Spinal suggestions

[CaliDreamin4Life]

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Lately struggling with a few spinals, especially in obese pregnant population. Any tips for difficult spinals....positioning? What's your go to secondary needle? Any suggestions appreciated.

Secondly, I never used anything but hyperbaric bupivicaine in residency. When and why in your practice do you use isobaric bupivicaine...what are clinical situations in which this has an advantage? Thanks!

 

[BobBarker]

We have a 22g 3.5" pencil point that works well in that population. So thick you don't need an introducer.

 

[BuzzPhreed]

I find that even with the larger bore spinal needles that are pencil point it's still hard to get through the layers. Usually I start with a 18g needle to "nick" the entrance point. Overall the risk is still very low for PDPH when you use a non-cutting needle (PenCan, Whitacre, Sprotte, GertieMarx, etc.) in my experience.

As far as isobaric vs. hyperbaric, you can experiment. Currently using a lot of mepivicaine in short urologic cases. Haven't yet used it in OB. I think the key in OB is to use intrathecal fentanyl (usu. 20mcg) and this makes a big difference especially if your OB routinely externalizes the uterus for repair.

 

[BobBarker]

I do this only in very difficult ones but first access the epidural space with a touhy then proceed with spinal anesthetic per routine using the tuohy as a long introducer so to speak. Bigger, stiffer tuohy needle provides much better tactile feedback than spinal needles.

 

[Impromptu]

I have similar advice.

For positioning, I tell them the traditional things, like lower your shoulders, lower your head, push your low back out against where you feel me pushing, visualize it like a mad cat, a shrimp, or an old lady knitting. A low, soothing voice helps reassure them. Tell them you understand it is tough to get into that position with a baby in the way. I count down from 10 with the numbing medicine, but always count slow enough so that I finish on 2 or 3.

In our kit is the 24 G Pencan needle. I try and use that one, smaller hole with a pencil point may lead to fewer spinal headaches.

For placement my first trick is to use the 22 G needle with the local anesthetic to try and gauge where your angle of attack should be. You can even leave that needle pointing the way until you can grab your introducer to take its place.

Second, have them give you feedback as you are advancing. Left or right.

Third trick is the 22 G without an introducer for more tactile feel.

Fourth trick is to use the epidural needle. I put in far more epidurals and can usually find the epidural space in seconds, even in the morbidly obese. Once you are in the epidural space, you are mere millimeters away from your goal.

Last trick, on those whom you think you are getting into the space but are failing to see spinal fluid, you can provide gentle aspiration.

Be a salesman, tell them how well they did, that their positioning was an integral part of getting it done quickly (not a lie). Much of their post memories of the experience can be influenced by you, your empathy and encouragement. Do this for the whole procedure, because having abdominal/pelvic surgery while wide awake can be very stressful, and they are likely to have high regard for you afterward. Maybe even name the child after you...hasn't happened yet, but it might.

 

[deleted162650]

For positioning (either spinals or epidurals) try having the pt sit cross-legged "Indian style." It is much easier to curl up and round out ones back this way as oposed to having your legs off the side of the bed/table. Try it yourself sometime.

 

[BuzzPhreed]

For positioning (either spinals or epidurals) try having the pt sit cross-legged "Indian style." It is much easier to curl up and round out ones back this way as oposed to having your legs off the side of the bed/table. Try it yourself sometime.

Ha ha. Good one. You obviously haven't seen our patient population. No way in hell they're going to sit indian style.

 

[deleted162650]

Ha ha. Good one. You obviously haven't seen our patient population. No way in hell they're going to sit indian style.

Trust me, our labor deck sees an average BMI north of 35 with LOR commonly in the 7-8cm range. You'd be surprised how many can still sit that way comfortably. Even if they can't try having them put their feet up on a chair or stool. Getting those knees up a little and taking the (often substantial) weight from gravity off the legs does wonders for rounding out the back.

 

[Gimlet]

Trust me, our labor deck sees an average BMI north of 35 with LOR commonly in the 7-8cm range. You'd be surprised how many can still sit that way comfortably. Even if they can't try having them put their feet up on a chair or stool. Getting those knees up a little and taking the (often substantial) weight from gravity off the legs does wonders for rounding out the back.

Agreed. This is my go-to trick for people who just aren't getting it with the positioning. It gets their pelvis tilted back so they can round out their lumbar spine without as much thoracic hunching. The young'ns having babies can almost all sit this way...I don't ask my elderly TKA and THA patients to do it, though!

We have a 22g 3.5" pencil point that works well in that population. So thick you don't need an introducer.

Wow, 22 seems big to use on the non-elderly in terms of PDPH risk. I only use them on 70+ year olds with creaky backs. Our kits have a 24g Sprotte and I was disappointed to hear it wasn't a 25 like I trained with. Then again, I had a lady come in for a blood patch who I had done a labor CSE with a 27g for the subarachnoid dose...no wet tap with the Tuohy from what I could tell (and the catheter threaded epidurally, obviously). So who knows.

