Threshold for Difficult Spinal

[pgg]

I hate the long whitaker spinal needles. They tend to bend and are flimsy. A big concern in my practice we have cse kits. However some staff still choose to place 25 gauge needles through non cse Thouy needles. It definitely makes me concerned about needle sheering and metal shavings. Thoughts?

I think it's probably not an issue with the blunt tip / pencil point type needles going through the Tuohy. The 25 & 27s are pretty flexible.

If you're trying to shove a cutting needle through the Tuohy then yeah maybe there's a risk of some scraping? I wouldn't do that.

Our CSE kits do not have that extra spinal hole. It's no longer a Tuohy needle then.

Label on the kit says Tuohy.

If you've never used one - it's definitely a superior option. Worth the extra expense? I have no idea what the actual cost is.

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[pgg]

Infiltrating lidocaine is uncommon in many areas of the world. Your technique is more common in many countries (no sedation, no infiltration, no introducer, 22-23g Quincke). Patients in the US are not as stoic as many patients elsewhere and demand sedation/lidocaine infiltration. Else, they jump around and it makes the spinal take much longer. I infiltrate everyone.

I do too but I wonder if there's a point to it. The introducer for the spinal needle is about as long as the needle used for infiltraring local.

I guess maybe it depends on how sure you are it'll be a single stick / single pass attempt.

Definitely agree there are different expectations concerning normal and tolerable procedural pain in other countries. However, I will say that as a result I often witnessed procedures done in needlessly painful ways, because of the generally stoic patients.

 

[Maz777]

I do too but I wonder if there's a point to it. The introducer for the spinal needle is about as long as the needle used for infiltraring local.

I guess maybe it depends on how sure you are it'll be a single stick / single pass attempt.

Definitely agree there are different expectations concerning normal and tolerable procedural pain in other countries. However, I will say that as a result I often witnessed procedures done in needlessly painful ways, because of the generally stoic patients.

Agreed. I think it's much smoother procedure if you infiltrate (even if you anticipate a single pass). I infiltrate for all peripheral nerve blocks as well. It's an added step that many skip, but it makes the whole procedure easier to perform. I guess I'm just like an old curmudgeonly surgeon who hates a moving target

 

[dabears505]

There's someone here who places epidurals without infiltration and his patients and nurses love him. Forgot who it was.

 

[DrAmir0078]

There's someone here who places epidurals without infiltration and his patients and nurses love him. Forgot who it was.

He definitely knows where the holy grail is!!! ... Call and inform Professor Robert Langdon !

 

[IMGASMD]

There's someone here who places epidurals without infiltration and his patients and nurses love him. Forgot who it was.

I had to do one with patient who is allergic to “all local anesthetics….” as a resident. Attending told me to use saline for infiltration.

I still remember exactly where it happened years later.

 

[coffeebythelake]

I had to do one with patient who is allergic to “all local anesthetics….” as a resident. Attending told me to use saline for infiltration.

I still remember exactly where it happened years later.

So what did you inject with the epidural? Opioid only? Meperidine?

 

[Twiggidy]

Must be a pretty important surgery to fix something else before fixing the critical AS.

Man. At my place they canceled a TAVR who had critical AS because she fell and broke her hip and the next day scheduled her for the hip pinning. I was like, "Dude, you want to make this hip pinning harder than it should be huh?"

 

[coffeebythelake]

Man. At my place they canceled a TAVR who had critical AS because she fell and broke her hip and the next day scheduled her for the hip pinning. I was like, "Dude, you want to make this hip pinning harder than it should be huh?"

They should have done a combo.

 

[Twiggidy]

They should have done a combo.

Since we do a good amount of our TAVR with very little anesthetic we could've done the TAVR and pinned her in the afternoon. But everyone was looking at me like I'm the crazy person

 

[Shimmy8]

There are more days than not when I have to quote the one and only Mugatu...

I feel like I'm taking crazy pills!

 

[coffeebythelake]

Since we do a good amount of our TAVR with very little anesthetic we could've done the TAVR and pinned her in the afternoon. But everyone was looking at me like I'm the crazy person

Sometimes I feel the anesthesiologist is the only sane person in the room. That is absolutely 100% a reasonable plan.

Perhaps one of you cardiac guys can correct me if I'm wrong but most recent AHA guidelines says ok to have ASA monotherapy after TAVR so I don't there would be any contraindications to neuraxial after this procedure. Or just do GA. Whatever.

 

[nimbus]

Not every severe AS patient gets a TAVR. Some get SAVR or SAVR/CABG or SAVR/mitral repair/+-CABG. They need a workup prior to tavr (CT angio chest, possibly iliofemoral angio, LHC, etc). TAVR is not always the answer for these patients. We give GA/ETT to quite a few of these patients for extensive dental extractions prior to TAVR and they do well since we know what to expect. Honestly they’re pretty cookbook. Aline, vasopressor drip, minimalist induction, go.

 

[nimbus]

Man. At my place they canceled a TAVR who had critical AS because she fell and broke her hip and the next day scheduled her for the hip pinning. I was like, "Dude, you want to make this hip pinning harder than it should be huh?"

If you do these with minimal anesthesia, were the cardiologists concerned about patient lying completely flat and motionless with a broken hip? Access concerns?

 

[coffeebythelake]

If you do these with minimal anesthesia, were the cardiologists concerned about patient lying completely flat and motionless with a broken hip? Access concerns?

I dont know if a hip fx pt is going to have that much pain just laying flat. Most of the time the problem is sitting them up for the spinal and that's why they often get GA.

 

[Twiggidy]

If you do these with minimal anesthesia, were the cardiologists concerned about patient lying completely flat and motionless with a broken hip? Access concerns?

i'll echo with @coffeebythelake just said in that most of these hip fractures dont want to move at all which is almost perfect for the cardiologist. it was a little while ago so i don't remember if the lady had trouble with leg position but she seemed to have them pretty straight in the OR for the pinning if i could remember. i honestly think everyone was more worried about keeping "records clean" than the best plan. but i also agree with you in that taking care of a critical AS is pretty cook book and a gimme answer on both written and oral boards.

 

[GassYous]

A pin takes like 30 minutes. You're in the room for an hour. Anyone can sit still for an hour. Give them like 20 of prop if they need it.

 

[dumbmedstudent]

Concerns of giving Iv heparin to pt w/ fresh hip fx?

 

[sakata8242]

Unless there's a strong indication to avoid a GA, my threshold is generally 3 attempts and then we go to sleep. Redirect 3 or 4 times per attempt before going to a different level. If I still can't get it after the third level, it's usually been over 7 minutes and I need to get things moving along. Off to sleep we go. This is one of the first things I tell residents when they are doing spinals out at our ASC - don't get tunnel vision. If you can't get it after redirecting 3-4 times, reposition, reassess, relocalize.

If GA is a contraindication, then quick progression from introducer, quincke, to essentially a CSE.