Wet Tap in L&D

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likeaboss

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If I get a wet tap on L&D, I never place a subarachnoid catheter. What i do is to just try another level and place the catheter epidurally, for safety reasons.

My question is, in this case should i decrease the pump rate to account for the theoretical leakage of the local anesthetic through the dural puncture into the subarachnoid space?

This just happened, and I cut my dose from 12ml to 10ml per hour. What do you guys think?
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You can. I don’t think it will make too much of a difference depending on the concentration of the infusion . I’d be more concerned during top off’s. Especially if that catheter needs to be loaded for a section.
 
Generally we place an intrathecal catheter running at 1ml/hr of eighth percent bup w/ 2mcg/ml fent. Room to go up to 2 ml/hr. We could try another level if we wanted to, but we keep the same rate as before 6/6/15.
 
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when you place the catheter intrathecally, how far do you thread it in? with an epidural i usually go to 12cm, is that the same for IT catheter or is there danger of high spinal in that case?
 
likeaboss said:
if u run the IT catheter at 1ml/hr of 0.125% bupi + fent, would you ever allow the patient to use PCEA as a bolus, say 1ml hourly?
Click to expand...
That's an option. If they don't have a good enough level, we'll increase to 2ml/hr...if that's not enough, I've been given permission to give them a 1ml/hr bolus. Done that once but lady delivered before she ever used the function.
 
i set my pumps with 0.125 bupivacaine + 2mcg/ml fentanyl to 12ml / hr basal + 6ml / hr q15min PCEA dose.

seems like we can apply that 1/10 epidural:IT dose rule of thumb to both of those numbers

run the IT basal rate at 1ml/hr, plus a 0.5ml bolus q15min...
 
I’ve never ran a intrathecal catheter in residency. The reason given was since it’s so rare, the department just did not want to train the l&d nurses to take care of it. I see first hand now at a community hospital how hard it is to change nursing protocol/policy. Cannot imaging at a big academic institution.
 
I might be in the minority here, but I've always felt like the "risk" of leaving an intrathecal catheter in place is overblown. Sure if someone doses it like an epidural, that's bad news bears... But if you clearly label the catheter as intrathecal (preferably near the hub), place large obvious signs on the patient's bed and the door to the room, make sure the nurse and patient both know what's up, and most importantly sign out to your colleagues... Is the risk of someone dosing it like an epidural really all that high? Weigh that against the benefits of an excellent block, plus a lower rate of PDPH after the wet tap...
 
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Personally I just thread the intrathecal catheter. I figure if I am potentially giving them a nasty headache I might as well let them have the best labor analgesia and a perfect anesthetic for a c-section if needed. I make sure to stick all kinds of labels at the catheter hub, on the infusion pump, and make sure to let both the nurse and charge nurse know.
 
Mman said:
Personally I just thread the intrathecal catheter. I figure if I am potentially giving them a nasty headache I might as well let them have the best labor analgesia and a perfect anesthetic for a c-section if needed. I make sure to stick all kinds of labels at the catheter hub, on the infusion pump, and make sure to let both the nurse and charge nurse know.
Click to expand...

In a case where you use a labor IT catheter for a C/S section, what is your cocktail?
 
likeaboss said:
when you place the catheter intrathecally, how far do you thread it in? with an epidural i usually go to 12cm, is that the same for IT catheter or is there danger of high spinal in that case?
Click to expand...
We have a protocol
Place IT catheter threaded 5 cm
Cosyntropin 1mg IV at delivery
Use infusion only: 2-3 ml/hr (recipe is same as epidural 0.08 bup./ fent 2mcg/ml)
Remove PCEA
Leave catheter for 24 hours post delivery
Label well and communicate with all staff
Inject 10cc PF saline just prior to removal of catheter
 
ghastly75 said:
We have a protocol
Place IT catheter threaded 5 cm
Cosyntropin 1mg IV at delivery
Use infusion only: 2-3 ml/hr (recipe is same as epidural 0.08 bup./ fent 2mcg/ml)
Remove PCEA
Leave catheter for 24 hours post delivery
Label well and communicate with all staff
Inject 10cc PF saline just prior to removal of catheter
Click to expand...

i bet u have a low incidence of PDPH in the event of a dural puncture...
 
ghastly75 said:
We have a protocol
Place IT catheter threaded 5 cm
Cosyntropin 1mg IV at delivery
Use infusion only: 2-3 ml/hr (recipe is same as epidural 0.08 bup./ fent 2mcg/ml)
Remove PCEA
Leave catheter for 24 hours post delivery
Label well and communicate with all staff
Inject 10cc PF saline just prior to removal of catheter
Click to expand...
Why the saline at the end?
 
ghastly75 said:

Anesthesiology

anesthesiology.pubs.asahq.org anesthesiology.pubs.asahq.org
Click to expand...