I hear you about the 22 being sturdy, though...pretty sure you could perform a trans-laminar spinal with them if you pushed hard enough!

 

[ranvier]

I like the cross legged technique. Much easier to reverse the lumbar lordosis due to a posterior pelvic tilt. (I was a PT before med achool)

 

[BuzzPhreed]

Trust me, our labor deck sees an average BMI north of 35 with LOR commonly in the 7-8cm range. You'd be surprised how many can still sit that way comfortably. Even if they can't try having them put their feet up on a chair or stool. Getting those knees up a little and taking the (often substantial) weight from gravity off the legs does wonders for rounding out the back.

Well, that's different. And something we do routinely.

 

[BuzzPhreed]

I hear you about the 22 being sturdy, though...pretty sure you could perform a trans-laminar spinal with them if you pushed hard enough!

That's what we have Neurologists for. And of course without fail it's a Quincke. Most of the blood patches I do this is the combo that led to it.

 

[bostonblaz]

I have only had to do it a few times for very difficult people that my CRNA and fellow anesthesiologist had failed. You need a fair amount of local and a large skin wheel. I walk up the sacrum as no matter how mushy/fat the person is you can feel the sacrum. The l5/s1 space is the largest of all spaces and very easy to get into no matter how poorly they are positioned. It is mildly uncomfortable for them when you walk up the sacrum but it hasn't failed me yet. Blaz

 

[Urzuz]

I have only had to do it a few times for very difficult people that my CRNA and fellow anesthesiologist had failed. You need a fair amount of local and a large skin wheel. I walk up the sacrum as no matter how mushy/fat the person is you can feel the sacrum. The l5/s1 space is the largest of all spaces and very easy to get into no matter how poorly they are positioned. It is mildly uncomfortable for them when you walk up the sacrum but it hasn't failed me yet. Blaz

Can you describe this technique in a little bit more detail (the steps you take in palpating, where you deposit local, where you start out pointing your tuohy, etc)? Seems like something that would be good to have in my back pocket...

 

[napman]

Can you describe this technique in a little bit more detail (the steps you take in palpating, where you deposit local, where you start out pointing your tuohy, etc)? Seems like something that would be good to have in my back pocket...

Taylor Approach
The Taylor, or lumbosacral, approach to spinal anesthesia is a paramedian approach directed toward the L5-S1 interspace. Due to the fact that this is the largest interspace, the Taylor approach can be used when other approaches are not successful or cannot be performed. As with the paramedian approach, the patient can be in any position for this approach: sitting, lateral, or prone.
Clinical Pearls

The needle should be inserted 1 cm medial and inferior to the posterior superior iliac spine, then angled cephalad 45-55 degrees.

This should be medial enough to reach the midline at the L5 spinous process.

After needle insertion, the first significant resistance felt is the ligamentum flavum.
The needle should be inserted at a point 1 cm medial and inferior to the posterior superior iliac spine, then angled cephalad 45-55 degrees. This should be medial enough to reach the midline at the L5 spinous process. After needle insertion, the first significant resistance felt is the ligamentum flavum, and then the dura mater is punctured to allow free flow of CSF as the subarachnoid space is entered. Figure 15 shows the Taylor approach to spinal anesthesia.

Figure 15: The Taylor approach to spinal anesthesia. The needle is inserted 1 cm medial and inferior to the posterior superior iliac spine, then angled cephalad 45–55 degrees.

 

[GasEmDee]

I put the patients legs up on a stool. If I can't feel any spinous landmarks, I find the epidural space with a Tuohy needle and LOR to air, being careful not to inject too much after finding the loss, so as not to push the dura away. Then I insert the long tuohy needle.

 

[CaliDreamin4Life]

Thanks all for the replies! For those who are using Touhy needles to find epidural space, what size and tip spinal needle do you use through this? I want to check if we have those in stock...

 

[CaliDreamin4Life]

Taylor Approach
The Taylor, or lumbosacral, approach to spinal anesthesia is a paramedian approach directed toward the L5-S1 interspace. Due to the fact that this is the largest interspace, the Taylor approach can be used when other approaches are not successful or cannot be performed. As with the paramedian approach, the patient can be in any position for this approach: sitting, lateral, or prone.
Clinical Pearls

The needle should be inserted 1 cm medial and inferior to the posterior superior iliac spine, then angled cephalad 45-55 degrees.

This should be medial enough to reach the midline at the L5 spinous process.

