Spinal Drain

[sanityonleave]

Hi SDN,

I'd love to hear what you folks are doing for spinal drains in your practice. We have a fairly busy complex TEVAR/FEVAR program and less commonly extent II/III TAAAs for which our surgeons request spinal drainage.

There's not a lot of data about failure/complication rates (except that they're high - failure rates as high as 20%/24h depending on who you believe) so I thought the hive mind might at least have the benefit of anecdata to share.

We've switched to using fluoro for the drain placement, which has made our success rate for placement quite high; however, I'm still seeing quite a few drain failures in the immediate postop period (<24h) - drains stop working without being dislodged. Most of the time there's visible clot obstructing the catheter, but it requires a lot of force to dislodge it (after the cath is removed) -- more than I'm comfortable using with the catheter in situ. We're using the soft silastic catheters, threading ~10cm into the intrathecal space under fluoro guidance.

Anyone have best practices from their experience? Any troubleshooting tips? I've chatted with our neurosurgeons but it's a rare procedure for them as well so I haven't been able to glean much.

Are you guys placing these the day before or day of? Turfing them to IR or NSGY?

Thanks in advance.

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[ERRES2288]

Neurosurgery places ours in OR after induction

 

[nimbus]

Part of the problem is that the catheters are so soft that they get pinched or kinked by bony structures very easily. I advance them pretty far too…6-10 cm beyond the tuohy tip. When a previously working catheter stops working, I’ve had luck with taking the dressing off and pulling the catheter back 1-2cm. Often this will get them to start draining again.

We do them the day of surgery in the OR, patient awake and sitting is easiest for me. I don’t use fluoro.


At my hospital, IR actually does all the TEVARs with cardiac surgery helping with groin access and closure. I once had a 450lb Samoan patient who needed TEVAR. Case was elective so I asked one of the IR guys put the drain in under fluoro for me. I didn’t want to be harpooning in no man’s land. The IR doc had never done one before so I helped him get oriented to the kit, told him about the importance of the stylette, etc. We did it the day before the TEVAR in the IR suite under fluoro in prone position with GA. He finally got into the csf space after hubbing and pressing the 14g tuohy. Team work makes the dream work.

 

[woopedazz]

We place them pre-induction in OT

 

[vector2]

Hi SDN,

I'd love to hear what you folks are doing for spinal drains in your practice. We have a fairly busy complex TEVAR/FEVAR program and less commonly extent II/III TAAAs for which our surgeons request spinal drainage.

There's not a lot of data about failure/complication rates (except that they're high - failure rates as high as 20%/24h depending on who you believe) so I thought the hive mind might at least have the benefit of anecdata to share.

We've switched to using fluoro for the drain placement, which has made our success rate for placement quite high; however, I'm still seeing quite a few drain failures in the immediate postop period (<24h) - drains stop working without being dislodged. Most of the time there's visible clot obstructing the catheter, but it requires a lot of force to dislodge it (after the cath is removed) -- more than I'm comfortable using with the catheter in situ. We're using the soft silastic catheters, threading ~10cm into the intrathecal space under fluoro guidance.

Anyone have best practices from their experience? Any troubleshooting tips? I've chatted with our neurosurgeons but it's a rare procedure for them as well so I haven't been able to glean much.

Are you guys placing these the day before or day of? Turfing them to IR or NSGY?

Thanks in advance.

Our TAA surgeon is gone and before that the volume wasn't high anyway (and thus the number of people who had expertise with spinal drains wasn't high), but we turfed to neurosurgery after induction for the very reasons you described. We couldn't have the ICU nurse blowing up our board runner or trauma doc's phone every 5 minutes for every little drainage complication that occurred postop.

 

[DrZzZz]

We have pretty low volume, probably 10-15 drains/yr. If it's a vascular case, we place it. There's no standard procedure for where it's done - preop, in the OR awake sitting, or in the OR asleep and lateral. Each doc does it differently. If it's a neurosurgery case, the neurosurgeon places it in the OR asleep. In either scenario, we do not manage the drains. Calls get directed to the neuro or vascular surgeon who did the case. We do check the drains daily purely for site infection and will remove the drain at surgeon request.

