the patient gets a long explanation of how it works and what to watch out for afterwards. Basically nobody (not even the nurse) is allowed to mess with the catheter in any way. They just gotta call us if there is an issue and we deal with it.