title: No risk of metal toxicity in combined spinal-epidural anesthesia.
abstract: Using the single level needle-through-needle technique for combined spinal-epidural anesthesia (CSE) may introduce very fine metal particles abraded by the spinal needle from the inner ground edge of the Tuohy needle into the patient. Either the local anesthetic administered epidurally or the peridural catheter may also pass intrathecally through the hole in the dura made by the spinal needle. To examine these concerns, the needle-through-needle technique was simulated in an in vitro model (18-gauge Tuohy needle; 27- or 29-gauge Quincke needle). The presence of abraded metal particles was identified by atomic absorption spectrography (AAS). The needles were then examined under an electron microscope. Metal particles could not be identified by using AAS in the needle-through-needle technique after normal clinical use, nor could traces of use be revealed by using an electron microscope to examine the Tuohy needle. With intentionally rough handling and caudal orientation of the spinal needle tip, minimal scratches could be seen by using an electron microscope, but there were no metal particles detected by AAS. In an anatomical preparation, the possible passage of the epidural catheter anesthetic through the dural puncture hole into the cerebrospinal fluid compartment was investigated endoscopically. Neither passage of dyed epidural local anesthetic nor penetration of the epidural catheter into the cerebrospinal fluid compartment could be demonstrated by endoscopy. We conclude that the needle-through-needle-technique is an acceptable way of performing CSE anesthesia. Endangering the patient by an unintentionally intrathecal misplacement of the epidural catheter seems to be very unlikely based on our in vitro model if small spinal needles (27- or 29-gauge) are used.
  
  
  CONCLUSIONS
  Atomic absorption spectrography shows no contamination of the intrathecal compartment by abraded metal particles from the Tuohy needle by combined spinal-epidural anesthesia with the needle-through-needle technique. In vitro, neither passage of dyed epidural local anesthetic nor penetration of the epidural catheter into the cerebrospinal fluid compartment could be demonstrated by endoscopy.
authors.affiliation: Department of Anesthesiology and Intensive Care Medicine, Karlsburg Hospital and Ernst-Moritz-Arndt-University, Greifswald, Germany.
authors.forename: D
authors.initials: D
authors.lastname: Holst
authors.forename: M
authors.initials: M
authors.lastname: Möllmann
authors.forename: B
authors.initials: B
authors.lastname: Schymroszcyk
authors.forename: C
authors.initials: C
authors.lastname: Ebel
authors.forename: M
authors.initials: M
authors.lastname: Wendt
mesh_terms: D000767:Anesthesia, Epidural / Q000295:instrumentation* / Q000379:methods; D000775:Anesthesia, Spinal / Q000295:instrumentation* / Q000379:methods; D000779:Anesthetics, Local / Q000008:administration & dosage / Q000134:cerebrospinal fluid; D002045:Bupivacaine / Q000008:administration & dosage / Q000134:cerebrospinal fluid; D002857:Chromium / Q000032:analysis; D004396:Coloring Agents; D004388:Dura Mater / Q000473:pathology; D004724:Endoscopy; D004867:Equipment Design; D006801:Humans; D008345:Manganese / Q000032:analysis; D008751:Methylene Blue; D008855:Microscopy, Electron, Scanning; D009339:Needles / Q000009:adverse effects; D009532:Nickel / Q000032:analysis; D012307:Risk Factors; D013054:Spectrophotometry, Atomic; D013129:Spinal Puncture / Q000295:instrumentation / Q000379:methods; D013232:Steel / Q000009:adverse effects* / Q000032:analysis; D013499:Surface Properties