Intrathecal Catheters

[FiO2@21]

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Has anyone ever intentionally placed one? I’ve always wanted to place one for those sicker patients we’re afraid to put asleep.

For people who have “carefully titrated” them in marginal patients, what were the boluses you’ve been doing?

And finally how do you place them? Do you use the same big tuohy needle and the epidural catheter?

 

[GassYous]

There are some cases reported on here with them. Sounds like they give around 2.5-5 mg of bupi at a time until the level is good. I've never placed one but I think it is the tuohy + epidural catheter.

 

[Toothpickwars]

I’ve done a handful this year for bad cardiopulmonary disease and lower extremity surgery or C-sections in the supermorbidly obese. Regular touhy, wet tap, thread catheter carefully 3-5cm (stop if paresthesias).

Dose with 1cc 0.25% isobaric bupi at a time for the sick, start with 1.2cc heavy for the obese.

Last hip fx was a guy with severe AS and an EF of 20%, ended up giving 10mg bupi with 15 fent, guy was in pacu off pressors 2 hours later.

 

[deleted126335]

Yes. A few in residency for elderly total joint patients. Those were mostly for teaching. Two post residency. Both 400+lb scheduled C-sections with slow OBs. Bevel parallel to dural fibers. No headaches.

 

[Mman]

have done it once in a while for old sick broken hip patient. Just took a regular epidural kit and pushed needle til I got CSF and threaded catheter. Ended up dosing with 0.5% bupivacaine, approximately 0.5 ml at a time. In that population it doesn't take much to get the effect.

 

[FiO2@21]

have done it once in a while for old sick broken hip patient. Just took a regular epidural kit and pushed needle til I got CSF and threaded catheter. Ended up dosing with 0.5% bupivacaine, approximately 0.5 ml at a time. In that population it doesn't take much to get the effect.

Were you able to sit them up? Or did you do it lateral?

 

[GassYous]

Were you able to sit them up? Or did you do it lateral?

Lateral is fine. Give them like 10-15 of ketamine.

For sitting them up I was taught to do sedation + fascia iliaca with high volume dilute local. I think sitting up makes for a quicker and easier spinal but it's harder on the patient.

 

[Mman]

Were you able to sit them up? Or did you do it lateral?

the ones I have done I never needed to sit them up. I suppose the positioning depends on the reason you are doing it in the first place.

 

[Arch Guillotti]

C-sections in the supermorbidly obese

How big are you talking? Sadly we have had a few come through with BMI in the 60 range.

 

[Status Sciaticus]

idk if the intrathecal catheters are widely available in the US? I haven't seen one at my institution at least?

 

[Toothpickwars]

How big are you talking? Sadly we have had a few come through with BMI in the 60 range.

The ones I’ve seen are in the 60+ range, Arch. Great for C section anesthesia when you really don’t want to put them to sleep and who knows where an epidural cath will end up.

Gandalf, we just use the springwound multiorifice epidural catheters.

 

[Toothpickwars]

have done it once in a while for old sick broken hip patient. Just took a regular epidural kit and pushed needle til I got CSF and threaded catheter. Ended up dosing with 0.5% bupivacaine, approximately 0.5 ml at a time. In that population it doesn't take much to get the effect.

These patients all stay supine for a while after repair anyway and tend to be old enough that PDPH isn’t a concern.

 

[nimbus]

idk if the intrathecal catheters are widely available in the US? I haven't seen one at my institution at least?

Small bore microcatheters were taken off the market in the US due to reports of cauda equine syndrome.

https://watermark.silverchair.com/590.pdf?token=AQECAHi208BE49Ooan9kkhW_Ercy7Dm3ZL_9Cf3qfKAc485ysgAAArwwggK4BgkqhkiG9w0BBwagggKpMIICpQIBADCCAp4GCSqGSIb3DQEHATAeBglghkgBZQMEAS4wEQQMwgcAW-JLZ413BgHNAgEQgIICb4K2akB4Ys-aFwFvVX_DD6pHOgSWm9b5IQJ7Sb1yU2DfdloGeRuVcRpCEV6FNjVsp64YIYuk5S9-RBZGaU3c1_4X5T_wsNdn0LOHeuQGF5x19CpG-Jzr_DPbqJrhG2XBXat615qxWDmLKN8nMPjbOE4tOZoOqf9Q7yK_JbNYeRv23aRS4rdEma55G5IpKTXhSEDrU6ijkywSfeHyWsKP0Vd-yPkjqS1uF7vzAk0xeiPo42UWXsxWlXOOs9DEcVQrhceLw8oppJc8bicy0M9HXFA_DOhauOD0Rkpfz8e9xmA3daiIOjOnEayHWERGUyi9CYsxoaUJVTWI-bgLo8eKsew2oljzMlwdekyvGhgIOZPqRFr77O-v3V57wsuwIrjyhkcjfaz9jY6qMv00VmwGKzLxLJsavj7eaLpzVe8J-N987CAE4dIbaJbz4BuOrqOhFn_j6AZcGl3Uhasv9beq2_GCsLvgwuHQqMrSIYSirsvUK_IPgb1q0Wt7vxJ_C0Z16VeCGHm2XaQPtoYF6nFdcy7HhRJkwXuGdaUa_VCbv269Ez8qVUjq1kMHGTQVIOtXcz0MuVmgCs3YfnhJhMPxAP84E57IXnXKK-oL9XpoUfuNayhVLOLGK2reJTAOyfGt5q1NZlXolxtllvrw8ZFSJ2YKEbwkehVH41FCPdR8Y1Bi1L3j1t-_s4dmyaT1_smEFVpCYRQy3VaPdgwYt_m-H4UvUmxsapAs0bET58cA9nZlsH9Da0pwoT3FBktDH6gg70hI6_PYEC-ZSq11Z5qP0Lffw-T7AIahBFd523ZA19yegJZmu2xlssZkc6gfdbHg

 

[Mman]

These patients all stay supine for a while after repair anyway and tend to be old enough that PDPH isn’t a concern.

they stay supine for most of the rest of their life

 

[Toothpickwars]

they stay supine for most of the rest of their life

Yeah 30 day mortality for any patients you would even consider doing a continuous spinal on for cardiopulmonary reasons is not great…

 

[woopedazz]

I was involved with a sick one with a Tuohy in 2019: Case discussion - a good day to wear brown underwear

Fun case.

 

[cchoukal]

I’ve done a couple over the years. Sick vasculopaths with bad hearts having long lower extremity vascular procedures. Just used the brain epidural kit. Started with 1.5-ish mls heavy bupiv and then maybe 0.5 ml every hr or so after the first two hrs.

 

[FiO2@21]

I was involved with a sick one with a Tuohy in 2019: Case discussion - a good day to wear brown underwear

Fun case.

Maybe it’s because I’m going into ICU, but I really like how you approached that case. I know 60-80% of my attendings probably would have firmly disagreed.