Common sense medicine and cerebrospinal lavage

I read with great interest the case report by Dias et al. 1, describing the successful treatment of accidental spinal potassium chloride administration using a cerebrospinal fluid (CSF) lavage technique. I wish to commend the authors’ decisive action to dilute and remove the excess potassium chloride in exchange for saline, thereby avoiding major irreversible complications. As the authors discuss, accidental intrathecal administration of potassium chloride can have serious temporary or permanent sequelae, including death. The concept of CSF lavage to manage intrathecal injection of excess or wrong drugs is not a novel one; over the last 30 years, multiple authors, including myself, have reported the use of CSF lavage in both obstetric and non-obstetric patients 2-4. In a recent obstetric case, we successfully used the same technique as Dias et al. to reverse accidental high spinal anaesthesia and prevent a total spinal 4. Nevertheless, CSF lavage is rarely mentioned as a potential method of managing complications associated with accidental intrathecal injection, particularly in obstetric cases. The recent focus on evidence-based medicine has thrown support behind the randomised controlled trial (RCT) as the gold standard in evaluating new treatments. Given the lack of RCT evaluation, it is therefore understandable that CSF lavage is not considered as a standard treatment for accidental intrathecal injection or high/total spinal anaesthesia. Obviously, a proper RCT would address the effectiveness and safety of CSF lavage; however, since the method is usually only performed in emergency situations, such a trial would be difficult to perform and unlikely to be published in the near future. While one must exercise caution before accepting the benefits of a new treatment and applying it clinically based only on case reports 5, perhaps we should reconsider the risks and benefits of CSF lavage from a common sense perspective. Indeed, as in the ‘parachute’ argument 6, some believe that the benefits of certain treatments or interventions are obvious despite a lack of RCT evidence. The current literature has yet to report any major drawbacks when CSF lavage is used in a clinically indicated emergency situation. Indeed, the technique has shown efficacy in addressing a number of potentially dangerous clinical scenarios and preventing serious or permanent damage, and the presence of an intrathecal catheter provides a convenient means to remove and replace contaminated CSF. Thus, I urge clinicians to consider utilising this lavage technique, in addition to providing cardiopulmonary support as needed, at least on a case-by-case basis, rather than ignoring and overlooking its potential life-saving benefits simply because the procedure has yet to be supported by RCT evidence.

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