Neuraxial Anesthesia and Tattoos

[BLADEMDA]

Today, more women are presenting with tattoos over their lumbar area. In the past these tattoos were avoidable by going to a non pigmented interspace. But, those days girls from 18-25 seem to have large tattoos and more than one tattoo. In my day as a Resident I never saw even one large lumbar tattoo (a small Rose on the ankle was it).

Times have changed (and I'm a dinosaur and don't like them so I have adapted my technique. Still, I'm getting women wth a tattoo covering the entire lumbar area from L1-S1 where even a paramedian technique won't solve the problem.

Any of you worried about sticking a needle through these tattoos? How about one of you Ob people doing a study on 100 patients followed over a few months?

I'm sticking these women through their tattoos when no other non pigmented areas are available rather than deny the patient the neuraxial technique.

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[BLADEMDA]

Neuraxial Anesthesia Through Tattoos: Is it Safe Puncturing The Dragon?

Barbara G. Jericho M.D.
Department of Anesthesiology, University of Illinois Medical Center at Chicago
Chicago, Il USA
Citation:* B.G. Jericho: Neuraxial Anesthesia Through Tattoos: Is it Safe Puncturing The Dragon?. The Internet Journal of Anesthesiology. 2009 Volume 20 Number 1. DOI: 10.5580/b46
Keywords:* Neuraxial anesthesia, tattoos
Abstract

Sir:

Tattoos have become increasingly popular. In the United States, more than 45 million people have tattoos1. Almost 50% of all tattoos are being done on women2. I have seen an increasing number of women with lumbar midline tattoos requesting labor epidurals. Neuraxial anesthesia in the lumbar region with a tattoo brings up the concern of introducing the pigment into the central nervous system. Many of us have surely asked ourselves at one time or another “Should I place the spinal or epidural needle through the tattoo or not through the tattoo if possible?”. As I have found, the practice among anesthesiologists varies. A survey in England revealed that 65% of consultant anesthetists with obstetric sessions place the needle through the tattoo during spinal or epidural anesthesia3 .

The main concern in performing neuraxial anesthesia through a tattoo rests

in the safety of the presence of the pigment of the tattoo in the intrathecal or the epidural spaces. Vasold et al. provided in vitro evidence that the tattoo pigments, (industrial

pigments not intended for human use by the chemical industry but rather to stain consumer goods) contain toxic and carcinogenic compounds, such as 2-ethyl-5-nitroaniline, 2,5-dichloraniline and 4-nitro-toluene4. More organic pigments are being used, yet the individual being tattooed or the tattoo artist may not know the composition of the ink. Hollow needles, with or without a stylet entrap tissue fragments (cores) in the bore as they pass into deeper tissues5. It is possible that introducing a needle through the pigment of a tattoo may result in a tissue core that contains pigment being introduced into deeper tissues. Subsequent injection may result in the entrapped tissue fragments containing pigment being deposited into the epidural, subdural, or subarachnoid spaces. The risk of introducing exogenous pigments into the epidural, subdural, or subarachnoid spaces may be clinically significant, because introducing exogenous pigments into these spaces may cause a chemically-induced arachnoiditis or result in the development of an epidermoid tumor6.

Although to date, there are no reported complications from inserting an epidural or spinal needle through the tattoo, this could be because in the past fewer patients had tattoos involving the midline of the lower back. Also, complications may take time to develop and it may be too early to see these complications which may occur later in time. Furthermore, the relation of the complication to the tattoo may not be made if time has passed. Therefore, because of safety concerns of introducing pigment into the intrathecal or epidural spaces with the use of hollow needles through tattoos during neuraxial anesthesia, and no specific guidelines to follow, a safe approach should be attempted. Therefore, the anesthesiologist might choose to avoid skin puncture through the pigment of the tattoo by selecting a different vertebral interspace, using the paramedian versus the midline approach, or finding an area free of pigment within the area of tattoo. When this cannot be accomplished, one may choose to nick the skin before inserting the spinal or epidural needle. The size of the nick should be larger than the needle being inserted and should penetrate through the dermis. This may minimize the incidence of coring. Finally, the patient with a tattoo should always be informed of the risks of this procedure.

 

[BLADEMDA]

Question

Lower back tattoo: OK to have an epidural?
Could a lower back tattoo keep me from having an epidural during labor?

Answer
from Roger W. Harms, M.D.

A lower back tattoo won't necessarily prevent you from having an epidural during labor. The exception would be if the tattoo is red, swollen or oozing fluid — or if the tattoo is recent and the affected skin is still healing.

Research on tattoos and epidurals is limited. Theoretical concerns — such as the development of skin cancer in the affected area years later — remain controversial. Actual reports of problems associated with epidurals and lower back tattoos are exceedingly rare.

If you have a lower back tattoo and decide to have an epidural during labor, the anesthesiologist will likely try to insert the needle through skin that isn't tattooed — such as an open area in the tattoo design.

If that isn't possible, the anesthesiologist might nick your skin before inserting the needle. This reduces any possible risk associated with trapping tattoo pigment inside the needle or depositing the pigment into deeper tissues.

