Creative treatment possibility

[LauraL840]

If anyone here has good communication with Schievink, Mokri, any anesthesiologist, or other neuro/neurosurgeon who treats csf leaks .... I have a question about a potential treatment possibility that I've been mulling around in my head. If you do have good communication, can you please pose this 'potential' treatment??????

Here's the 'treatment' (as I would define it):

Autologous Epidural Blood Infusion

What I'm 'proposing' is where a patient would come in and donate their own blood which would then be infused into the epidural space following a bolus injection (same as high volume or regular volume epidural blood patch and utilizing the same injection site - catheter). This would have to be done as inpatient and preferably over a 7-10 day period, OR, if portable equipment is available and sterility can be insured, it could be done outpatient (but doubtful).

Here's why I think it would work:
Blood is proven to be cheap, readily available, and effective in sealing the dura FOR MOST spinal leakers. It improves clotting time and delivers oxygen to the injured tissue. However, blood only lasts in that space for a limited period of time so if a person has multiple leak sites, scar tissue, a larger leak, or other complicating factors; EBP's don't always work.

This would essentially be like doing back to back epidural blood patches in a four day window of time (which seems to be the 'standard' for duration of effective clotting time in the epidural space), except the blood would be continuously infused into that space bringing fresh clotting factors and oxygen. Once the bolus injection is completed, then a bag of blood would be hung connected to an infusion pump and the remaining blood product infused over several days. I'm thinking at an infusion rate that is continual but comfortable to reduce nerve root irritation. If additional blood is needed, it can be harvested from the patient while the infusion is taking place.

I'm also interested in what a DOCTOR would think about not only infusing blood into the epidural space, but also plasma or platelets, which would be thicker.

It all makes sense in my head ... but so does NOT canceling a medically disabled child's insurance while they are still seeking treatment and relief from their disability! :mad:

Lots of things make sense to me, but may not work from the point of a viable treatment as doctors would consider.

[Tamaretta]

Laura, you are a PRIZE!!!! These are my questions/concerns/experiences:

1. The highest rate Taylor was ever able to tolerate a spinal infusion was 14 cc/hr. That was using an external catheter and Elliotts B solution. (Elliotts B solution is the closest "match" to CSF in pH, etc.) After 6 days, due to the external cath she developed meningitis. HOWEVER , those six days were the only time in 5 years that her headache has been below a "7" and she didn't need anti-emetics 24/7. Also, every neuro and neurosurgeon she's ever seen would only allow an external cath or drain to be in a MAXIMUM of 7 days.

2. Back in Houston, she had an intrathecal device placed and normal saline was infused. (Docs here said Elliotts B was cost prohibitive) She could only tolerate 5 cc/hr of saline before getting neuropathy in her hands and feet and NEVER got the results she got from the Elliotts B. Later, the docs d/c the infusion due to the poor results and the theory that possibly the infusion was "forcing" more holes into her weak dura and not allowing healing. (One other thing, be ADAMANT that they start the infusion very slowly, i.e. 1 cc/hr for 8 hrs, then 2 cc/hr for 8 hrs, etc. We had an idiot, ooops I mean resident, that wanted to start her at 14 cc since that's what worked before....)

3. CLOTTING: In the past, Taylor had a type of PICC line (vein) called a Groshong that had a special valve/tip on the end that DOESN"T require heparin to keep the line from clotting. She doesn't have that type now and her infusion must run at 30 cc/hr to keep the line patent.

So, my questions:

1. Are epidural caths available with the Groshong valve? Otherwise, how can you keep the tip from clotting off while infusing without using heparin - which would defeat the purpose?

2. After drawing blood, how long is it stable without preservatives in the frig?

3. How long is blood stable without preservatives at room temperature (i.e. infusion time)?

4. Would mixing the blood with blood substitutes allow for longer clotting time?

5. Are blood substitutes (other than NS) safe for intrathecal use?

6. Could you mix the Elliott B solution with blood to reduce the clotting time while not compromising the viscosity?

Any vampires/phlebologist/neurosurgeons/medical professionals/wannabe's with any answers?

