Lumbar Drain in PP

[sevoflurane]

Any one been asked to do one of these? Did you do it? No neurosurgon around to place it at my hospital. Asked to do it post spine surgery with dural tear.

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[sevoflurane]

Thanks for your input DM. At my residency program we were never asked to put these in. Seen lots put in by Neuro or on the other side of the drapes in the Pain room. I was wondering if this would be considered out of our scope of practice since we don't routinely do them.

I hear you, the process is excatly the same: sterility, csf, catheter.... No more difficult than a spinal or epidural or intrathecal catheter after accidental spinal for that matter. That 15G touhy is not small... and it sure looks midevil with that stainless steel monster stylet. The other difference and the reason I was a little reluctant is that usually I have stuff going into the patient and not out.

Either way, I don't have to manage it, which was my main concern.

Other than that, as you stated, it's pretty simple.

 

[Bertelman]

Thanks for your input DM. At my residency program we were never asked to put these in. Seen lots put in by Neuro or on the other side of the drapes in the Pain room. I was wondering if this would be considered out of our scope of practice since we don't routinely do them.

I hear you, the process is excatly the same: sterility, csf, catheter.... No more difficult than a spinal or epidural or intrathecal catheter after accidental spinal for that matter. That 15G touhy is not small... and it sure looks midevil with that stainless steel monster stylet. The other difference and the reason I was a little reluctant is that usually I have stuff going into the patient and not out.

Either way, I don't have to manage it, which was my main concern.

Other than that, as you stated, it's pretty simple.

We have been doing them more frequently. Haven't placed one yet, but have had to manage it. Can be a pain in the ass troubleshooting when the flow slows down. I'd be surprised if you didn't have to manage it post-placement. If they aren't comfortable placing it, they probably shouldn't be fiddling with it, either.

 

[ProRealDoc]

Thanks for your input DM. At my residency program we were never asked to put these in. Seen lots put in by Neuro or on the other side of the drapes in the Pain room. I was wondering if this would be considered out of our scope of practice since we don't routinely do them.

I hear you, the process is excatly the same: sterility, csf, catheter.... No more difficult than a spinal or epidural or intrathecal catheter after accidental spinal for that matter. That 15G touhy is not small... and it sure looks midevil with that stainless steel monster stylet. The other difference and the reason I was a little reluctant is that usually I have stuff going into the patient and not out.

Either way, I don't have to manage it, which was my main concern.

Other than that, as you stated, it's pretty simple.

What did you do when you had to do a TAA?

 

[jwk]

Any one been asked to do one of these? Did you do it? No neurosurgon around to place it at my hospital. Asked to do it post spine surgery with dural tear.

Why doesn't your spine surgeon do it? If they can't manage their complications, then they shouldn't be doing the surgery in the first place.

 

[dhb]

We do them (not in PP) we use an epidural kit 18G neeedle and a 18G central line kit: wire through the tuohy then catheter over wire.

 

[proman]

What's the indication, refractory CSF leak? A lumbar drain for dural tear is a bit unusual, normally reserved for persistent CSF leaks from dural tears that have failed surgical revision. Maybe referral to a neurosurgeon to repair the tear would be more appropriate.

As for the drain, we ideally place them in our pain clinic under fluoro (IR is another option). Ours go through a 14ga Tuohy and are catheter-over-wire type. They can turn into real struggles when the catheter goes in easily but no CSF comes out.

 

[NitrousOx]

We put them in all the time for TAA and Endo TAAs.

We use one of 2 options:

1. Use a regular epidural kit and place the epidural cather (20g) in the CSF

Con: Fails more often

2. Use a integra medical sciences, CSF monitoring kit, comes with a 14g Tuohy and a 16g wired catheter.

Con: harder to find these kits and these wired catheters need to be lubricated with saline before they pass easily through the Tuohy

 

[sevoflurane]

What did you do when you had to do a TAA?

Don't place a lumbar drain.

 

[sevoflurane]

Why doesn't your spine surgeon do it? If they can't manage their complications, then they shouldn't be doing the surgery in the first place.

Good surgeon. Really nice guy. Brings in A LOT of revenue. I'm the first guy to place one this year.

 

[sevoflurane]

What's the indication, refractory CSF leak? A lumbar drain for dural tear is a bit unusual, normally reserved for persistent CSF leaks from dural tears that have failed surgical revision. Maybe referral to a neurosurgeon to repair the tear would be more appropriate.

As for the drain, we ideally place them in our pain clinic under fluoro (IR is another option). Ours go through a 14ga Tuohy and are catheter-over-wire type. They can turn into real struggles when the catheter goes in easily but no CSF comes out.

Understood. We don't have a neurosurgeon (thank the gods above). I'm guessing he wanted to give this a try before referring.

 

[sevoflurane]

Patient is doing fine.... 110 cc's since 8:00 am (post call). Thank you all for your responses.

Kinda of funny how learning never stops in anesthesia. What a fantabulous specialty.

So far this week Monday-Tuesday morning:

2 MAC catheters, 2 TEE, multiple a-lines, 2 lumbar plexus with magic IV potions and this a.m. a lumbar drain and of course... TOOL blazing in the OR's via surgeons request.

Why would you ever choose anything else?

Still buzzn' post graduation. 😎

 

[Arch Guillotti]

Why doesn't your spine surgeon do it? If they can't manage their complications, then they shouldn't be doing the surgery in the first place.

I have never bought into this school of thought. Plenty of physicians perform procedures that can cause complications that we have to get someone else to fix.

 

[jwk]

I have never bought into this school of thought. Plenty of physicians perform procedures that can cause complications that we have to get someone else to fix.

Agreed, but this doesn't seem to be one of them. Frequent "incidental durotomies" are a bad sign. However 😉 - I have a significant personal bias towards neuro-spine and am not nor have I ever been an ortho-spine proponent. I've seen far too many complications and issues from the ortho-spine guys at the various places I've been on staff, and very few from our neuro guys, all of whom have always placed their own spinal drains if need be.

 

[bullard]

Agreed, but this doesn't seem to be one of them. Frequent "incidental durotomies" are a bad sign. However 😉 - I have a significant personal bias towards neuro-spine and am not nor have I ever been an ortho-spine proponent. I've seen far too many complications and issues from the ortho-spine guys at the various places I've been on staff, and very few from our neuro guys, all of whom have always placed their own spinal drains if need be.

Ditto on the neuro-spine >> ortho-spine question.

 

[jennyboo]

At our place Neurosurgery place their own lumbar drains for intracranial indications, while we place them preop for Vascular Surgery upon request for TAAs.

The vascular surgery drains then get managed in the SICU by the vascular surgeon according to some vague protocol (which involves the attending surgeon saying "I feel like capping the drain today" then "remove drain 24 hours after capping"), until signs of cord ischemia turn up and then it stays open for longer and these patients then end up on pressors for several days.

So I see no reason why you can't include lumbar drain placement in your practice, but 1) who is gonna manage the drain after it's placed and decide when to close the drain and pull it, and 2) do you really want to treat a patient with spinal pathology when the spine surgeon is out of options?

I have never seen a spinal drain used for primary spine pathology and would not feel comfortable placing and managing a drain in this capacity.