Keep in mind that placing a needle through the tattoo might result in a small scar that could alter the appearance of the tattoo.

If you're concerned about the unknowns associated with tattoos and epidurals, you might ask your health care provider about other options for pain relief during labor — such as relaxation exercises, breathing techniques, or oral or injected medications.

 

[BLADEMDA]

Yet while the risk of introducing tattoo dye into the spinal column along with the syringe used to administer an epidural is apparently roundly dismissed in the U.S., in Canada it is being considered as a possibility, even to the point that some doctors are refusing to perform the procedure through inked-on body art. Alberta RN, a Canadian publication, noted in 2004 that:
Reliable studies are not yet available on the long-term effects of dyes and heavy metals dragged into the epidural and subarachnoid spaces. Anesthesiologists are increasingly concerned about the safety of inserting needles and epidural catheters through tattooed areas and in some situations, anesthetists will refuse to perform epidurals if they can't find tattoo-free skin to go through.

 

[Gern Blansten]

Have done it many times. I have also heard many OB anesthesia "experts" who know more about than myself and they have, thus far, stated that they believe there is minimal to no risk.

 

[Gern Blansten]

If you're concerned about the unknowns associated with tattoos and epidurals, you might ask your health care provider about other options for pain relief during labor — such as relaxation exercises, breathing techniques, or oral or injected medications.

Good luck with that. It seems that tatoo needles must sensitize persons to be more sensitive to pain from needles etc, since some of the biggest whimps/needle phobes I have taken care of have had multiple large tatoos.

 

[Bertelman]

Not only do I go right through it, I often remark where I landed, and comment positively if the "art" is midline. Off-centered work just distracts me.

 

[Consigliere]

I indiscriminately shove my 17 gauge Touhy through ink on a routine basis. F uck 'em

 

[Mr Wizard]

I hope that these doctors who are refusing neuraxial anesthesia through back tattoos are using the published technique to prevent coring through medications vials. This risk has actually been documented and there are some means to help prevent it. Until any chance of risk has been elicited, patient care and safety should not be denied because of a theoretical risk.

How to Enter a Medication Vial Without Coring

Jonathan V. Roth, MD

There is a longstanding recommended technique of needle insertion into a medication vial that reduces the risk of coring. The needle should be inserted at a 45–60° angle with the opening of the needle tip facing up (i.e., away from the stopper). A small amount of pressure is applied and the angle is gradually increased as the needle enters the vial. The needle should be at a 90° angle just as the needle bevel passes through the stopper.



I suggest a new study to be done titled How to Enter a Tramp Stamp Without Coring. Avoiding the tattoo is a good idea if possible, but we are there to help the patient. Talk about this theoretical risk, document it if this helps your inner peace, but don't just deny the patient.

 

[BLADEMDA]

I hope that these doctors who are refusing neuraxial anesthesia through back tattoos are using the published technique to prevent coring through medications vials. This risk has actually been documented and there are some means to help prevent it. Until any chance of risk has been elicited, patient care and safety should not be denied because of a theoretical risk.

How to Enter a Medication Vial Without Coring

Jonathan V. Roth, MD

There is a longstanding recommended technique of needle insertion into a medication vial that reduces the risk of coring. The needle should be inserted at a 45–60° angle with the opening of the needle tip facing up (i.e., away from the stopper). A small amount of pressure is applied and the angle is gradually increased as the needle enters the vial. The needle should be at a 90° angle just as the needle bevel passes through the stopper.



I suggest a new study to be done titled How to Enter a Tramp Stamp Without Coring. Avoiding the tattoo is a good idea if possible, but we are there to help the patient. Talk about this theoretical risk, document it if this helps your inner peace, but don't just deny the patient.

I'm not sure that anyone in the U.S. is denying a patient Neuraxial anesthesia due to a Tattoo. My reserach indicated Canadian and European Anesthesiologists were the ones willing to "deny" Neuraxial blocks due to ink on the skin; even then, those providers were likely just a small minority.

 

[BLADEMDA]

I hope that these doctors who are refusing neuraxial anesthesia through back tattoos are using the published technique to prevent coring through medications vials. This risk has actually been documented and there are some means to help prevent it. Until any chance of risk has been elicited, patient care and safety should not be denied because of a theoretical risk.

How to Enter a Medication Vial Without Coring

Jonathan V. Roth, MD

There is a longstanding recommended technique of needle insertion into a medication vial that reduces the risk of coring. The needle should be inserted at a 45–60° angle with the opening of the needle tip facing up (i.e., away from the stopper). A small amount of pressure is applied and the angle is gradually increased as the needle enters the vial. The needle should be at a 90° angle just as the needle bevel passes through the stopper.



I suggest a new study to be done titled How to Enter a Tramp Stamp Without Coring. Avoiding the tattoo is a good idea if possible, but we are there to help the patient. Talk about this theoretical risk, document it if this helps your inner peace, but don't just deny the patient.

