Prone position: A possible method to decrease post dural puncture headache (PDPH) during surgery

Caffeine and Sleep in Preventing Post-spinal Headache: Which One is More Effective?

OBJECTIVE

The study aimed to determine the effects of caffeine consumption and sleep on post-spinal headache after spinal anesthesia.

BACKGROUND

Post-spinal headache is among the most well-known and common complications of spinal anesthesia. Although caffeine consumption is recommended to prevent headache after spinal anesthesia, caffeine does not prevent headache and causes sleep-related problems. No study in the literature found a correlation between sleep and caffeine consumption after spinal anesthesia and post-spinal headache.

METHODS

The research is a descriptive and cross-sectional study. The study sample comprised 425 patients who underwent elective surgery in a research hospital. The research data were collected by face-to-face interviews between April 2021 and December 2023. The "Sociodemographic and Clinical Characteristics Form," "Richard-Campbell Sleep Scale," "Insomnia Severity Index," and "Visual Analog Scale" were used in data collection. Factors affecting post-spinal headache were determined using binary logistic regression analysis.

RESULTS

According to the binary logistic regression, the insomnia severity score (OR = 1.234; p < .001), sleep quality score (OR = .992; p < .01), postoperative sleep duration (OR = .619; p < .05), and not consuming coffee (OR = .035; p < .001) are statistically significant predictors of post-spinal headache and explain 57.7% of the variance. A one-unit increase in patients' insomnia severity increased the probability of experiencing a post-spinal headache by 23.4%. With a one-unit increase in sleep quality, there was an 8% decrease in the probability of experiencing spinal headache, and a 3.81% decrease in the probability of experiencing post-spinal headache with an increase in sleep duration after surgery. The probability of experiencing post-spinal headache was 0.35 times higher in individuals who did not consume caffeine after surgery than in those who consumed it.

CONCLUSION

The present study demonstrated that insomnia severity and sleep quality were more effective than caffeine consumption in preventing post-spinal headache. Insomnia and decreased sleep quality may cause a significant burden in developing post-spinal headache in patients and may cause post-spinal headache to be observed more frequently. Therefore, the use of caffeine in preventing or reducing post-spinal headache may adversely affect the duration and quality of sleep and increase the severity of insomnia.

Treatment and Prevention of Post-dural Puncture Headaches: A Systematic Review

Post-dural puncture headache (PDPH) is occasionally an inevitable side effect of neuraxial anesthesia, which can happen after spinal anesthesia or if an accidental dural puncture (ADP) happens during epidural anesthesia. The treatment and prevention options for PDPH differ widely from one institution to another. The management of PDPH is heterogeneous in many institutions because of the absence of clear guidelines and protocols for the management of PDPH. This study aimed to summarize all articles published during the past decade that discussed the treatment or prevention of PDPH. From 2013 to 2023, 345 publications were filtered for all treatment and prevention approaches used for PDPH patients. The Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) 2020 guidelines were followed for conducting this systematic review, and 38 articles were included for analysis and review. Existing data come from small randomized clinical trials and retrospective or prospective cohort studies. This review supports the effect of oral pregabalin and intravenous aminophylline in both treatment and prevention. Intravenous mannitol, intravenous hydrocortisone, triple prophylactic regimen, and neostigmine plus atropine combination showed effective and beneficial outcomes. On the other hand, neither neuraxial morphine nor epidural dexamethasone showed promising results. Consequently, the use of neuraxial morphine or epidural dexamethasone for the prevention of PDPH remains questionable. Regarding the posture of the patient and its consequences on the incidence of the headache, lateral decubitus is better than a sitting position, and a prone position is better than a supine position. Smaller non-cutting needles play a role in avoiding PDPH. Minimally invasive nerve blocks, including sphenopalatine ganglion or greater occipital nerves, are satisfyingly effective. Epidural blood patches remain the more invasive but the gold standard and ultimate solution in patients resisting medical therapy. This study highlights the need for larger research to define the best approach to prevent and treat PDPH.

Success rates of endotracheal intubation using the standard method versus the modified-ramped position

Background

The sniffing position used in intubation has disadvantages, including suboptimal glottic view, respiratory problems, increased risk of aspiration, and pain. In this regard, we have proposed new conditions to facilitate intubation and tube placement in patients with a Mallampati score higher than 2, by introducing a new position called the modified rapid airway management positioner (RAMP) position. The authors compared various parameters to improve intubation conditions between these two positions.

Methods

This intervention is a randomized clinical trial study, with a random sampling method that divides the patients into two groups: a control group placed in the standard position (S) and an intervention group placed in the modified (M) RAMP position. An anesthesiologist performed intubation. In group (S), patients were placed in the supine position as usual, and a pillow with a height of 10 cm was placed under their heads. In group (M), the patients were placed in the supine position on a modified RAMP with a triangular shape, 15 cm in height, and 80 cm in length, at a 30° angle. The pillow had lengths of 20 and 80 cm.

Results

In the present study, 112 patients were investigated, consisting of 58 women (51.8%) and 54 men (48.2%). The intubation time in the intervention group using the modified RAMP roll technique was significantly shorter (51.25 s) compared to the control group using the standard method (88.39 s) (P=0.019).

Conclusion

The results of the study showed that the modified RAMP roll improved the general conditions of intubation and led to a better view of the glottis in direct laryngoscopy. This is a very important aspect of intubation, and with a better view of the pharynx and glottis, the intubation procedure can be performed with higher quality, reducing the number of intubation attempts and the duration of the procedure.