Gauge Spinal Needle Research Articles

Combined spinal-epidural anesthesia for cesarean section; needle-through-needle approach.

The Portex "Spinal/Epidural Set" is designed for combined spinal-epidural (CSE) anesthesia by the needle-through-needle approach. We evaluated the technical and clinical usefulness of CSE with this needle set, and also isobaric tetracaine, for cesarean section. Thirty patients for cesarean section were included. In the left decubitus position, a 16-gauge epidural needle was introduced by the loss-of-resistance method into the lumbar intervertebral space. A 26-gauge spinal needle was threaded through the epidural needle into the subarachnoid space. Tetracaine dissolved in saline was injected. A 17-gauge catheter was advanced into the epidural space. The analgesic level was checked by the pin-prick method. The insertion in the first attempt was successful in 21 cases (70%) of the patients, and difficulty in insertion was not experienced. Inadvertent dural puncture occurred in one case, but no accidental subarachnoid catheterization was observed. Spinal anesthesia with tetracaine (11.1±0.5 mg) reached the level of Th6 on average, with a relatively wide range. Five cases (13%) were supplemented by epidural anesthesia. No postspinal headache was noted. CSE technique by the needle-through-needle approach is easy to handle, and provides a speedy, reliable, and flexible analgesia as well as postoperative pain relief for patients undergoing cesarean section.

Prenatal diagnosis of haemoglobin Bart's disease by cordocentesis at 12-14 weeks' gestation.

Couples with alpha-thalassaemia-1 face a 25 per cent risk of having fetuses with haemoglobin (Hb) Bart's disease. Prenatal diagnosis is conventionally performed by DNA studies of chorionic villi or amniocytes obtained from chorionic villus biopsy or amniocentesis. DNA studies are expensive and time-consuming. We identified 11 affected pregnancies on abdominal ultrasound examination at 12-14 weeks when the placental thickness exceeded the mean plus 2 SD measurement for the gestational week and the cardiothoraic ratio was more than 0.5. Cordocentesis was then performed with a free hand technique. The procedures were successful in ten cases using a 26-gauge spinal needle with a 20-gauge introducer. Hb Bart's disease was confirmed in all cases by Hb electrophoresis. The procedure was unsuccessful in one case when a 22-gauge spinal needle was used. Hb study of fetal blood collected at abortion also confirmed Hb Bart's disease. In conclusion, ultrasound findings of concomitant placentomegaly and cardiomegaly at 12-14 weeks is highly specific of disease in pregnancies at risk of Hb Bart's disease. Cordocentesis and Hb study in pregnancies with these sonographic manifestations may be an alternative prenatal diagnostic approach. This diagnostic approach is of particular value in areas where resources for molecular studies are limited.

Dural Puncture with a 26-Gauge Spinal Needle Affects Spread of Epidural Anesthesia

Dural Puncture with a 26-Gauge Spinal Needle Affects Spread of Epidural Anesthesia

Transient radicular irritation after hyperbaric lidocaine spinal anesthesia in parturients

Two cases of transient radicular irritation in pregnant patients are presented. Both cases involve the combination of spinal anesthesia employing hyperbaric 5% lidocaine and a small gauge pencilpoint needle as well as the surgery being performed in the lithotomy position. We recommend that until the potential for lidocaine-induced neuroradicular irritation under these circumstances is evaluated prospectively, hyperbaric lidocaine should not be used for cases in which a small gauge spinal needle is employed and the patient is placed in the lithotomy position.