 

[Beeftenderloin]

TEVARs get drain placed by NSGY in OR after induction, prior to start of procedure. For open thoracoabdominals, we had one too many open cases get delayed by bloody taps due to fear of spinal hematoma once they get heparinized for bypass. Now they get their drain placed by NSGY in OR day before surgery. Also, as above, this practice prevents us from get paged with questions/complications.

 

[Lecithin5]

We have pretty low volume, probably 10-15 drains/yr. If it's a vascular case, we place it. There's no standard procedure for where it's done - preop, in the OR awake sitting, or in the OR asleep and lateral. Each doc does it differently. If it's a neurosurgery case, the neurosurgeon places it in the OR asleep. In either scenario, we do not manage the drains. Calls get directed to the neuro or vascular surgeon who did the case. We do check the drains daily purely for site infection and will remove the drain at surgeon request.

Nice- what’s your secret to having all drains be managed by neuro/vasc? It’s the exact opposite here. Obviously the ones we place we manage. But somehow we also end up managing everybody else’s drains/complications, including ones placed by neurosurgery and interventional radiology. I know, it makes absolutely no sense (the excuse is that in the middle of the night, we’re the only ones that are consistently available…).

 

[DirtDocMD]

We leave those to the neurosurgeons. Their surgery (surgical site), their problem.

Little to no need from our vascular surgeons, but if needed, we’d turf to IR...

 

[DrZzZz]

Nice- what’s your secret to having all drains be managed by neuro/vasc? It’s the exact opposite here. Obviously the ones we place we manage. But somehow we also end up managing everybody else’s drains/complications, including ones placed by neurosurgery and interventional radiology. I know, it makes absolutely no sense (the excuse is that in the middle of the night, we’re the only ones that are consistently available…).

I wish I knew. Was like that before I arrived and I'd certainly like it to continue that way.

 

[woopedazz]

We leave those to the neurosurgeons. Their surgery (surgical site), their problem.

Little to no need from our vascular surgeons, but if needed, we’d turf to IR...

They place all your epidurals too? 😜

 

[drmwvr]

They place all your epidurals too? 😜

Your epidurals drain CSF?😜

 

[Iso4ane]

Your epidurals drain CSF?😜

They will...if I want the too.

 

[nimbus]

Your epidurals drain CSF?😜

One of my funny partners says, “If you can do a wet tap on L&D, then you can do a lumbar drain. I was the wet tap king during residency, so I am an expert on lumbar drains.” 😂

 

[sanityonleave]

One of my funny partners says, “If you can do a wet tap on L&D, then you can do a lumbar drain. I was the wet tap king during residency, so I am an expert on lumbar drains.” 😂

I have been known to joke occasionally when we're struggling with a lumbar drain, "We should send them up to L&D - one of the junior residents could put this in for us in a heartbeat."

 

[Iso4ane]

I have been known to joke occasionally when we're struggling with a lumbar drain, "We should send them up to L&D - one of the junior residents could put this in for us in a heartbeat."

I have a partner that suggested if you can’t get a lumbar drain, just do a wet tap epidural, it won’t drain as quickly, but could be good enough if you’re dead set on draining fluid.

 

[DrN2O]

For those that had the drain placed the day before, where does the patient go over night? ICU? I think placement under fluoro in anatomically challenging patient is best, but they have to go to the ICU here.

 

[Arch Guillotti]

For those that had the drain placed the day before, where does the patient go over night? ICU? I think placement under fluoro in anatomically challenging patient is best, but they have to go to the ICU here.

Stupid question but why the ICU?

 

[nimbus]

Stupid question but why the ICU?

We generally don’t place them the day before but I think it would be fine to go to the floor if the drain is capped or clamped and clearly labeled. The case I posted above was already in ICU due to esmolol drip.

 

[Lecithin5]

Stupid question but why the ICU?

