TEVAR drain

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anbuitachi

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Recently saw a board practice question about lumbar drains in TEVAR and the recommendation is to postpone the case if it was a traumatic lumbar drain placement due to lots of heparinization and a very high risk of epidural hematoma.

Just wondering what people do in their practice. It's not that uncommon to see blood tinged CSF especially with a 14 g needle. Also occasionally see the red blood presumedly from an epidural vein you hit. When do you guys actually tell the surgeon you are cancelling cause you hit a vein??
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IME it is very uncommon to see blood. Whenever possible I sit them up so I know I’m midline, LOR to NS, then stylette back in. Puncture the dura which is very easy to feel because you get a lot of tactile feedback with the big needle. I’ve been doing 1-2 per month for the last 5+ years and haven’t had to cancel one yet. All of them were big gushes of clear CSF. I do get a paresthesia almost every time I advance the catheter and warn the patients ahead of time.
 
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nimbus said:
IME it is very uncommon to see blood. Whenever possible I sit them up so I know I’m midline, LOR to NS, then stylette back in. Puncture the dura which is very easy to feel because you get a lot of tactile feedback with the big needle. I’ve been doing 1-2 per month for the last 5+ years and haven’t had to cancel one yet. All of them were big gushes of clear CSF. I do get a paresthesia almost every time I advance the catheter and warn the patients ahead of time.
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Why bother to get LOR?
 
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If CSF is not completely clear, case cancelled and delayed until next day.

If there’s a tiny tinge or blood we’ll drain more CSF then make sure it clears up.
 
nimbus said:
IME it is very uncommon to see blood. Whenever possible I sit them up so I know I’m midline, LOR to NS, then stylette back in. Puncture the dura which is very easy to feel because you get a lot of tactile feedback with the big needle. I’ve been doing 1-2 per month for the last 5+ years and haven’t had to cancel one yet. All of them were big gushes of clear CSF. I do get a paresthesia almost every time I advance the catheter and warn the patients ahead of time.
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really? i feel like tactile is not that great especially in these old sclerotic backs
 
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Pitfalls?

I know one tip is don’t pull catheter back against a static needle (sheer).
 
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anbuitachi said:
Recently saw a board practice question about lumbar drains in TEVAR and the recommendation is to postpone the case if it was a traumatic lumbar drain placement due to lots of heparinization and a very high risk of epidural hematoma.

Just wondering what people do in their practice. It's not that uncommon to see blood tinged CSF especially with a 14 g needle. Also occasionally see the red blood presumedly from an epidural vein you hit. When do you guys actually tell the surgeon you are cancelling cause you hit a vein??
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Studying for oral boards and I've seen contradicting statements over this between UBP, OCD lectures, and Jensen. Any official guidelines or evidence one way or the other?
 
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It should be very uncommon to see blood tinged CSF IMO.

I have postponed cases where I've gotten frank dripping blood out of the needle. Small heme, meh, shouldn't be a big deal. But if I have a 14g needle in the lumen of an epidural vein, I'll postpone the case a few hours.

I've never used LOR during this procedure. I don't see anything wrong with doing it, but seems unnecessary IMO.
 
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okayplayer said:
One of our vascular guys is asking us to start placing these. Some trepidation among my group (small community practice). Who manages these postop where you are?
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I insist on personally managing these. There is a ton that can go wrong.

Notably, the surgeons used to just drain to some popoff number, which I find dangerous. Excessive drainage can be lethal if it results in an intracranial bleed.

Nowadays if the patient is neuro intact, I don't drain anything. A few CC's an hour to ensure the system is patent, the rest of the time I leave it closed to the transducer for pressure monitoring.
 
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We have standing orders. Typically we drain them to 5-10cm water pressure above the RA in a supine patient depending on how aggressively we want to drain, but no more than 15ml per hour. If the patient sits up we have it clamped.

On occasion, we have had the csf become blood tinged after 2-3 days. At that point I’ll get a head CT to rule out SAH. And as long as the patient is asymptomatic, we just pull it.
 
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If the patient is not manifesting spinal cord ischemia, why drain anything?
 
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Hawaiian Bruin said:
If the patient is not manifesting spinal cord ischemia, why drain anything?
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Prevention? Isn’t the whole point to prevent signs of spinal cord ischemia? If you put it in but don’t drain anything, I would expect a higher incidence of spinal cord ischemia. Why wait until that point?
 
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nimbus said:
We have standing orders. Typically we drain them to 5-10cm water pressure above the RA in a supine patient depending on how aggressively we want to drain, but no more than 15ml per hour. If the patient sits up we have it clamped.

On occasion, we have had the csf become blood tinged after 2-3 days. At that point I’ll get a head CT to rule out SAH. And as long as the patient is asymptomatic, we just pull it.
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I think this is a totally reasonable approach and very similar to what we do here in fellowship. All about prevention, if they show signs of ischemia we push the SCP lower to 2-5.
 