Dural Puncture with a 26-Gauge Spinal Needle Affects Spread of Epidural Anesthesia

Dural Puncture with a 26-Gauge Spinal Needle Affects Spread of Epidural Anesthesia

Dural Puncture with a 26-Gauge Spinal Needle Affects Spread of Epidural Anesthesia

To the Editor: We wish to comment on Suzuki et al.'s article [1], which suggests that dural puncture without intrathecal injection of local anesthetic in a combined spinal epidural technique increases the caudal spread of epidurally administered mepivacaine: 1. The study was not blinded, since the same anesthesiologist performed and assessed the block. 2. Increased caudal spread is not explained by Bernards et al.'s study [2], which actually showed that the flux of local anesthetic through a dural hole made by a 27-gauge Whitacre needle was not increased. However, flux did increase after dural puncture with larger needles (24-gauge Sprotte and 18-gauge Tuohy). 3. Since all patients were kept in the left lateral position throughout, intrathecal movement of mepivacaine, if in fact this did occur, presumably behaving as a hypobaric solution within the cerebrospinal fluid, would have affected the right upper side of the body more than the left lower side. Surprisingly, only the left side was tested. 4. The concept of puncturing the dura without injection in a combined spinal epidural technique is regarded as a useful clinical method to improve caudal analgesia by the authors without any mention of potential morbidity associated with the spinal component such as meningitis [3]. Simon Walker, MBBS Roshan Fernando, FRCA Department of Anaesthesia; Royal Free Hospital; London, United Kingdom

Dural Puncture with a 26-Gauge Spinal Needle Affects Spread of Epidural Anesthesia

In Response: We did not state the position of the patients correctly in our article [1]. The patients were turned from left lateral to the supine position after insertion of the epidural catheter. Local anesthetic was injected while the patients were kept in the supine position. Since bilateral spread of local anesthetic in both epidural and subarachnoid spaces was predicted, assessment of the spread of analgesia was performed only on the left side of the body. Nobuaki Suzuki, MD Department of Anesthesia; Prefectural Nichinan Hospital; Miyazaki, Japan; Mayumi Takasaki, MD, PhD; Department of Anesthesiology; Miyazaki Medical College; Miyazaki, Japan

Dural Puncture with a 26-Gauge Spinal Needle Affects Spread of Epidural Anesthesia

Dural Puncture with a 26-Gauge Spinal Needle Affects Spread of Epidural Anesthesia

Nerve Block in Prostate Surgery

Purpose We describe a novel technique for anesthetizing the prostate, which should be used for patients at risk undergoing prostate surgery with general, spinal or epidural anesthesia. Materials and Methods Local anesthesia to the prostatic plexus supplemented by monitored anesthesia care was performed on 40 patients with outflow obstruction secondary to an enlarged prostate. Of the patients 34 underwent transurethral resection of the prostate, 5 underwent visual laser ablation and 1 underwent transurethral electrovaporization. A 20 gauge spinal needle was inserted via a suprapubic approach toward the base and apex of the prostate, and guided by the left index finger inserted into the rectum. Lidocaine was injected into the prerectal space. Bulging of the rectal wall caused by the amount of lidocaine injected was appreciated. Insertion into the proper area was essential for a good anesthetic result. Results Adequate anesthesia levels could be obtained without major complications. All but 1 patient with poor bladder compliance were rendered free of a Foley catheter. There were no deaths. Conclusions This technique has definite advantages for patients who are at risk for prostate surgery with general or spinal anesthesia.

Dural Puncture with a 26-Gauge Spinal Needle Affects Spread of Epidural Anesthesia

Dural Puncture with a 26-Gauge Spinal Needle Affects Spread of Epidural Anesthesia

The effects of needle type, gauge, and tip bend on spinal needle deflection.