It’s (mostly) silly to me, but any person with a drain (regardless if capped and not draining/transducing) at our hospital goes to icu as well. Partly because of unfamiliarity with them by nurses (but they’re capped, so who cares!), but mostly in the event they become uncapped or disconnected and they start leaking suddenly etc. Still, I think that even if that were to happen, all a floor nurse has to do is call quickly for help. But I guess the close monitoring of an ICU makes everyone feel better.

 

[Beeftenderloin]

For those that had the drain placed the day before, where does the patient go over night? ICU? I think placement under fluoro in anatomically challenging patient is best, but they have to go to the ICU here.

The lumbar drain alone isn’t an ICU indication at our hospital. These patients get their drain with NSGY in OR under MAC, then go to the floor once they clear PACU, unless a higher level of care is indicated for some other reason.

 

[vector2]

For those that had the drain placed the day before, where does the patient go over night? ICU? I think placement under fluoro in anatomically challenging patient is best, but they have to go to the ICU here.

Depends on the institution. We do so few that even the ICU can be a dangerous place. A pt once had a cerebellar stroke at my shop because the drain was "sluggish" so the nurse thought it would be a good idea to lower the drain the gravity, leave, and then do god knows what for 20 minutes while a waterfall of CSF exited the pt's body. This was despite the fact that they're essentially not supposed to touch the thing and call NSGY for any q's

 

[sanityonleave]

For those that had the drain placed the day before, where does the patient go over night? ICU? I think placement under fluoro in anatomically challenging patient is best, but they have to go to the ICU here.

All of ours go to the unit overnight if they're placed preop. I guess if you just clamped it overnight it would probably be fine (though there's always the risk of disconnection), but we tend to drain a few gtts q1h for patency. I'd be pretty reluctant to send them to the floor.

For NSGY procedures, they place their own drain. We're only placing them for vascular / CT surg.

 

[Onefellswoop87]

Unless at an institution that does this regularly, I think the unit is the best place for these drains.

One time I placed an intrathecal catheter for a laboring patient after a wet tap. I labeled the catheter, the pump and a sign on the door with something to the extent of “intrathecal catheter, anesthesia to remove,” so of course the labor and delivery nurse disconnected it from the bupivicaine bag so it drained CSF on to the new mom’s pillow. But it’s ok, she followed directions as I was the one that removed the catheter from the patient. That was a fun educational session to new mom and the charge nurse.

I see the possibility for more potential badness with a spinal drain before/after a big surgery if not in an ICU.

Work and instruct towards the lowest common denominator

 

[The Duck Knows]

Ours also go to the unit. Before COVID I thought this was lame and hated the 2-3 beds taken up by otherwise stable patients with drains. Now we have such new nurses (even in the ICU) that I’m borderline neurotic on anything with this level of potential downside. Having a new ICU nurse leave an art line stopcock open and finding a blood-soaked chuck on morning rounds certainly didn’t help. Giving a few units of blood and filing a safety report is one thing. An iatrogenic herniation is another.

 

[OB1🤙]

For TEVAR, we put them in awake in the OR and manage them postop. It is an ongoing nightmare but safest for the patients that we maintain control over the process.

Neurosurgery is its own thing, those surgeons place and manage them and that’s the way it should be.

 

[DrN2O]

Never underestimate the creative ignorance/stupidity of people. Catheter gets uncapped/unclamped. Meds get injected. That's why at a lot of places they go to a specialized unit that is familiar with the drain. Also, do these drains get capped overnight, or do you drain to keep it open? The arrow epidural wired catheter gets kinked and clotted very easily, but does the bigger siliconized drain also clot?

 

[cchoukal]

We rarely do them the day before (sometimes the patient gets pre-admitted and if they're just hanging around the ICU...), but usually on the day of surgery. We use a dedicated device with a larger and more pliable catheter, which is styleted (if anyone cares, I can dig up the brand/item # tomorrow). I only do a handful a year, but they all seem to go in easily and I don't believe any have failed post-op. I recall a very high failure rate for the Braun epidural catheter when used for this purpose.