1. Wet Taps…Now What? Lauren Toler NU794 University of Pennsylvania

2. A Review… Indications for Epidural Anesthesia – Analgesia alone (labor) – Adjunct to general anesthesia – A sole technique for surgical anesthesia

3. Layers Skin Subcutaneous Supraspinous ligament Interspinous ligament Ligamentum flavum Epidural Dura Subdural

4. Relative ContraindicationsAbsolute Contraindications Patients with difficulty understanding procedure Patient refusal Unable to cooperate with practitionerUncorrected coagulopathies Pt with chronic neurologic d/oInfection at the site Pt with fixed volume cardiac statesElevated ICP LA allergy Demyelinating lesion Spinal deformity Stenotic heart lesion

5. Differential Blockade Review B fibers- sympathectomy C fibers- temperature, pain (dull) A-delta- temperature, pain (sharp) A-gamma- muscle spindle fibers A-beta- vibration, touch, pressure A-alpha- proprioception

6. Un-intened dural puncture Options Thread Spinal Catheter Re-site Epidural First PDPH described over 100 years ago in 1898 Risk of inadvertant dural puncture is between 0.2-4% Third most common cause litigation in obstetric anesthesia according to closed claims

7. What would you do? In a ten year retrospective study conducted in the UK revealed out of 72 unintended dural punctures: 49%-spinal catheter, 51% re-site epidural Instituted hospital guidelines: – 28% Spinal cath – 41% Re-site epidural – 31% Allowed either Does your hospital have a policy?

8. Thread spinal catheter Pros Superior analgesia Limit multiple sticks Minimizes time Cons Infection Spinal Cord Trauma Neurotoxicity Inappropriate Injection

9. Infection Risk with spinal catheters Infections associated with meningitis Streptococcus Infections associated with epidural abscess S. aureus Data is inconclusive

10. Spinal catheter & spinal cord trauma Where does the spinal cord end in an adult? – L1-2 (range: T12 to L3) – 19% of population conus medullaris ends below L1 A majority of the time, anesthetists mis-identify level of interspace – 29% correctly identified – 3% at a lower interspace – 68% of the time, interspace identified at higher interspaces What can you do? – Limit catheter distance – Be weary of parasthesias during insertion Broadbent, C.R., Maxwell, W.B., Ferrie, R., Wilson, D.J., Gawne-Cain, M. and Russell, R. (2000). Ability of anaesthetists to identify a marked lumbar interspace. Anaesthesia, 55, 1122-1126.

11. Spinal catheters Inappropriate injection Local injection intended for epidural catheter – High spinal – Total spinal How can we prevent this? – Education – Institute protocols – Label catheter, chart, electronic record, pump, patient door – Remove any additional ports (3-way stop cocks) – Hand off report

12. Prevention It’s a spinal catheter!!!!

13. Local Toxicity Symptoms

14. Re-site Epidural Catheter Pros Increased safety eliminates potential to be misidentified as spinal catheter Cons Infection Inferior analgesia compared to spinal cath Increased risk of headache Unexpected high block/high spinal

15. References Sharpe P. Accidental dural puncture in obstetrics. BJA CEPD Reviews 2001;1:81-4. Tourtellotte WW, Haerer AF, Heller GL, Somers JE. Post lumbar puncture headache. Springfield, IL: Charles C Thomas, 1964. Chadwick HS. An analysis of obstetric anesthesia cases from the American Society of Anesthesiologists closed claims project database. Int J Obstet Anesth 1996;5:258-63. http://www.apsf.org/newsletters/html/2014/winter/ltr02-spinal.htm