Ah, the Hakim study. 90 patients and 50% reduction in PDPH for those getting ACTH. We used to give it in residency as a “Hail Mary” before blood patch. This hasn’t been replicated in other studies, really. I like this Cochrane review which investigates it and other meds:

www.ncbi.nlm.nih.gov

PubMed

PubMed® comprises more than 38 million citations for biomedical literature from MEDLINE, life science journals, and online books. Citations may include links to full text content from PubMed Central and publisher web sites.
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov

Anywhere that does a high volume of OB is going to have some small incidence of wet taps (yes I know everyone on SDN is super macho with perfect skillz which never fail, but I’m talking the real world). Most wet taps for those of us not in training occur in difficult patients due to anatomy or body habitus. Often these patients don’t have the fondest memories of their epidural placement which makes them very shy about agreeing to a blood patch, so I’ve found only the most symptomatic will go for it routinely - and you know the poor gal when you see it, lying still/flat in the dark room.
 
The evidence for placing an IT catheter after accidental Dural puncture isn’t the best either. Here’s SOAP’s stance:

soap.org

Accidental Dural Puncture - SOAP

Accidental Dural Puncture and Post Dural Puncture Headache Management: Intrathecal Catheter Placement vs. Therapeutic Epidural Blood Patch vs. Prophylactic Epidural Blood PatchThe management of an accidental dural puncture (ADP) and post-dural puncture headache (PDPH) in the peripartum period...
soap.org

This has mostly to do with what you are comfortable with as a practice and institution. When I joined we routinely placed intrathecal catheters for wet taps, but within 6 months had 2 “near misses” when the L&D RN programmed the pump with epidural settings - it was quickly caught by a couple of our astute CRNAs who went back to check and make sure, but it was alarming enough for us to change our practice. They personally make me very nervous - it doesn’t seem that the analgesia is as adequate (either all or nothing), and improper management could very well be lethal. Lots of risk for questionable gain, at least to me, for it to be a routine practice. But I know others feel differently, and that’s why it’s good to have a discussion with invested parties (L&D RNs ESPECIALLY if you aren’t personally programming and hooking up the pump) ahead of time when developing a policy surrounding wet taps.

Now we only place IT catheters if it was a very difficult epidural placement or if C/S is imminent. If it’s just a bad luck wet tap, pull out and go a level above or below. The new catheter we dose slowly given the large defect in the dura.
 
AdmiralChz said:
The evidence for placing an IT catheter after accidental Dural puncture isn’t the best either. Here’s SOAP’s stance:

soap.org

Accidental Dural Puncture - SOAP

Accidental Dural Puncture and Post Dural Puncture Headache Management: Intrathecal Catheter Placement vs. Therapeutic Epidural Blood Patch vs. Prophylactic Epidural Blood PatchThe management of an accidental dural puncture (ADP) and post-dural puncture headache (PDPH) in the peripartum period...
soap.org

This has mostly to do with what you are comfortable with as a practice and institution. When I joined we routinely placed intrathecal catheters for wet taps, but within 6 months had 2 “near misses” when the L&D RN programmed the pump with epidural settings - it was quickly caught by a couple of our astute CRNAs who went back to check and make sure, but it was alarming enough for us to change our practice. They personally make me very nervous - it doesn’t seem that the analgesia is as adequate (either all or nothing), and improper management could very well be lethal. Lots of risk for questionable gain, at least to me, for it to be a routine practice. But I know others feel differently, and that’s why it’s good to have a discussion with invested parties (L&D RNs ESPECIALLY if you aren’t personally programming and hooking up the pump) ahead of time when developing a policy surrounding wet taps.

Now we only place IT catheters if it was a very difficult epidural placement or if C/S is imminent. If it’s just a bad luck wet tap, pull out and go a level above or below. The new catheter we dose slowly given the large defect in the dura.
Click to expand...
I hear ya. Our protocol was adopted from large University Mother institution .
We are a specialized unit, fetal cases and deliveries . Physician only and pretty low volume . So far this protocol works for us, but there have been a few that still require /request EBP.
 