[LauraL840]

And you think I'M a prize!!!!!

You've got some great insight into this (I kinda thought you might with Taylor's experiences) and THANK YOU so much for your input. I'll look into some of your questions as time permits.

I do think I recall that for pre-op autologous blood donation, that blood can be donated up to 6 weeks in advance. It's expensive to keep blood that long and I do believe 'additives' are required. I think that patients can donate their own blood at a higher rate than say donating blood to Red Cross which makes you wait like 6 or 8 weeks between donations.

The infusion rate questions are EXCELLENT! I was thinking of the procedure looking like a normal EBP and then (using same cath) beginning to infuse. It might cause less irritation, rebound ha, high-pressure sensations, to just infuse without performing EBP. My infusion opinion is that you should start slow and increase slowly until relief is noticed (of course a patient lying down has different 'relief' than when resuming 'normal' movement). It would be good to try this with patient supine or in trendelenburg for the first 24-48 hours ... bedpan use and easy foods to eat while lying down. Then slowly increase movement.

The whole 'meningitis' issue really concerns me though with having a cath placed that long. My thinking lines up with the doc who said 7 days max.

I would also think having a PICC line placed to increase fluids and give meds would also be helpful. I wonder if it would be advisable to run a 7-10 day course of broad spectrum antibiotics while infusing blood to 'prevent' meningitis. It won't help if it's a 'chemical' meningitis (irritation from blood), but that's a pretty low risk for most EBPs.

Catheter options:
I found this type just now that sounds somewhat like the Groshong...
http://www.bardaccess.com/picc-dupen.php

OK, I did just have a total PIPE dream of a concept that would probably work, but it will likely never happen! An EBP with umbilical cord blood ... it's CHOCK FULL of stem cells!

I just wish doctors would communicate ideas like these amongst themselves and try to figure out a solution for people like us who either are suffering directly or watching a loved one suffer from this FIXABLE injury!

That's all for now! :D

[LauraL840]

Most of what I find on Elliot's B is that its used as a "Diluent for the intrathecal administration of methotrexate sodium and cytarabine for the prevention or treatment of meningeal leukemia or lymphocytic lymphoma."

Seems to me if that's the case, then you could use it as a diluent mixed with blood to reduce clotting time, but it does appear to affect viscosity ... it's classified as a diluent which means it's used as a thinner.

I did find their website:http://www.elliottsbsolution.com/which does, at least, tell you what Elliot's B IS (Elliotts B Solution (buffered intrathecal electrolyte/dextrose injection) .....Elliotts B Solution is comparable in pH, electrolyte composition, glucose content, and osmalarity to cerebrospinal fluid) Pretty much what you said! LOL

I'm going to cut and paste some information about autologous blood donation from a site that appears to be 'related' to what I'm thinking of. The site is:http://www.bloodbook.com/autolog-1.html
Bear in mind that this site is a blood bank, so there are terms, etc that indicate fees and retrieval issues, etc that may not apply if you have a facility that will harvest the blood and store it. Therefor most of the information is not pertinent, so here are the parts that probably are:

TYPES of AUTOLOGOUS BLOOD for TRANSFUSION

Five categories of autologous transfusions are generally recognized:


Preoperative autologous Blood donation, transfusion and storage (PABD): units of Blood are drawn from a patient usually starting (in the short term case) three to five weeks before an elective surgical procedure and stored for transfusion at the time of the surgery.


Intraoperative hemodilution: Blood is collected at the start of surgery and the fluid volume lost is replaced with appropriate IV solutions, and then finally, stored Blood is reinfused after surgery.

Intraoperative Blood salvage: Blood is salvaged from the surgical area during the operation for re-infusion during or after the surgical procedure.

Postoperative Blood salvage: Blood is collected after the surgical procedure is complete by drainage of the operative area and re-infused.


