TEVAR drain

[nimbus]

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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.

Because we do have experience poking big needles in the back and most surgeons don’t.

 

[vector2]

Because we do have experience poking big needles in the back and most surgeons don’t.

Honestly if I ever needed a thoraco I would want my interventional pain (or IR) buddy to do the drain under fluoro the day before surgery. Failure rate for an experienced anesthesiologist doing it anatomically is very low, but I wouldn't want to be subject to time pressure from the surgeon, multiple passes/redirects, the risk of there being a bit of heme and proceeding with the surgery immediately etc. Slick interventional guy looking at the interlaminar space on the screen has almost a 100% first time pass success rate. Can't say the same about myself when I do neuraxial blind.

 

[pgg]

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.

The surgeons at one of the places I work do them for all of these reasons.

The last time I did one myself was in fellowship.

 

[jwk]

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.

One of our vascular surgeons gets a neurosurgeon to place drains for him.

It's a lot like eye blocks. Almost zero pluses from an anesthesia standpoint and lots of minuses.

 

[caligas]

Stylet leads 2-1...

 

[okayplayer]

Stylet leads 2-1...

I haven’t done a ton of these but I start with the stylet in and pull it if there is any paresthesia and then try to advance just the catheter.

 

[AdmiralChz]

Add me to the stylet group. I’ve never seen anyone put it in without it, I doubt any of my partners do it.

 

[sethco]

Stylet leads 2-1...

Everybody in my group uses the stylet. Significantly easier to thread

How many out there are putting it in on asleep patients? Have a couple people in my group that do this

 

[T-burglar]

Lumbar cistern access of any kind is fine to do asleep in my opinion

 

[abolt18]

One of our vascular surgeons gets a neurosurgeon to place drains for him.

It's a lot like eye blocks. Almost zero pluses from an anesthesia standpoint and lots of minuses.

At my program, vascular always consults neurosurgery to places these drains. It either gets done the day before surgery or in the OR after induction.

 

[dchz]

+1 for stylet. Don't like the flexibility of the catheter and how it can be pushed against the sharp 14g needle without the stylet

 

[Orin]

What I never really understood about this whole bump the case thing, is why I should be bothered by an epidural bleed with a lumbar drain placement. Wouldn't you just drain some CSF to improve the cord perfusion pressure and call it a day?

+1 Stylet unless you drive it into the cord. That's a bad day.

 

[vector2]

What I never really understood about this whole bump the case thing, is why I should be bothered by an epidural bleed with a lumbar drain placement. Wouldn't you just drain some CSF to improve the cord perfusion pressure and call it a day?

+1 Stylet unless you drive it into the cord. That's a bad day.

An epidural bleed causing enough mechanical compression to be symptomatic needs to be evacuated in the OR. Sure, having the spinal drain may help to mitigate the damage a bit, but no one wants to take a fresh TEVAR (or god forbid an open thoraco) back to the OR for any procedure.

 

[deleted697535]

Bump again.
Doing my first in a while tomorrow. I'll have a colleague with me. Pt on heparin 5k sc q8 as afib prophylaxis.
So sitting up, lor to saline l45, then styler back in and push a couple mm til puncture flavin and csf drip, then thread floppy noodle an extra 5cm and whip out touhy?

That basically it?
Troubleshoot moments to consider
1 if tinge of blood,
2 if floppy noodle wont thread consider using stylet in noodle

My colleague will set up codman drain system but anything about that I should know?

 

[vector2]

Bump again.
Doing my first in a while tomorrow. I'll have a colleague with me. Pt on heparin 5k sc q8 as afib prophylaxis.
So sitting up, lor to saline l45, then styler back in and push a couple mm til puncture flavin and csf drip, then thread floppy noodle an extra 5cm and whip out touhy?

That basically it?
Troubleshoot moments to consider
1 if tinge of blood,
2 if floppy noodle wont thread consider using stylet in noodle

My colleague will set up codman drain system but anything about that I should know?

No need for LOR. Just go for the wet tap

 

[nimbus]

As mentioned above, I wouldn’t even attempt to advance the floppy noodle without the stylet. I would start with the stylet preloaded.

 

[T-burglar]

I recommend slightly off midline approach. The catheter is much more compressible than labor epidural catheters and can get pinched between spinous processes when the lumbar lordosis is exaggerated lying supine. This makes it stop draining and transducing pressures

 

[NightNight]

As mentioned above, I wouldn’t even attempt to advance the floppy noodle without the stylet. I would start with the stylet preloaded.

This. I tried once without stylet and never will again.

 

[B-Bone]

Also make sure to prime the catheter with saline before inserting the stylet (at least if you're using the same kit I have). That stylet can be murder to pull out dry.

 

[deleted697535]

Went great. No stylet even in our kit so we obvi didnt use it

 

[nimbus]

Went great. No stylet even in our kit so we obvi didnt use it

Maybe a different kit and catheter.

 

[deleted162650]

That stylet can be murder to pull out dry.

That's why I always lick it first.