Post LP Headache

[EM2013]

So in my ER, I'm pretty sure we are using 18g needles with the "cutting" style tip. I've been rotating on Anesthesia and they've basically lambasted me for not instead grabbing a 20 or 22 g "pencil point" tipped needle that is outside of the kit as they claim it reduces post-LP/spinal headache. I know that some literature has found a decrease in headache with using these "pencil point" tips but how applicable this is to the ED? I was wondering what people thought about this and what you do in your own practice.

My own take is that:

1) Using 20-22 g needles would make the procedure painfully slow .

2) If we are doing an LP, the patient most likely has a headache to begin with.

3) If they are sick enough that we are doing an LP, they most likely are going to be spending 2-3 days supine anyway which will eliminate any spinal headache.

Any thoughts / links to landmark literature on the topic would be greatly appreciated!

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[Siggy]

1) Using 20-22 g needles would make the procedure painfully slow .

2) If we are doing an LP, the patient most likely has a headache to begin with.

3) If they are sick enough that we are doing an LP, they most likely are going to be spending 2-3 days supine anyway which will eliminate any spinal headache.

Any thoughts / links to landmark literature on the topic would be greatly appreciated!

1. Can't comment on this.

2. If you can avoid worsening or extending the time frame of the spinal headache shouldn't you do so?

3. Not always. Not doing timely blood patches for patients with spinal headaches was a point of contention with both one of my IM attendings and one of my OB/Gyn attendings.

 

[deleted109597]

1. So what. Do what's right. Do to patients what you would want done to you.
2. When we reduce fractures, their bone already hurts. Doesn't mean we should make it hurt more just because we can.
3. Laying down does not prevent spinal headaches.

Whitacre (and other) needles require a different skill set than Quinke needles. EPs are not very good at them yet, I hope they get better in the future.

 

[dotcb]

Use a 22G needle

I've tried both types of needle and they're both easy to use. My shop only has standard (cutting) needles. I've never had a patient of mine have a post LP HA that I was aware of. My colleagues likely would contact me if this did happen.

Do what you can to minimize this problem, but experientially it is a small problem.

 

[Bostonredsox]

I use 20g for all my floor and Ed LPs. I usually use the 18 in the kit for those in the unit as they're usually sedated and pleasantly enjoying the benefits of mechanical ventilation. The data isn't great but it really is not any more difficult with a 20 then an 18 in my experience.

 

[deleted109597]

I use 20g for all my floor and Ed LPs. I usually use the 18 in the kit for those in the unit as they're usually sedated and pleasantly enjoying the benefits of mechanical ventilation. The data isn't great but it really is not any more difficult with a 20 then an 18 in my experience.

It's not the difference in a 20 vs 18. It's the difference in blunt vs cutting. Blunts can require a skin nick with an 18 so they can pass through.
As far as 18s causing PDPHA, incidence is pretty close to 50% based on most studies. Just because people don't come back doesn't mean they aren't happening.

 

[B-Bone]

I routinely use a 25 or 27 for spinal anesthetics, so when I do go to a 22 (all pencil-point needles, btw), I feel like the CSF is rushing back at me. I have never seen a PDPH from a spinal anesthetic with a pencilpoint 22g or smaller. please do your patients (and whoever does your blood patches) a favor and use a 22g pencilpoint. If you don't have one handy (a common complaint in the ED), just ask your local anesthesiologist and he'll give you a boxfull (and think you're the bomb for even thinking about it).

 

[EM2013]

Thanks for all the advice! These tips are good to know for when I start internship in June!

 

[Tiger26]

I routinely use a 25 or 27 for spinal anesthetics, so when I do go to a 22 (all pencil-point needles, btw), I feel like the CSF is rushing back at me. I have never seen a PDPH from a spinal anesthetic with a pencilpoint 22g or smaller. please do your patients (and whoever does your blood patches) a favor and use a 22g pencilpoint. If you don't have one handy (a common complaint in the ED), just ask your local anesthesiologist and he'll give you a boxfull (and think you're the bomb for even thinking about it).

Agree with B-Bone

1) The data is pretty well established that smaller needles reduce post-LP headaches

2) Post-LP headaches seem like they really hurt, so why not try to avoid them

3) If you can't get a successful LP with a 22g pencil tip Whitacre needle, you need to get better at doing LPs.

4) As Ninja said, lying supine seems to have no correlation in the literature with post-LP headache risk

 

[southerndoc]

We do a LOT of LP's at my hospital, and most of us use pencil tip needles.

 

[Rendar5]

I've tried pencil-point needles, but for some reason have had bad luck with them (yes I do the nick first) except for the very first time I used one. so any tips would be greatly appreciated. I usually reach for a 20 or 22g cutting needle and would not touch an 18g with a 20 foot pole.

 

[EM2BE]

We use Whitacres at my hospital. I found if you get caught using the cutting needle by attendings, you will get yelled at. Intern lessons learned early on. Now I couldn't imagine using the cutting needle. I've used 25 gauge on babies/small children, but 22 gauge otherwise. And I've had to use our "OB" needles on occasion due to obesity.

 

[EM2BE]

I've tried pencil-point needles, but for some reason have had bad luck with them (yes I do the nick first) except for the very first time I used one. so any tips would be greatly appreciated. I usually reach for a 20 or 22g cutting needle and would not touch an 18g with a 20 foot pole.