Autologous self stored Blood (Blood banking): your own Blood is preserved in a frozen state for use by you or your designee at a later time, in case your need of a Blood transfusion arises. The safest Blood you can receive is your own! This process eliminates donor-transmitted diseases. If you have a rare Blood type, or if your Blood contains rare components, this process may mean the difference between life and death (and be covered by insurance). Autologous Blood is always a perfect match. It will be there when you need it..... regardless of a general Blood shortage. Not everything about Blood is known. Your Blood is unique in its composition. In addition to the groups of A, B, O and Rh types, there are as many as 100 or more sub-types. The chances of obtaining a transfusion from an unrelated stranger, where all sub-types match, is estimated to be less than 1 in 100,000. You will not form harmful antibodies or have a transfusion reaction when you receive your own blood.

Who is qualified to be an Autologous Blood donor?


Those who are not anemic (starting Hemoglobin must be at least 11 grams, slightly lower than required of a regular Blood donor, i.e., 12 grams).

Those who have no medical condition that could cause problems during or after the Blood donation process.

Children weighing over 65 pounds.

Those who are having planned surgery that routinely requires a Blood transfusion (except in cases where long term storage is desired).

Those who have veins large enough for the procedure.


What is the cost to me?

The cost of Autologous Blood collection, testing, storage and distribution to the final point of use is great. Since this 'self storage' is discouraged by the 'Blood establishment,' there is no real assistance given by those best suited to help. You must look into every aspect of this process before you commit to the long term arrangements. Sometimes there is insurance assistance, but this is rare. Remember, as you consider the expense of paying for the storage of your own blood, in times of emergency, you may still require Blood from random donors. The medical facility treating you may not be able to obtain and prepare your stored Blood in time of need.

What are the benefits of Autologous Blood transfusion?


Availability..... in contrast with donor blood, the patient's type of Blood is instantly available and requires no cross matching.

Safety..... no risk of transfusion reactions due to incompatibility.

Purity..... no risk of transmitted disease, such as, among others, HIV/AIDS, Hepatitis B & C, HTLV 1&2, & Syphilis.

Acceptance..... sometimes Blood donation is the source of fear or taboo, in others the infusion of Blood is prohibited by religion. Often autologous Blood transfusion may overcome some of these objections.

What factors increase risk for Autologous donation?

Pediatric Donors - Statistics demonstrate that autologous Blood donation is safe for children from ages seven to18 years. The lower age limit is determined by the ability of the child to safely cooperate and their availability of suitable veins. The maximum amount of Blood that may be safely withdrawn at one sitting is approximately 12% of the donor's Blood volume.

Adult Cardiac Donors - Experience with pre-operative autologous Blood donations in adult cardiac patients suggests that this technique is safe and effective in reducing homologous Blood requirements. A thorough physical examination prior to donation is recommended, and continuous EKG and Blood pressure monitoring during and after donation is prudent. The consensus of objective experts is that isovolemic autologous donation can safely be used in patients scheduled for cardiac surgery, based on the absence of subjective complaints, without objective monitoring. Exceptions are those patients with unstable angina, critical aortic stenosis, and recent myocardial infarction.

Is there something often overlooked that I should remember?

Yes..... keep a written record of every name, every date and every number. Be certain of the accuracy and legibility of every one of your records. You must also have these records available to you at all times. If you do not have your notes with you, they will be of little value! The other paramount rule is to make certain that you always know the final and complete delivered costs Blood Book - END
What a MOUTHFUL!

Here's a website that discusses the benefits of iron-rich foods and diet as it relates to the 'strength' of blood. http://www.ironrich.com/


Definitions and uses of Blood Products (Merck):
http://www.merck.com/mmpe/sec11/ch146/ch146c.html

I've got to run for now ... time to fix dinner! More later!