Although the use of fine-gauge spinal needles reduces the incidence of postdural puncture headache, they are associated with increased risk of placement failure as a result of deflection and bending. This in vitro study quantifies spinal needle deflection from the axis of insertion with respect to needle type, gauge, and tip bend. In addition to straight-tip needles, those with standardized 5 degrees and 10 degrees tip bends were studied. The purpose was to examine the effect of tip bend, which has been described with small gauge spinal needles after bony contact, on needle path deflection. Needles studied included Quincke (Q), Sprotte (S), and Whitacre (W) in sizes ranging from 18-gauge to 29-gauge. Needles were inserted perpendicularly into porcine paraspinous muscle followed by radiologic investigation. Measurements of needle deflection from the axis of insertion at depths of 20, 40, and 60 mm were performed in a blinded fashion. Straight-tip Q needle deflection, but not W or S, was correlated with gauge and depth of insertion. Although there were differences within needle type groups, needle deflection was generally correlated with the degree of tip bend. We conclude that spinal needle deflection is dependent on the type of needle (W < S < Q), and that the magnitude of deflection is related to gauge (large < small) and tip bend (straight < 5 degrees < 10 degrees).

The Effects of Needle Type, Gauge, and Tip Bend on Spinal Needle Deflection

Although the use of fine-gauge spinal needles reduces the incidence of postdural puncture headache, they are associated with increased risk of placement failure as a result of deflection and bending. This in vitro study quantifies spinal needle deflection from the axis of insertion with respect to needle type, gauge, and tip bend. In addition to straight-tip needles, those with standardized 5 degrees and 10 degrees tip bends were studied. The purpose was to examine the effect of tip bend, which has been described with small gauge spinal needles after bony contact, on needle path deflection. Needles studied included Quincke (Q), Sprotte (S), and Whitacre (W) in sizes ranging from 18-gauge to 29-gauge. Needles were inserted perpendicularly into porcine paraspinous muscle followed by radiologic investigation. Measurements of needle deflection from the axis of insertion at depths of 20, 40, and 60 mm were performed in a blinded fashion. Straight-tip Q needle deflection, but not W or S, was correlated with gauge and depth of insertion. Although there were differences within needle type groups, needle deflection was generally correlated with the degree of tip bend. We conclude that spinal needle deflection is dependent on the type of needle (W < S < Q), and that the magnitude of deflection is related to gauge (large < small) and tip bend (straight < 5 degrees < 10 degrees). (Anesth Analg 1996;82:297-301)

Combined Spinal/Epidural Anesthesia for Outpatient Surgery

Department of Anesthesiology, The Hospital for Special Surgery, Affiliated with The New York Hospital and The Cornell University Medical College, 535 East 70th Street, New York, New York 10021.In Reply:--We appreciate Joshi's support of our data. Success with the combined spinal-epidural (CSE) needle-through-needle technique relates to some degree to the protrusion length of the spinal needle beyond the tip of the epidural needle. In our study and in clinical practice, we have found that some patients require up to a 15-mm clearance. [1]In this same study, when a 3-inch Weiss epidural needle was used, there was adequate needle length in all patients. However, the technical price that one pays with an exceedingly long protrusion length is diminished stability of the needle-through-needle setup. We prefer a spinal needle that protrudes at least 12 mm but no longer than 15 mm.However, we disagree with Joshi regarding the use of an epidural needle with a separate "back hole." No data support the use of a back hole in terms of CSE success. To the contrary, in the study by Joshi and McCarroll, [2]the needle combination using an epidural needle with a separate back hole had a 15% failure rate, whereas the normal Tuohy needle was associated with a 100% success rate in 13 patients. Further, there are no data from a prospective, blinded study supporting the better "feel" of dural penetration with an epidural needle that has a separate back hole. I have been able to perceive dural penetration using a 27-G Whitacre spinal through a Weiss epidural needle in the vast majority of patients. However, this also is anecdotal, unblinded, and operator-dependent. This claim must be evaluated with the investigators properly blinded and dural "feel" graded and confirmed (e.g., by the presence of cerebrospinal fluid) if meaningful conclusions are to be drawn.In a study of fresh cadavers using epiduroscopy, Holmstrom et al. [3]concluded that "it was impossible to force 16 or 18 gauge epidural catheters through the dural hole made by a single dural puncture with a 25 gauge spinal needle." No data show a reduction in dural penetration with the catheter when a needle with a separate back hole is used. We agree that it is important to select a matched spinal and epidural needle combination of proper length to achieve acceptable success. Similar to Joshi, we recommend a protrusion length of the spinal needle of at least 12 mm. However, beyond this, there are inadequate data to conclude what constitutes the "optimal" needle combination.William F. Urmey, M.D., Jennifer Stanton, B.S., Nigel E. Sharrock, M.B., Ch.B., Department of Anesthesiology, The Hospital for Special Surgery, Affiliated with The New York Hospital and The Cornell University Medical College, 535 East 70th Street, New York, New York 10021.

