Jetpearl Number 2

[jetproppilot]

In the very large parturient (say three bills and up) doing a spinal is much easier with a 22" spinal needle and, anecdotally, post dural puncture headaches in the very large parturient is rare. Consider saving yourself time by starting with a 22" in this parturient population."

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[drccw]

At around 400 lbs I pretty much start with a 17G introducer.. much easier for probing the deeper tissues

 

[Gern Blansten]

In the very large parturient (say three bills and up) doing a spinal is much easier with a 22" spinal needle and, anecdotally, post dural puncture headaches in the very large parturient is rare. Consider saving yourself time by starting with a 22" in this parturient population."

Agree. The extra length gained by not needing to use the introducer for the 25 Ga is also frequently needed.
(**I assume you mean 22 Ga and not 22 inch)

 

[lfesiam]

Agree. The extra length gained by not needing to use the introducer for the 25 Ga is also frequently needed.
(**I assume you mean 22 Ga and not 22 inch)

I am diggin' the daily Jetpearls.

boy, have you ever seen the needle break in half? saw that one time, lady was was super obese, BMI 60-70ish. 4 michellin tires (if you count the rolls). can't even tell she was prego.

 

[Coastie]

I've needed a 22 inch spinal needle a time or two.

 

[Planktonmd]

I have not used a # 22 spinal needle in more than 5 years.
In my hands it's either a 25 Whitacre or in the real big ones a CSE.
But many people like the # 22 needles.

 

[bostonblaz]

Something I never knew until I became an attending. If a spinal is difficult or the person is super fat the best way to increase success is to use the sacrum as your best friend. You can always feel it, use your local there and walk up until you find you self in the l5 s1 space. It even work in severe curvature as most time that maybe the only space that is not overly rotated. As you walk off the sacrum it is mildly uncomfortable so it helps when you have sedation on board. If it is a prego just use lots of local and your sweet words. Jet I likke this a lot, I wish someone had been doing tbhis while I was training. Blaz

 

[GoodmanBrown]

I am diggin' the daily Jetpearls.

boy, have you ever seen the needle break in half? saw that one time, lady was was super obese, BMI 60-70ish. 4 michellin tires (if you count the rolls). can't even tell she was prego.

If a needle breaks in half, if it's embedded, are they sent to surgery to get it out? How does this affect the labor process? (Other than adversely...)

 

[Mman]

In the very large parturient (say three bills and up) doing a spinal is much easier with a 22" spinal needle and, anecdotally, post dural puncture headaches in the very large parturient is rare. Consider saving yourself time by starting with a 22" in this parturient population."

I like 22 g spinal needles in the super big ones, but I'll rarely start with it unless they are gigantic (400+). I find in most 300-350 lbers that the 25 g works fine but I just need to lean on the introducer a little.

 

[rsgillmd]

In the very large parturient (say three bills and up) doing a spinal is much easier with a 22" spinal needle and, anecdotally, post dural puncture headaches in the very large parturient is rare. Consider saving yourself time by starting with a 22" in this parturient population."

I would just do a CSE in these patients. If I get a wet tap, then I'll make it a continuous spinal. In my experience people that big rarely get post-dural puncture headaches, so we are in agreement on that. I think two of them did, but they did not require a blood patch.

Someone else mentioned about L5-S1. I agree with that also. You can usually guesstimate where it is without too much difficulty. As one of attendings in residency taught me: it is the largest interspace, and the least position dependent.

 

[pgg]

Something else to consider when you're having trouble is a low thoracic epidural.

There are a number of technical advantages to a T10-12 epidural in morbidly orbese parturients
- T10-12 spinous processes are almost as horizontal as those of lumbar spine
- Spinous processes usually more easily palpable above the lumbar concavity
- Easier to identify midline
- Above lower back fat pad – shorter distance to epidural space, less catheter migration
They tend to be as technically easy to place as lumbar epidurals in non-obese patients.

It's described and endorsed in Datta's book, Anesthetic and obstetric management of high risk pregnancy. I think the first published series was Blass in Anesthesiology in 1994. He also described a landmark "Blass's Line" he named after himself which aids in estimating the level of T10 in fat women - a line between the patients bilateral fat pads.

Anyway, point being, when faced with an uncooperative obese lumbar spine that simply won't accept an epidural, there's some successful precedent for marching a few extra spaces up the back and placing what will probably be a technically easier and just as effective catheter, for either labor analgesia or section. Reduced sacral spread from higher placement isn't as big a problem as one might expect. It works ... though I haven't done one since I was a resident as my current OB volume is small and low risk (fatties get turfed out).

 

[Noyac]

If a needle breaks in half, if it's embedded, are they sent to surgery to get it out? How does this affect the labor process? (Other than adversely...)