I found it's a completely different feel. The cutting needle you can just enter without much of a problem. The Whitacre at first makes you feel like you keep hitting bone when you actually hit ligaments that you have to pass through. After I got used to the difference in feel, it was much easier to do.

 

[Tiger26]

I found it's a completely different feel. The cutting needle you can just enter without much of a problem. The Whitacre at first makes you feel like you keep hitting bone when you actually hit ligaments that you have to pass through. After I got used to the difference in feel, it was much easier to do.

Agree--it's a little different feel.

Either way, the way I look at LPs is that if you're confident you're lined up right and you're not getting anything, then you just need to go in further.

One of the other things I do is get more lido than what the kit has--typically put in 4-8 cc, which I think theoretically opens up that space somewhat.

Also, I use a sharpie to mark down the entire vertebra and the iliac crests (like how anesthesia marks out sites for nerve blocks in the OR), which keeps me more aware after the patient is prepped and draped. For what it's worth, a sharpie is just as sterile, if not more so, than a surgical marker.

 

[EM2BE]

Agree--it's a little different feel.

Either way, the way I look at LPs is that if you're confident you're lined up right and you're not getting anything, then you just need to go in further.

One of the other things I do is get more lido than what the kit has--typically put in 4-8 cc, which I think theoretically opens up that space somewhat.

Also, I use a sharpie to mark down the entire vertebra and the iliac crests (like how anesthesia marks out sites for nerve blocks in the OR), which keeps me more aware after the patient is prepped and draped. For what it's worth, a sharpie is just as sterile, if not more so, than a surgical marker.

Forgot to mention about the extra lidocaine. I use 10cc on an adult.

 

[Daiphon]

Forgot to mention about the extra lidocaine. I use 10cc on an adult.

Use lido w/epi... local vasoconstriction cuts down on the RBCs & maximizes your chance of getting a bottle out of your attending. d=)

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[Rendar5]

I've had 5 or 6 champagnes during residency, but never with the Peds/ED attending who would actually give them out. The only one I had as an attending this year, I gave myself some bubbly (which was weird because the pt was bleeding like a stuck pig from the lido injection and I had to hold pressure for a full 30 seconds after the LP needle came out).

 

[EM2BE]

Use lido w/epi... local vasoconstriction cuts down on the RBCs & maximizes your chance of getting a bottle out of your attending. d=)

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I can get lido with bicarb out of a cart. Most of the time lido with epi is in the pixis. It's just easier to go without epi most of the time. I've gotten 4 bottles this year. Some attendings don't give out bottles or I'd have more.

 

[Daiphon]

I've had 5 or 6 champagnes during residency, but never with the Peds/ED attending who would actually give them out. The only one I had as an attending this year, I gave myself some bubbly (which was weird because the pt was bleeding like a stuck pig from the lido injection and I had to hold pressure for a full 30 seconds after the LP needle came out).

Then you have cheap attendings. Some people have no sense of tradition...

I can get lido with bicarb out of a cart. Most of the time lido with epi is in the pixis. It's just easier to go without epi most of the time. I've gotten 4 bottles this year. Some attendings don't give out bottles or I'd have more.

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[Tiger26]

Use lido w/epi... local vasoconstriction cuts down on the RBCs & maximizes your chance of getting a bottle out of your attending. d=)

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I do this too--I routinely get champagne taps using lido with epi. Maybe it's just voodoo but it seems to work for me

 

[Xerxes1729]

I don't think I've even seen an 18g spinal needle. I feel bad when we're out of 22g and I have to use a 20g.

 

[Birdstrike]

It is not so clear cut as Anesthesiologists try to make it seem, at times. It's easy to say, "Use a smaller bore needle." They spend a lot of time doing labor epidurals, peri-operative epidurals, etc, many of which are elective. Their goal to avoid a wet tap always (unless doing a spinal, obviously). They also don't want to have you calling constantly, asking them to patch your dural punctures, when they have other work to do.

On the other hand, in the ED, the goal is to get a "wet tap" every time, and an ED LP is by definition, not elective. You want to get CSF. That's the whole point of the procedure. You want to get the LP quickly, reliably and get it every time. You need to know if the patient is dying of bacterial meningitis or SAH. You have to know. Yet, you want to reduce the risk of post dural puncture headache if you can, of course. So if you are using a 20 gauge needle, you should use a 22, right? Well, if you are using a 22, why don't you use a 25? Well, then someone comes along a says, "I use a 27, I've only had one patient that needed a blood patch, in 30 years." Then along comes Poindexter who counters with, "You're an idiot, I use 30 gauge spinal needles. I've never had a patient with post dural puncture headache."

So you try the 30 gauge and it's like trying to get an LP with a wet noodle and the CSF takes 6 hours to drip out, and you're LP failure rate is huge and now IR is irritated because you're constantly calling them for LPs under fluoro. That's no ideal, either.

So you have to balance ease and efficiency of performing the procedure (large bore/lower gauge = greatest ease and efficiency) versus lowest complications rate (smaller bore/higher gauge = less risk of post dural puncture headache). If you are comfortable doing LPs with a very small bore (25-27 gauge) pencil point, then use one. If not, use what you need to use to get the LP. (Though, I must say an 18 gauge is huge for an LP, probably overkill and makes a significant hole in the dura). In the ED, you are not doing an LP for kicks and giggles. You're doing one to determine if your patient could be at risk of dying. You don't have the option of "cancel case".

Like lots of things in Medicine, many of these questions haven't been definitively answered. Here's a study that's looking to answer this question.