Ultrasound-guided fine needle aspiration biopsy of portal vein thrombosis in liver cirrhosis: results in 15 patients.

Between 1988 and 1992 ultrasound-guided fine needle aspiration biopsies of thromboses in the main branches of the portal vein were carried out in 15 patients with liver cirrhosis. The aims of the study were to evaluate the usefulness, feasibility and diagnostic accuracy of this procedure in cirrhotics with known or suspected hepatocellular carcinoma. The procedure was carried out only in patients with a platelet count > or = 40,000/microL and prothrombin activity > or = 40%. A single pass, with a 22 gauge spinal needle, was performed in the portal vein lumen. Diagnosis of the aetiology of the portal vein thrombosis was obtained in all 15 cases. In 12 cases, a cytological diagnosis of hepatocellular carcinoma was made. In one case, the neoplastic cells aspirated were compatible with adenocarcinoma, and a subsequent colonoscopy confirmed the presence of colonic cancer. The material aspirated was compatible with chemically-induced thrombosis in one patient who had undergone several percutaneous ethanol injection sessions for treatment of hepatocellular carcinoma, and in the last case only blood was aspirated, thus ruling out the coexistence of hepatic cancer. We conclude that fine needle aspiration biopsy of portal vein thrombosis is a feasible, low risk procedure that facilitates the diagnosis of hepatocellular carcinoma when fine needle biopsy of focal liver lesions fails. Fine needle aspiration biopsy of portal vein thrombosis is also useful in excluding neoplastic aetiology of portal vein thrombosis.

Combined spinal epidural anaesthesia: The single space double-barrel technique

We present our own single-space method for performing combined spinal epidural anaesthesia. A spinal introducer and a Tuohy needle are sited in the same interspace. After insertion of the epidural catheter the introducer is used as a guide for a 25 gauge spinal needle. The advantages of this technique over other methods are explored. A series of 90 patients who received combined spinal epidural anaesthesia for elective Caesarean section is presented. The incidence of side effects (hypotension, nausea and vomiting, itching, post dural puncture headache) was comparable with those of other series. However, a high incidence (26.6%) of paraesthesiae during insertion of the spinal needle was noted. We suggest that this finding may be related to the use of pencil-point needles.

Evaluation of Combined Spinal-Epidural Anesthesia Using Two Different Techniques

Background and Objectives. This investigation was designed to evaluate combined spinalepidural anesthesia with a needle-through-needle technique using two different needle sets. One kit has a standard 16-gauge Tuohy needle and a 26-gauge spinal needle that extends 13 mm beyond the tip of the Tuohy needle (set A). The other kit consists of a 16-gauge Tuohy needle with an aperture in its curve (back hole) for the insertion of a 26-gauge spinal needle that protrudes 10 mm beyond the tip of the epidural needle (set B). Methods. Combined spinal-epidural anesthesia was used in 40 consecutive consenting patients scheduled for elective total knee arthroplasty who were randomized into two groups. Needle set A was used in group A, and needle set B was used in group B. Special attention was paid to difficulties in performing the blocks and to any complications of the technique. Results. The length of the spinal needle was inadequate in 15% of patients from group B, whereas the length in group A was adequate in all. The aperture on the back of the Tuohy needle from group B provides a better “feel” of dural puncture. There was no difficulty in the insertion of the epidural catheter. There was no evidence of subarachnoid placement of the epidural catheter in either group. None of the patients had unexpectedly extensive spinal block. No patient developed postdural puncture headache. All patients had adequate surgical anesthesia. Infusion of bupivacaine (0.1%) with fentanyl (2 μg/mL) provided adequate postoperative analgesia. No respiratory depression was noted. Conclusions. Combined spinal-epidural provides satisfactory surgical and postoperative analgesia for total knee arthroplasty. An improved needle set for the needle-through-needle technique would be one with a modified Tuohy needle having an aperture at the back and a spinal needle protruding more than 13 mm beyond the Tuohy needle.

