Champagne Tap?

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Zanegray said:
I did read that advancing only with the stylet in place - whether protective of epidermoid cyst or not - helps reduce post LP headache. Another thing to consider!
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Source please? The only things I've seen that effected post-LP HA were small needle size, replacing stylette prior to removal of needle, and use of an atraumatic needle. Apparently making sure the needle is parallel to the fibers of the dura helps also:

http://guidelines.gov/content.aspx?id=8102
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Did one a few days ago and got 2 WBC 4 RBC. So close.
 
Arcan57 said:
Source please? The only things I've seen that effected post-LP HA were small needle size, replacing stylette prior to removal of needle, and use of an atraumatic needle. Apparently making sure the needle is parallel to the fibers of the dura helps also:

http://guidelines.gov/content.aspx?id=8102
Click to expand...

Agreed. I have never heard that stylet in for advancing does anything for headache. Yes, stylet in for removal does decrease PDPH.
 
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So basically I was taught needle parallel to fibers, stylet in at all times whether advancing or withdrawing. Is this basically correct and accepted, or is there something else I should do in the future?
 
sylvanthus said:
So basically I was taught needle parallel to fibers, stylet in at all times whether advancing or withdrawing. Is this basically correct and accepted, or is there something else I should do in the future?
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That is the generally accepted opinion. No one will ever get angry at you for doing it with that method.
 
I only see case reports published in PubMed; not even case series. I would say its frequency is sufficiently uncommon as to be beyond the lower bounds of the ability to estimate its true incidence.

If you leave the stylet in, you will probably reduce, but not prevent, epidermoid cyst formation, based on biological plausibility. However, evidence suggests that success rates for LPs are improved when the needle is advanced with stylet removed. It is likely more will be harmed by the consequences of failed LPs than by epidermoid cyst formation. Therefore, the technically correct method is probably more likely to lead to overall patient harms.
 
Anyone ever get a med student a bottle of champage if they got a champagne tap?
 
Another necrobump, but pulled off my first champagne tap last night. RBC=0 WBC=1 (still counting it). Attending acknowledged but I don't think the bottle of champagne is coming... I think I'm gonna have to bring that back once I hit attending status.
 
alehar said:
Another necrobump, but pulled off my first champagne tap last night. RBC=0 WBC=1 (still counting it). Attending acknowledged but I don't think the bottle of champagne is coming... I think I'm gonna have to bring that back once I hit attending status.
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0/1?

It needs to be 0/0.
 
alehar said:
Another necrobump, but pulled off my first champagne tap last night. RBC=0 WBC=1 (still counting it). Attending acknowledged but I don't think the bottle of champagne is coming... I think I'm gonna have to bring that back once I hit attending status.
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Nope, not a champagne tap. Better luck next time.
 
So as a 4th year on second EM elective my first LP ever was a champagne tap. Still not sure how the heck that happened but I got my bottle of bubbly (probably because the attending was my friend) however he did say in his 3 years as aPD and 5 years working with residents/students this was the first bottle he had to give away. I was super excited. Guessing it won't happen again for a VERY long time.
 
Pediatrician here.....

I must be missing something, because to me a "champagne" tap means no RBCs and has nothing to do with WBCs.

The whole idea behind a champagne tap is that theoretically you minimize trauma and get a "clean" entry into the thecal sac and thus withdraw CSF that is "untraumatized" by ruptured blood vessels. Of course, HSV can lead to copious RBCs in the CSF fluid, so this is just a theoretical distinction between traumatic and atraumatic. For babies at risk of HSV it is important to document whether the LP was traumatic or not.

Theoretically a "champagne" tap is something that indicates the relative skill of the operator. What does the lack or presence of WBCs have to do with the skill of the operator?

For the record, I've gotten many champagne taps but they were all in neonates, which are much easier IMHO than older kids and adults.

One other comment: for neonates at least, the nurses holding the baby in just the proper way with the right amount of restraint are much more responsible for the champagne tap than the person doing the needle stick IMHO.
 
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Socrates25 said:
Pediatrician here.....

I must be missing something, because to me a "champagne" tap means no RBCs and has nothing to do with WBCs.

The whole idea behind a champagne tap is that theoretically you minimize trauma and get a "clean" entry into the thecal sac and thus withdraw CSF that is "untraumatized" by ruptured blood vessels. Of course, HSV can lead to copious RBCs in the CSF fluid, so this is just a theoretical distinction between traumatic and atraumatic. For babies at risk of HSV it is important to document whether the LP was traumatic or not.

Theoretically a "champagne" tap is something that indicates the relative skill of the operator. What does the lack or presence of WBCs have to do with the skill of the operator?

For the record, I've gotten many champagne taps but they were all in neonates, which are much easier IMHO than older kids and adults.

One other comment: for neonates at least, the nurses holding the baby in just the proper way with the right amount of restraint are much more responsible for the champagne tap than the person doing the needle stick IMHO.
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Mine was 0/0 but I agree with socrates I thought just no RBC as it's considered an atraumatic tap. Maybe I missed something.
 
I get them bout 50% of the time, but I don't use the 1st couple drops anyway. Needle insertion site, if i'm using a cutting needle, is always adjacent the lido injection site. Pencil point needles go into the lido site. Only had a handful of 0/0's though. Last one was a 0/0 with a 22g pencil point, though 20g quinke is my typical needle.
 