[cacoelho]

hmmm....Elliotts B Solution...sounds like Gatorade..wouldn't that be cheaper.....just kidding.
I'm new here and really appreciate all the posts by "veterans"
I'm a spontaneous leaker...boy, what an education
Alice

[Tamaretta]

Sorry you're here Alice, but if you're a leaker--well you've come to the right place.....Elliots B is EXACTLY like Gatorade, only different...tee hee oh yeah and it costs about $10,000/pint (price only slightly exaggerated)

[guineapig]

hey Laura,

the ebp w/ umbilical cord blood would be wonderful, but it will only work if parents instructed the preservation of it at birth and it was kept so. one can't use stem cells from someone else (say a newborn on floor 2); must use one's own.

who was it that had ebps within 7 days? cacoelho/Alice? what were the volumes, particularly the first. i had a 22cc lumbar patch followed by a circa 60cc lumbar/thoracic about 10 days later. from this second one (or a combo of both) i had gradual, good improvement. i wonder how the improvement would have been without the first patch; maybe less? the 3rd patch, about 10 weeks after the 2nd improved symptoms even more; but the greatest improvement difference came from the 2nd patch.

i don't think your wonderful thinking will work. the blood coagulates which prevents other blood (infusion as you describe) from entering the epidural space. we need it to coagulate, that is how the tamponade of patch works.
i have thought of time proximate patches irrelevant of how well the patient is feeling. say 3 in a row separated by 5 to 15 days depending upon how much blood was injected. it would depend upon how much coagulated blood was absorbed leaving more room for fresh blood; and hoping that the dura is sealed, remains sealed, and that the new blood reinforces that fresh seal which otherwise would unseal were it not for the new blood.

yep, it might work. one could mix contrast agent into the blood, so following about 4 or 5 days a myelogram would enlighten how much blood was absorbed and if the epidural space was ready for more blood in the location which has absorbed the most blood and is the highest open area. maybe, maybe.

i still believe chronic leakers salvation lies in stem cells. which btw, i understand that the marrow does make stem cells which are released into the blood stream along with the usual blood cells, travel to wounded/damaged sites and become new tissue. so, in away, an ebp does deliver stem cells to the dura, just not enough.

ok, here is the football, someone take it and run.


If anyone here has good communication with Schievink, Mokri, any anesthesiologist, or other neuro/neurosurgeon who treats csf leaks .... I have a question about a potential treatment possibility that I've been mulling around in my head. If you do have good communication, can you please pose this 'potential' treatment??????

Here's the 'treatment' (as I would define it):

Autologous Epidural Blood Infusion

What I'm 'proposing' is where a patient would come in and donate their own blood which would then be infused into the epidural space following a bolus injection (same as high volume or regular volume epidural blood patch and utilizing the same injection site - catheter). This would have to be done as inpatient and preferably over a 7-10 day period, OR, if portable equipment is available and sterility can be insured, it could be done outpatient (but doubtful).

Here's why I think it would work:
Blood is proven to be cheap, readily available, and effective in sealing the dura FOR MOST spinal leakers. It improves clotting time and delivers oxygen to the injured tissue. However, blood only lasts in that space for a limited period of time so if a person has multiple leak sites, scar tissue, a larger leak, or other complicating factors; EBP's don't always work.

This would essentially be like doing back to back epidural blood patches in a four day window of time (which seems to be the 'standard' for duration of effective clotting time in the epidural space), except the blood would be continuously infused into that space bringing fresh clotting factors and oxygen. Once the bolus injection is completed, then a bag of blood would be hung connected to an infusion pump and the remaining blood product infused over several days. I'm thinking at an infusion rate that is continual but comfortable to reduce nerve root irritation. If additional blood is needed, it can be harvested from the patient while the infusion is taking place.

I'm also interested in what a DOCTOR would think about not only infusing blood into the epidural space, but also plasma or platelets, which would be thicker.

It all makes sense in my head ... but so does NOT canceling a medically disabled child's insurance while they are still seeking treatment and relief from their disability! :mad:

Lots of things make sense to me, but may not work from the point of a viable treatment as doctors would consider.