Coring is a problem with Propofol Vials. I have seen it many times in the syringes of CRNAs. Needles equal to or larger than 18G can cause coring of the rubber into the propofol solution. So, either use a smaller needle than 18G or a filter needle. Anyone else noticed this same issue?

 

[BLADEMDA]

After one inserts a needle through the stopper of a medication vial, a small piece of the stopper is sometimes sheared off (known as coring) and can be noticed floating on the liquid medication. Because of its small size, personnel are not on the lookout for this, or if visualization is blocked by a label, a matching background, or a colored vial, the coring may go unnoticed. This small foreign body can then be aspirated into a syringe and injected into a patient. For many years, the contamination of parenteral fluids and medications by particulate matter has been recognized as a potential health hazard and has been associated with adverse reactions ranging from clinically occult pulmonary granulomas detected at autopsy to local tissue infarction, pulmonary infarction, and death (1,2). Evidence suggests that particle contaminants may not pose a major threat in intact tissue, but may severely compromise tissue perfusion in patients with prior microvascular compromise of vital organs (e.g., after trauma, major surgery, or sepsis) (1). Finally, there is the potential for neurologic damage should such material pass to the left side of the circulation and occlude a cerebral vessel.
Although steps have been taken by some pharmaceutical companies to reduce the risk of coring, manufacturing and quality control standards vary between companies. Economic pressures leading to the increased use of generic drugs, counterfeit drugs, or drugs purchased over the Internet, particularly in developing countries, may result in medication packaging with an increased risk of coring (1).
Although coring is most likely a low-frequency event, other reports of coring (3,4) as well as patent applications for needles that prevent coring suggest that coring continues to occur and is a problem that has not been completely solved.

 

[BLADEMDA]

http://resources.metapress.com/pdf-preview.axd?code=xwy7d2u70d1c1lt9&size=largest

Coring is a problem with 20 ml vials of propofol as well

 

[BLADEMDA]

 

[Mr Wizard]

Coring is a problem with Propofol Vials. I have seen it many times in the syringes of CRNAs. Needles equal to or larger than 18G can cause coring of the rubber into the propofol solution. So, either use a smaller needle than 18G or a filter needle. Anyone else noticed this same issue?

This potential problem led my department in residency to switch to blunt-fill needles to try to decrease coring. We had 18G blunt-fill needles and then smaller short-bevel needles kept in the anesthesia carts. There have been subsequent case reports of coring with propofol vials when using the blunt cannulas so I actually wonder how effective blunt needles decrease this risk. I have never witnessed it with the blunt-fill needles though.

 

[BLADEMDA]

The answer to the CORING issue of Propofol Vials is simply to use 18G needles with a filter. Yes, these needles are a pain to use compared to a regular 18G needle due to their filter which slows the rate of drawing up the medication; but, I use them the majority of the time to draw up propofol:

 

[speicte]

I go right through the tatoos. Never heard of anyone having an issue, but you could probably get sued for not putting one in.

As far as coring, I have had multiple instances of blunt-tip plastic needle punching a 'core' and then having either difficulty filling the syringe b/c it blocks the blunt-tip or the core can go into the syringe. You have to be careful.

 

[DrN2O]

Tattoo helps you--let you know where the midline used to be. Saved me more than one.

 

[Bertelman]

Tattoo helps you--let you know where the midline used to be. Saved me more than one.

I wouldn't count on it.

 

[pgg]

Maybe it's reckless of me to blow this off, but I'm going to blow this off.

I think it's silly to worry about tattoos. We're painting the patient's back with neurotoxic betadine or chlorhexidine and driving a needle through that fresh unbound liquid. Pigment bound to the dermis seems an odd thing to worry about.

As for coring ... the needle gets introduced with a stylet in place. Comparing that risk to puncturing a rubber propofol vial stopper with a stylet-less cutting needle doesn't make sense.


I'll generally work around tattoos if it's not too much trouble because I think it's a little rude to deliberately put even a 1/17" scar on someone's treasured expression of snowflake-uniqueness, but I wouldn't give it a second thought if that's where the needle needed to go.

 

[BLADEMDA]

Maybe it's reckless of me to blow this off, but I'm going to blow this off.

I think it's silly to worry about tattoos. We're painting the patient's back with neurotoxic betadine or chlorhexidine and driving a needle through that fresh unbound liquid. Pigment bound to the dermis seems an odd thing to worry about.

As for coring ... the needle gets introduced with a stylet in place. Comparing that risk to puncturing a rubber propofol vial stopper with a stylet-less cutting needle doesn't make sense.


I'll generally work around tattoos if it's not too much trouble because I think it's a little rude to deliberately put even a 1/17" scar on someone's treasured expression of snowflake-uniqueness, but I wouldn't give it a second thought if that's where the needle needed to go.

I avoid the tattoo area if at all possible so the tiny scar doesn't mess up the art work. It is simply a courtesy to the patient.

I also agree the the prep solution is neurotoxic and more of an issue than the stable ink pigment.

The "experts" recommend we make a nick in the skin prior to inserting our Epidural needle. Is this really necessary? Where is the data for this recommendation?