Last year as a TY intern I got my first champagne tap (0/0). But you guys are way wrong, that stuff tasted nothing like champagne.
 
Recently got my first champagne tap at the end of an otherwise very rough night. No champagne though I did have a glass of wine when I got home. I've done a few where I get the RBC = 1 and too just feel like the lab is playing with me! :)
 
Socrates25 said:
Pediatrician here.....

I must be missing something, because to me a "champagne" tap means no RBCs and has nothing to do with WBCs.

The whole idea behind a champagne tap is that theoretically you minimize trauma and get a "clean" entry into the thecal sac and thus withdraw CSF that is "untraumatized" by ruptured blood vessels. Of course, HSV can lead to copious RBCs in the CSF fluid, so this is just a theoretical distinction between traumatic and atraumatic. For babies at risk of HSV it is important to document whether the LP was traumatic or not.

Theoretically a "champagne" tap is something that indicates the relative skill of the operator. What does the lack or presence of WBCs have to do with the skill of the operator?

For the record, I've gotten many champagne taps but they were all in neonates, which are much easier IMHO than older kids and adults.

One other comment: for neonates at least, the nurses holding the baby in just the proper way with the right amount of restraint are much more responsible for the champagne tap than the person doing the needle stick IMHO.
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This is what I always heard, but now I'm not sure.
 
I find if I let the first couple of liters of CSF fall on the field and just collect the very last bit of CSF my rate of champagne taps go up.
 
I get them all the time. I'd guess more than 30% on easy LPs. I suspect it is somewhat lab dependent. My student, who I guided through his first LP the other day, had a champagne tap. That's some good coaching there!
 
I had a champagne tap last night and my attending brought a bottle of champagne this morning. I use the stilett to go through the skin but then pull it out and wait till csf comes if not I slowly advance without the stilett in place if needed. I used to keep the stilett in and advance waiting for the '' pop'' and then would always get bloody taps... So I changed and if worked better in the babies. Also I go on lumbar space higher than the iliac crest and have been successful ever since.
 
Use the stylet to clear out the blood that likes to develop at the tip of the needle from the puncture, and let the first few drops hit the bed and you'll see champagne more often.
 
Stylette is there so you dont PLUG THE LUMEN OF THAT SMALL ASS SPINAL NEEDLE WITH TISSUE AND GET A "DRY TAP."

Stylette doesnt do JACK SQUAT for spinal headache. Go parallel to fibers, use small gauge, do NOT USE CUTTING edge needle, use a blunt tip (whitacre).

I usually dont give two shats about a post puncture headache in someone I think has meningitis.

Got straight 0's down the line ONCE. done tons of LP's.
 
hopefulgasman said:
We use EPIC at my shop and my most recent tap results read RBC <1. Does this count as a champagne tap or not since it’s technically not 0?
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your lab tech is an a***ole. :p
 
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This was a fun thread to read.
hopefulgasman said:
We use EPIC at my shop and my most recent tap results read RBC <1. Does this count as a champagne tap or not since it’s technically not 0?
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I'm curious to know what instrument your lab used for the count. Most labs use a Sysmex automated hematology analyzer that'll do all body fluids (older versions of the instrument don't perform counts on clear/colorless CSFs). The downside to this instrument is that the linearity of the instrument does not go down to a count of 0, so if the instrument reports a RBC/WBC count of 0, we'll perform a manual count (which is the reason why they'll take a little longer than normal) and you most likely won't get that champagne tap because we'll probably find something.

I'm guessing your lab uses the Iris iQ200 Elite, which is used for performing microscopies of UAs and fluids. It calculates the RBCs by subtracting the nucleated cells from the total cells identified in the fluid. I'm guessing that's why your lab reported it as <1 because some images were seen in both categories, but didn't exactly subtract the RBC count to 0 (or that lab tech was being an a$$hole). On a positive note, this instrument does have a linearity down to 0. I attached some images to help clarify what we see on the instrument vs what is seen under a microscope. For the record, labs use hemocytometers for cell counts and not by placing a drop on a slide and counting away like these images insinuate.
 

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Since covid I've been deathly scared of doing LP's, probably not rationally so
 
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dingdong28 said:
This was a fun thread to read.

I'm curious to know what instrument your lab used for the count. Most labs use a Sysmex automated hematology analyzer that'll do all body fluids (older versions of the instrument don't perform counts on clear/colorless CSFs). The downside to this instrument is that the linearity of the instrument does not go down to a count of 0, so if the instrument reports a RBC/WBC count of 0, we'll perform a manual count (which is the reason why they'll take a little longer than normal) and you most likely won't get that champagne tap because we'll probably find something.

I'm guessing your lab uses the Iris iQ200 Elite, which is used for performing microscopies of UAs and fluids. It calculates the RBCs by subtracting the nucleated cells from the total cells identified in the fluid. I'm guessing that's why your lab reported it as <1 because some images were seen in both categories, but didn't exactly subtract the RBC count to 0 (or that lab tech was being an a$$hole). On a positive note, this instrument does have a linearity down to 0. I attached some images to help clarify what we see on the instrument vs what is seen under a microscope. For the record, labs use hemocytometers for cell counts and not by placing a drop on a slide and counting away like these images insinuate.
Click to expand...
My thoughts exactly!
 
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Since this thread got necro'd I've done ~20 LPs in residency and have 4-5 champagne taps. I leave the stylet in when advancing FWIW.
 
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