I can’t remember exactly the cost of cosyntropin, but for how rarely you use it for PDPH prevention after wet tap I don’t remember cost being a hindrance.

That study if I remember right was a pretty good study. It was actually prospective and randomized....which is rare in our journals. Everything nowadays is a crappy metaanalysis of a bunch of crappy retrospective studies so I’m somewhat surprised this preventative measure hasn’t really caught on. It’s pretty safe and not overly expensive. Am I missing something about that study that invalidates it? And maybe it has caught on in practices except in my neck of the woods...?
 
I have not been impressed with Cosytropin. Neostigmine/atropine has actually surprised me with its effectiveness.
 
IMGASMD said:
I’ve never ran a intrathecal catheter in residency. The reason given was since it’s so rare, the department just did not want to train the l&d nurses to take care of it. I see first hand now at a community hospital how hard it is to change nursing protocol/policy. Cannot imaging at a big academic institution.
Click to expand...

Totally agree. The main issue is staffing having familiarity with running the intrathecal catheter. We're fortunate enough to have fantastic OB nurses, however that's definitely not the case everywhere thinking back to residency. Nightmare situation, OB nurse messes with pump because patient in pain, shift change is happening, bumps rate to 10 because they think running at 1cc/h must have been a mistake, maybe throws in a bolus for good measure, pt in respiratory distress, you started covering OB 10 min ago, get the call, realize what happened, while everyone is falling over each other trying to even get you an ambubag, let alone a blade, tube, and meds, pt goes into bradycardic vs hypoxic PEA arrest.......

Yeah, so basically if you're going to run an IT catheter, label the daylights out of everything, make sure all of the nursing staff is aware, post it on the board, send out an overhead PSA. Personally, I would just pop in another catheter and not have to worry about it. Threading the prior catheter and not dosing it, removing after 24-48 hours to reduce incidence of PDPH might be an option, I've never personally done it though
 
OTCAwesome said:
Totally agree. The main issue is staffing having familiarity with running the intrathecal catheter. We're fortunate enough to have fantastic OB nurses, however that's definitely not the case everywhere thinking back to residency. Nightmare situation, OB nurse messes with pump because patient in pain, shift change is happening, bumps rate to 10 because they think running at 1cc/h must have been a mistake, maybe throws in a bolus for good measure, pt in respiratory distress, you started covering OB 10 min ago, get the call, realize what happened, while everyone is falling over each other trying to even get you an ambubag, let alone a blade, tube, and meds, pt goes into bradycardic vs hypoxic PEA arrest.......

Yeah, so basically if you're going to run an IT catheter, label the daylights out of everything, make sure all of the nursing staff is aware, post it on the board, send out an overhead PSA. Personally, I would just pop in another catheter and not have to worry about it. Threading the prior catheter and not dosing it, removing after 24-48 hours to reduce incidence of PDPH might be an option, I've never personally done it though
Click to expand...


lol there are OB nurses that touch the pump somewhere? I have never seen one!
 
facted said:
How long is the effect good for? What dosing do you use?
Click to expand...


I use the dosing straight outta the article. I think it's 20mcg/kg Neostigmine and 10mcg/kg Atropine mixed together and diluted into a 20cc syringe given over 10 minutes, but please cross-reference me on that. I've done it twice now.

Once on a teenager who had a raging PDPH after a tap by neurology. Cosyntropin did nothing. Tried this. Was sure she was gonna get a patch later, but nope. Went home cured - no patch needed.

Second time I did it prophylactically on a 60yo F that I did a spinal on for a TKA. She was on the fluffy side, but somehow I miraculously got CSF with the introducer needle. Gave it in the OR during the case and no PDPH ever developed.
 
SaltyDog said:
I use the dosing straight outta the article. I think it's 20mcg/kg Neostigmine and 10mcg/kg Atropine mixed together and diluted into a 20cc syringe given over 10 minutes, but please cross-reference me on that. I've done it twice now.

Once on a teenager who had a raging PDPH after a tap by neurology. Cosyntropin did nothing. Tried this. Was sure she was gonna get a patch later, but nope. Went home cured - no patch needed.

Second time I did it prophylactically on a 60yo F that I did a spinal on for a TKA. She was on the fluffy side, but somehow I miraculously got CSF with the introducer needle. Gave it in the OR during the case and no PDPH ever developed.
Click to expand...