I've never seen a patient wake up without a deficit and go on to develop one later.

IMO the point of this procedure is to have a mechanism in place where IF the patient wakes up with a deficit, then you can rapidly restore SCPP.

Once the patient wakes up and moves their legs, you know that somehow, via some path, enough red blood cells are delivering enough oxygen to the spinal cord. This renders your prophylactic drain unnecessary.

Yeah, keep it in a day just in case. But to my way of thinking, removing CSF in a patient with adequate SCPP and no neuro deficit imparts substantial risk without benefit.
 
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We admit these patients to the ICU night before, place it there and then. Just case there is some blood, we can wait until the morning to use it and not delay the case.
 
Hawaiian Bruin said:
I've never seen a patient wake up without a deficit and go on to develop one later.

IMO the point of this procedure is to have a mechanism in place where IF the patient wakes up with a deficit, then you can rapidly restore SCPP.

Once the patient wakes up and moves their legs, you know that somehow, via some path, enough red blood cells are delivering enough oxygen to the spinal cord. This renders your prophylactic drain unnecessary.

Yeah, keep it in a day just in case. But to my way of thinking, removing CSF in a patient with adequate SCPP and no neuro deficit imparts substantial risk without benefit.
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At our institution we have seen delayed onset paraplegia postop on an open TAAA repair. I personally leave them for 48hrs before I pull. IRRC, delayed-onset paraplegia can occur up to 48 hrs post op.
 
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Open repairs IMO are a little different, with ongoing fluid shifts, BP swings, inflammation etc.

After a TEVAR, in my experience, what you get when you wake up is what you get.

The article I linked above contains recommendations for limiting drainage, it's well worth a read. Not saying my way is the only right way, but it's definitely important to recognize just how easy it is to overdrain when you leave these systems open (I've seen it many times), and just how dangerous that is.
 
Hawaiian Bruin said:
It should be very uncommon to see blood tinged CSF IMO.

I have postponed cases where I've gotten frank dripping blood out of the needle. Small heme, meh, shouldn't be a big deal. But if I have a 14g needle in the lumen of an epidural vein, I'll postpone the case a few hours.

I've never used LOR during this procedure. I don't see anything wrong with doing it, but seems unnecessary IMO.
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I have always done them with 17g epidural tuohy needle and epidural catheter intrathecally.. why are we using 14g? I have seen some fancy kits that dont appear to be doing anything more than the epidural cath is doing.. ami i missing something?
 
Hoya11 said:
I have always done them with 17g epidural tuohy needle and epidural catheter intrathecally.. why are we using 14g? I have seen some fancy kits that dont appear to be doing anything more than the epidural cath is doing.. ami i missing something?
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There's a real lumbar drain kit vs just threading an epidural catheter. The larger lumen and fluffier walls make it easier to get fluid out and not hurt things. It's also meant to be in the CSF, is fully radio-opaque, and is FDA approved to keep in for a while unlike that epidural catheter.
 
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Hawaiian Bruin said:
I've never seen a patient wake up without a deficit and go on to develop one later.
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Just this past year we had a patient wake up normal after TEVAR and he presented 5 days later with new onset paraplegia. He didn't get better. Lumbar drain wouldn't have prevented that one since he had already been sent home, but from my understanding the incidence of delayed onset spinal cord ischemia is higher with TEVAR than open TAA repair so the quoted statement doesn't always ring true.

Incidentally, the above mentioned case brought up an interesting issue for the on call anesthesiologist. Patient had been sent home on Plavix. Presents with paraplegia and vascular wants another spinal drain to salvage function. What do? My most risk averse parter actually wound up replacing the lumbar drain after deciding potential benefit outweighed risk of hematoma complicating the clinical picture.
 
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Gimlet said:
Just this past year we had a patient wake up normal after TEVAR and he presented 5 days later with new onset paraplegia. He didn't get better. Lumbar drain wouldn't have prevented that one since he had already been sent home, but from my understanding the incidence of delayed onset spinal cord ischemia is higher with TEVAR than open TAA repair so the quoted statement doesn't always ring true.

Incidentally, the above mentioned case brought up an interesting issue for the on call anesthesiologist. Patient had been sent home on Plavix. Presents with paraplegia and vascular wants another spinal drain to salvage function. What do? My most risk averse parter actually wound up replacing the lumbar drain after deciding potential benefit outweighed risk of hematoma complicating the clinical picture.
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He is already paraplegic on presentation. Gotta do something. Even if a hematoma arises it probably won’t make it worse than it already is.
 
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Gimlet said:
Just this past year we had a patient wake up normal after TEVAR and he presented 5 days later with new onset paraplegia. He didn't get better. Lumbar drain wouldn't have prevented that one since he had already been sent home, but from my understanding the incidence of delayed onset spinal cord ischemia is higher with TEVAR than open TAA repair so the quoted statement doesn't always ring true.