NO, they are sent for an MRI.

 

[h2oriderz]

NO, they are sent for an MRI.

hahahahahaha!

 

[GoodmanBrown]

NO, they are sent for an MRI.

Touche. I was so close to replying, "Oh, I thought they might just get a magnet." Then I thought real hard about what an MRI is... Long day.

Would you just do a C/S while you're in the OR, or would they delay labor?

 

[Apollyon]

NO, they are sent for an MRI.

Touche. I was so close to replying, "Oh, I thought they might just get a magnet." Then I thought real hard about what an MRI is... Long day.

I thought needles were made from stainless steel (or at least had a nickel content in them) and are non-magnetic (due to the nickel)!

 

[rsgillmd]

I thought needles were made from stainless steel (or at least had a nickel content in them) and are non-magnetic (due to the nickel)!

That's a good question. I'm on call in L&D tomorrow (Saturday). If I remember, I'll take a magnet with me from home and see what happens.

 

[Idiopathic]

ill sometimes elect to place a CSE with no epidural catheter in these patients as im extremely confident that i can find the epidural space with a touhy and from there it shouldnt be terribly difficult to pierce the dura

EDIT: HOWEVER the spinal needle is extremely unsteady in the touhy so thats the tradeoff, ive had more than one shot of marcaine spray me in the face because the spinal needle backed out ever so slightly into the ligament, usually after barbotage

 

[loveoforganic]

http://www.wisegeek.com/is-stainless-steel-magnetic.htm

 

[granolabar2]

Something I never knew until I became an attending. If a spinal is difficult or the person is super fat the best way to increase success is to use the sacrum as your best friend. You can always feel it, use your local there and walk up until you find you self in the l5 s1 space. It even work in severe curvature as most time that maybe the only space that is not overly rotated. As you walk off the sacrum it is mildly uncomfortable so it helps when you have sedation on board. If it is a prego just use lots of local and your sweet words. Jet I likke this a lot, I wish someone had been doing tbhis while I was training. Blaz

How much local do you use to get this up to t4 for a section (or have you only used this for labor pain?) do you have experience placing epidural catheters at this level also? Are they as effective for stage 1 labor as an epidural placed higher? [YOUTUBE][/YOUTUBE]

 

[Jay K]

My practice is usually CSE as well, using tuohy to find space. The spinal needles we have for threading are not long enough though in my opinion to ensure 100% (don't know why they don't stock a longer needle for this), so I'll thread the catheter for insurance (kits opened already anyways). Didn't practice with 22G in training, but they're available in my current workplace, and they're certainly easier to use at times. Maybe with practice I'll forgo CSE's.

 

[IN2B8R]

In the very large parturient (say three bills and up) doing a spinal is much easier with a 22" spinal needle and, anecdotally, post dural puncture headaches in the very large parturient is rare. Consider saving yourself time by starting with a 22" in this parturient population."

Good one, Jet: you and I come from same school of thought on this topic.

 

[rsgillmd]

ill sometimes elect to place a CSE with no epidural catheter in these patients as im extremely confident that i can find the epidural space with a touhy and from there it shouldnt be terribly difficult to pierce the dura

EDIT: HOWEVER the spinal needle is extremely unsteady in the touhy so thats the tradeoff, ive had more than one shot of marcaine spray me in the face because the spinal needle backed out ever so slightly into the ligament, usually after barbotage

Are you sure the needle is backing out or is the connection between your spinal needle and your syringe? If your needle is backing out then that is a technical deficiency easily corrected with practice.

Initially when I tried to avoid opening a spinal kit for the syringe I sprayed some of my spinal anesthetic mixture, but quickly discovered that the problem was the connection. The typical 25/27 ga. Whittacre needles are designed for use with a luer slip syringe, whereas my 3 ml syringe I was using for injection had a luer lock tip. That is slightly more challenging in that you have to keep the spinal needle from moving while simulatenously twisting a luer lock syringe into the spinal needle. But again, if yuou practice it once or twice, smooth aspiration and injection should not be a problem once you have a seal. It's easier to inject the larger volume for a spinal anesthetic for C/S with a 25 ga. needle. I used to reserve the 27 ga. needles for labor CSEs or straight spinals.

At my current institution the 3 ml syringes are luer slip, and they don't even have a 27 ga. Whittacre, so there are no worries.

 

[hoyden]

I thought needles were made from stainless steel (or at least had a nickel content in them) and are non-magnetic (due to the nickel)!

***looking at the stainless steel needle hanging on the small magnet***

I have always thought stainless steel IS magnetic

 

[bostonblaz]

if it is hyperbaric it wont matter, i have never put an epidural there but i assume it will be the same.

 

[DipriFan]

Great stuff in these pearls, Jet (et al). Keep em coming!