Epidural blood patch

Neurology is an ER specialty nowadays and there are a few therapeutic interventions in emergency neurology that can really make your day, among them

  • cool treatments for migraine (propofol, ketamine, oxygen)
  • the BPPV liberation maneuvers
  • quick-and-easy thrombolysis
  • the epidural blood patch.

I find that many experienced neurologists don’t routinely do blood patches, but prescribe tedious bed rest and caffeine for weeks. Why that should be is not clear, yet we aim to improve matters by teaching the basic technique in one session.

Remark that there is indeed evidence for the blood patch (even the Cochrane nowadays recognises it).

Here is my recipe

  • Get two persons
  • Sterile garments for both of them
  • One traumatic LP needle (Quincke), standard size, a butterfly, 2 syringes 20 ml preferrably Luer lock
  • Prep both the arm for venipuncture and the standard LP field on your sitting patient (position as for sitting-LP)
  • Use maximum sterile technique (grade III: iodine-containing, 3 times, full exposition time)
  • Both put on sterile garments and simultaneously start working
  • Advance your Quincke needle 1 cm below the skin, pull out the mandrin, put on a syringe with about 10 ccs of air
  • Start oscillating the plunger and advance the needle until you can suddenly push in air (loss-of-resistance)
  • Fix the needle at this depth with your left hand (this is important)
  • Get the sterilly obtained 15-20 ccs of patient blood
  • Slowly push the blood in (there is some resistance here, continually increasing), noting that the patient feels the pressure
  • Expect the blood to explode suddenly, so beware to wear glasses
  • Pull everything out, put on a strip, then have the patient stand up and feel no pain anymore.