Incidentally, the above mentioned case brought up an interesting issue for the on call anesthesiologist. Patient had been sent home on Plavix. Presents with paraplegia and vascular wants another spinal drain to salvage function. What do? My most risk averse parter actually wound up replacing the lumbar drain after deciding potential benefit outweighed risk of hematoma complicating the clinical picture.
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The aneurysm is fixed. Why not just jack up the pressure? It's map - CSF pressure isn't it
 
Not that anyone asked, but from a vascular surgeon perspective at our institution (6-7 TEVAR/month)...

Anesthesia always manages, generally kept out of the hands of surgeons and their meddling. One of the most protocoled things in our CVICU.
Delayed paraplegia after both TEVAR and open TAAA is a very real thing. Virtually none of our drains come out less than 48 hours. We are taught that if you do enough, you will see it. My anecdotal training experience in a high volume center would corroborate this and it is a really ****ty feeling.
I've never had a TEVAR cancelled because of tap, but I also generally don't get to the OR until after the puncture is done, so I have no idea how common blood in the tap is.
 
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While delayed deficits >24 hours may very rarely happen, in someone who is an easy back and who is otherwise doing well and ready to go marching around the unit on POD#1, I won't hesitate to pull that catheter (which has been essentially clamped since waking the patient up.

If they somehow go from full strength to paraplegic a day or two after taking the catheter out, put another one in. Never seen it, not saying it doesn't exist, but I'm not gonna keep a patient in the unit for it.

If they're a tough back, yeah, I'll leave it in a little longer. Either way, I'm not going to aggressively drain an asymptomatic patient.
 
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anbuitachi said:
yea but in a situation like that when you are anticoagulated, unless your csf pressure is ridiculous, which it usually isn't, you'll probably get like 10 mmhg higher perfusion pressure. much easier to raise MAP, assuming your map isn't already like 200
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You’ll have no idea what the csf pressure is unless you have a drain. Typically the strategy is to both increase MAP AND decrease CSF pressure. Read the section titled “Rescue therapy for delayed paraplegia” in the review HB linked.
 
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Bumping old thread.

Those that place these using the lumbar drain kit, do you use the catheter stylet or just thread the wet noodle?
 
Agreed that this is a serious procedure that anesthesia should manage exclusively. You may not be liable for complications of mismanagement once you hand it off to the ICU but it is in your patients best interest for you to manage it.

As an aside These drains are interesting because you can see for yourself the physiology of the subarachnoid space. Hypercarbia causes really impressive increases in CSF pressure for example.
 
Newtwo said:
Question. How does this not damage the cord?
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Take a look at a lumbar MRI axial section. In the lower lumbar region there is a ton of space with all the nerves hanging out at the bottom due to gravity.
 
caligas said:
Bumping old thread.

Those that place these using the lumbar drain kit, do you use the catheter stylet or just thread the wet noodle?
Click to expand...


I’ve had 0% success rate advancing the floppy catheter beyond the needle tip without the stylette so I preload the stylette every time.
 
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Hawaiian Bruin said:
I've never seen a patient wake up without a deficit and go on to develop one later.

IMO the point of this procedure is to have a mechanism in place where IF the patient wakes up with a deficit, then you can rapidly restore SCPP.

Once the patient wakes up and moves their legs, you know that somehow, via some path, enough red blood cells are delivering enough oxygen to the spinal cord. This renders your prophylactic drain unnecessary.

Yeah, keep it in a day just in case. But to my way of thinking, removing CSF in a patient with adequate SCPP and no neuro deficit imparts substantial risk without benefit.
Click to expand...

Agree with this. We place spinal drains with the intent to drain more aggressively if the patient wakes up with a deficit.

We target an ICP during the case as we do not perform neuro monitoring.

After, if the patient wakes up neuro intact we do nothing but monitor ICP for about a day. But I’ve also never seen a patient later develop a deficit.

I have seen these drains work. One of my patients woke up weak and improved with drainage after increasing MAP

As far as placement, I do not cancel for a tinge of blood as long as it clears. I also find it very rare to get frank blood but I would cancel for that (have never had to yet, have done about 20+ drains so far). I have seen completely clear, near flawless placements go on to develop blood tinge in the system after heparin which always makes me nervous. I really don’t know how to prevent that. Other than it clogging the system I’ve never seen a patient harmed from it.
 
caligas said:
Bumping old thread.

Those that place these using the lumbar drain kit, do you use the catheter stylet or just thread the wet noodle?
Click to expand...

I’ve never used the stylet. Just thread the floppy noodle like an epidural. Haven’t had an issue.
 
Question: why don't the surgeons do this drain?

A) we are not trained in these drains any more than they are
B) the drain is for the surgery, not for the anesthesia
C) how the drain placement goes determines the timing of the surgery

Sounds like surgery stuff to me.
 
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Just had a thought, we should get the wet tap poster in here for his tips and tricks.
 
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