After needle insertion, the first significant resistance felt is the ligamentum flavum.
The needle should be inserted at a point 1 cm medial and inferior to the posterior superior iliac spine, then angled cephalad 45-55 degrees. This should be medial enough to reach the midline at the L5 spinous process. After needle insertion, the first significant resistance felt is the ligamentum flavum, and then the dura mater is punctured to allow free flow of CSF as the subarachnoid space is entered. Figure 15 shows the Taylor approach to spinal anesthesia.

Figure 15: The Taylor approach to spinal anesthesia. The needle is inserted 1 cm medial and inferior to the posterior superior iliac spine, then angled cephalad 45–55 degrees.

Are you using the introducer needle for this approach?

 

[napman]

Are you using the introducer needle for this approach?

The only time I used it was in a older lady for hip. I used a 22g pencile point with out an introducer

 

[napman]

I had to used pre procedural ultrasound to identify intervertibral space in morbidly obese patient couple of times. Is any one using US routinely for neuraxial blocks?

 

[Triple AAA]

Secondly, I never used anything but hyperbaric bupivicaine in residency. When and why in your practice do you use isobaric bupivicaine...what are clinical situations in which this has an advantage? Thanks!

I was wondering about this as well, particularly after the recent thread with the bad Marcaine and failed spinals. I would think Isobaric Marcaine would be just as reliable as hyperbaric, with less chance of a sympathectomy. I also have not used it for OB, but would be interested in trying it.

 

[RxBoy]

I was wondering about this as well, particularly after the recent thread with the bad Marcaine and failed spinals. I would think Isobaric Marcaine would be just as reliable as hyperbaric, with less chance of a sympathectomy. I also have not used it for OB, but would be interested in trying it.

Only time I use isobaric is when I consider patient positioning for the case. I use it for all hip replacements because you can place the block and not worry about positioning. You also dont have to waste valuable OR time waiting for the hyperbaric to set in one side before you turn the pt with operative hip up.

I disagree about isobaric and sympathectomy. Its more about proper dosing and injection speed. If you do a spinal with 12 mg heavy bup vs 15 mg iso, iso will cause a lot larger drop. If you do a 12 mg heavy vs 12 mg iso, i havent seen much of a difference although the literature argues otherwise. One thing I recently changed is adding fentanyl while using lower bupivicaine doses. As for injection speed, slamming it in will cause much bigger swings. I inject over 30 sec to a minute. I remember reading a study they did it for 5 min but I think thats way too long in a fast turnover private practice OR.

Conversely the greatest advantage to hyperbaric bupivicaine is your ability to control the sympathectomy on sided procedures. A tka with a pt with bad cardiac function... Just do the block in the lateral position with operative knee down and let the hyperbaric set in for 3-5 min before turning. Very minimal cv changes with this approach.

Reasons not to use isobaric... Even the PF bottles clearly states "not for spinal" on the bottles which could potentially have legal ramifications. Second is convenience, much easier to draw up the vial right there in the kit.

 

[deleted162650]

Thanks all for the replies! For those who are using Touhy needles to find epidural space, what size and tip spinal needle do you use through this? I want to check if we have those in stock...

26g Gertie Marx, you could use any spinal needle that's long enough, but this needle was developed specifically for this purpose

I had to used pre procedural ultrasound to identify intervertibral space in morbidly obese patient couple of times. Is any one using US routinely for neuraxial blocks?

I dont use it routinely, but I have a low threshold to bust it out on the right pts. See my post on this issue in the tips and tricks thread.

As far as Iso v Heavy Bupi: Iso is great for orthopedic procedures where you really only need lumbar level coverage. You're injecting at the lumbar level, and it stays there. It's technically very slightly hypobaric so for a hip in the lateral position you'll actually get a little (not too much different) denser block on the operative side without the need to do any repositioning. Hyperbaric is the way to go if you need any thoracic level coverage due to a visceral component to the surgery i.e. most OB situations.

 

[RxBoy]

Lately struggling with a few spinals, especially in obese pregnant population. Any tips for difficult spinals

"Is this gonna hurt?"


Sometimes you gotta just throw a hail mary and wish for the best.

 

[Ronin2258]

"Is this gonna hurt?"


Sometimes you gotta just throw a hail mary and wish for the best.

How did you get pictures of my last c-section patient as a resident?

Position is everything here. That having at least one long spinal needle available.

She at least looks like she has what I call "fluffy fat." That areolar, loose, compressible fat that you can actually feel things through, and possibly feel for the processes and at least get an idea where things are. I can deal with that. I would just remind her I am going to be pushing/feeling for things like a fiend. It beats the "rigid fat;" the dense stuff that you can't feel crap through.

I have been able to get an epidural into one of these types at L2-L3, which gave her good coverage for labor and the inevitable C-section. True, the catheter was in 15cm at the skin, but it worked. That was one of those times the nurse had both hands full: One to hold the patient, the other onto the rosary silently praying I would make it (Catholic hospital.)

Now the last one I did a spinal for a section like that...Think I should present that in the private forum.