That’s because you got lidocaine with the introducer needle not CSF :laugh: 😉
 
Anyone here doing sphenopalatine ganglion blocks for PDPH? Apparently it's the new thing. I know some people who've done em with good success
 
Ezekiel2517 said:
Anyone here doing sphenopalatine ganglion blocks for PDPH? Apparently it's the new thing. I know some people who've done em with good success
Click to expand...
This has been discussed once or twice over the past year, if you go looking. If I remember there were some good tips and recommendations shared regarding the SPG block.
 
OneFellSwoop said:
I can’t remember exactly the cost of cosyntropin, but for how rarely you use it for PDPH prevention after wet tap I don’t remember cost being a hindrance.

That study if I remember right was a pretty good study. It was actually prospective and randomized....which is rare in our journals. Everything nowadays is a crappy metaanalysis of a bunch of crappy retrospective studies so I’m somewhat surprised this preventative measure hasn’t really caught on. It’s pretty safe and not overly expensive. Am I missing something about that study that invalidates it? And maybe it has caught on in practices except in my neck of the woods...?
Click to expand...
In my experience Cosyntropin works great, it even works after a failed blood patch. I don't think it should be used prophylactically though.
If the patient does not develop headaches there is no need to give anything.
 
Ezekiel2517 said:
Anyone here doing sphenopalatine ganglion blocks for PDPH? Apparently it's the new thing. I know some people who've done em with good success
Click to expand...

I’ve done it twice, offered it three times. Once it worked, once it just delayed doing the blood patch, and once the patient refused on the basis of not wanting something shoved up her nose. I think it’s a better delay technique than fioricet, but not the definitive treatment. I also think it’s good option for the “atypical” headaches with no documented wet tap. It seems we get called a lot for headaches that are simply postpartum tension headaches or migraines and it may help with those when other treatments aren’t working. If there is a documented wet tap, you are better off making sure they get a EBP before they go home, so you aren’t doing it a few days later while you’re on call and juggling the OR schedule. I’m not convinced it will replace blood patches.
 
Ezekiel2517 said:
Anyone here doing sphenopalatine ganglion blocks for PDPH? Apparently it's the new thing. I know some people who've done em with good success
Click to expand...
We've done them and they work, but they're temporary in our experience and frequently require blood patch.
 
Consigliere said:
Me neither dude. Those ho's won't even replace the epidural infusion. Good times getting a call at 0300 to replace the epidural bag.
Click to expand...

I used to walk through and replace every single bag at 10 pm just for that reason.
 
dr doze said:
Yes. The screaming teenager can bolus her own epidural. (PCEA) But the baccalaureate trained professional Registered Nurse can’t touch anything.
Click to expand...
Except the cake and doughnuts. They touch those quite frequently judging by the number of yard wide asses I see.
 
SaltyDog said:
I use the dosing straight outta the article. I think it's 20mcg/kg Neostigmine and 10mcg/kg Atropine mixed together and diluted into a 20cc syringe given over 10 minutes, but please cross-reference me on that. I've done it twice now.

Once on a teenager who had a raging PDPH after a tap by neurology. Cosyntropin did nothing. Tried this. Was sure she was gonna get a patch later, but nope. Went home cured - no patch needed.

Second time I did it prophylactically on a 60yo F that I did a spinal on for a TKA. She was on the fluffy side, but somehow I miraculously got CSF with the introducer needle. Gave it in the OR during the case and no PDPH ever developed.
Click to expand...
from this?
www.ncbi.nlm.nih.gov

Addition of Neostigmine and Atropine to Conventional Management of Postdural Puncture Headache: A Randomized Controlled Trial - PubMed

Neostigmine/atropine was effective in treating PDPH after only 2 doses. Neostigmine can pass the choroid plexus but not the blood-brain barrier. The central effects of both drugs influence both cerebrospinal fluid secretion and cerebral vascular tone, which are the primary pathophysiological...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov
 
ghastly75 said:
from this?
www.ncbi.nlm.nih.gov

Addition of Neostigmine and Atropine to Conventional Management of Postdural Puncture Headache: A Randomized Controlled Trial - PubMed

Neostigmine/atropine was effective in treating PDPH after only 2 doses. Neostigmine can pass the choroid plexus but not the blood-brain barrier. The central effects of both drugs influence both cerebrospinal fluid secretion and cerebral vascular tone, which are the primary pathophysiological...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov
Click to expand...


I think that’s the one. That’s the dose I used. Still surprised that it seems to work but I’ll take it.
 
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