Use of 29-gauge spinal needles and a fixation device with combined spinal epidural technique.

One hundred patients between 15-46 years, undergoing elective surgery, were given spinal anaesthesia using 29-gauge spinal needles introduced through a Tuohy needle with a fixation device. Successful spinal anaesthesia was achieved in 98%. A success rate of 100% was achieved when a combined spinal epidural technique was used. Ninety-eight percent of the patients would prefer the same anaesthesia procedure for similar kind of surgery in the future.

Vital dye sham intrarenal lesions: Assessment of risk of intra-abdominal tumour spread during laparoscopic nephrectomy and morcellation

SummaryThe advancement of a new surgical technique, such as laparoscopic nephrectomy, raises questions regarding its safety and efficacy. This minimally invasive procedure could have its major clinical utility in the treatment of malignant renal neoplasms. Adenocarcinomas of the kidney are well known for their propensity to seed should tumour spillage occur, as has been documented in the case of large transcutaneous biopsies [1–3]. It is vital to assess the feasibility of performing laparoscopic nephrectomy and morcellation without spilling cancer cells.Thirteen pigs underwent general endotracheal anaesthesia and were placed in the modified left flank-up position for laparoscopic left nephrectomy. A 22 gauge spinal needle was used to inject 3–5 cm3 of vital dye into the antero-lateral aspect of the left kidney. Ten of the 13 kidneys were injected without immediate extravasation and underwent successful laparoscopic resection from the renal fossa. Seven of the 10 kidneys were subsequently removed from the ...

THE TECHNIQUE OF PERCUTANEOUS ULTRASOUND GUIDED FINE‐NEEDLE ASPIRATION BIOPSY AND AUTOMATED MICROCORE BIOPSY IN SMALL ANIMAL GASTROINTESTINAL DISEASES

Techniques for obtaining percutaneous ultrasound‐guided biopsies of the gastrointestinal tract were evaluated. The efficacity of ultrasonographic detection of gastrointestinal lesions has been established in veterinary medicine. Percutaneous ultrasound‐guided aspiration biopsies were performed using either a 22 gauge spinal needle or a 20 gauge Westcott needle. The microcore automated biopsy was performed using a 18 gauge Tru‐cut‐like needle, assisted by an automated biopsy gun. These techniques are rapid, and easily performed. The techniques were considered safe for the patient, no complications such as hemorrhage, peritonitis or abscessation have occured in our study. These techniques are of particular interest when lesion can not be biopsied successfully by endoscopy and when surgical resection is not recommended.

An evaluation of a combined spinal/epidural needle set utilising a 26-gauge, pencil point spinal needle for caesarean section.

We have conducted a prospective study into the ease of use and incidence of postdural puncture headache with the 'Portex' combined spinal/epidural set. The pack contains a 16-gauge Tuohy needle of standard 8 cm shaft length with a matching 26-gauge pencil point spinal needle. The study included 150 consecutive combined spinal/epidural anaesthetics for lower segment Caesarean section. Eighty-eight percent of the cases fulfilled the criteria as technically perfect, i.e. cerebrospinal fluid obtained at the first attempt after identifying the epidural space. There were two cases of significant postdural puncture headache requiring blood patch due to puncture by the 26-gauge spinal needle giving an incidence of 1.3%. This compares favourably with previously reported rates in obstetric patients.