The effect of serial in vitro haemodilution with maternal cerebrospinal fluid and crystalloid on thromboelastographic (TEG®) blood coagulation parameters, and the implications for epidural blood patching

Evidence-based clinical practice guidelines on postdural puncture headache: a consensus report from a multisociety international working group

INTRODUCTION

Postdural puncture headache (PDPH) can follow unintentional dural puncture during epidural techniques or intentional dural puncture during neuraxial procedures such as a lumbar puncture or spinal anesthesia. Evidence-based guidance on the prevention, diagnosis or management of this condition is, however, currently lacking. This multisociety guidance aims to fill this void and provide practitioners with comprehensive information and patient-centric recommendations to prevent, diagnose and manage patients with PDPH.

METHODS

Based on input from committee members and stakeholders, the committee cochairs developed 10 review questions deemed important for the prevention, diagnosis and management of PDPH. A literature search for each question was performed in MEDLINE (Ovid) on 2 March 2022. The results from each search were imported into separate Covidence projects for deduplication and screening, followed by data extraction. Additional relevant clinical trials, systematic reviews and research studies published through March 2022 were also considered for the development of guidelines and shared with contributors. Each group submitted a structured narrative review along with recommendations graded according to the US Preventative Services Task Force grading of evidence. The interim draft was shared electronically, with each collaborator requested to vote anonymously on each recommendation using two rounds of a modified Delphi approach.

RESULTS

Based on contemporary evidence and consensus, the multidisciplinary panel generated 50 recommendations to provide guidance regarding risk factors, prevention, diagnosis and management of PDPH, along with their strength and certainty of evidence. After two rounds of voting, we achieved a high level of consensus for all statements and recommendations. Several recommendations had moderate-to-low certainty of evidence.

CONCLUSIONS

These clinical practice guidelines for PDPH provide a framework to improve identification, evaluation and delivery of evidence-based care by physicians performing neuraxial procedures to improve the quality of care and align with patients' interests. Uncertainty remains regarding best practice for the majority of management approaches for PDPH due to the paucity of evidence. Additionally, opportunities for future research are identified.

Accidental dural puncture during epidural blood patch: a narrative review

Whilst performing an epidural blood patch (EBP) to treat post dural-puncture headache following accidental or intentional dural puncture, the risk of a subsequent accidental dural puncture (ADP) is commonly quoted as 1%. However, a recent review reported only three documented cases. It seems likely that this complication is more common than is acknowledged, yet there is a paucity of literature and an absence of any guidance as to how to proceed in practice. This review addresses three unanswered questions regarding ADP during EBP: what is the incidence; what are the immediate clinical consequences; and what is the optimal clinical management? The incidence may reasonably be estimated to be 0.5-1%. Even on large units, this complication will not be experienced by every consultant anaesthetist during their career. It is likely to occur 20-30 times per year in the United Kingdom, and in greater numbers in those countries with higher epidural rates. Immediately re-attempting an EBP at a different level may be a reasonable management approach which has high efficacy, and is without clear evidence of significant harm. However, the limited evidence means that the risks are poorly characterised, and more data may lead to alternative conclusions. There is uncertainty amongst obstetric anaesthetists about how to manage ADP during EBP. More data and pragmatic guidance, which evolves with further evidence, will ensure optimal care for patients suffering this compound iatrogenic complication.

Factors associated with failed epidural blood patch after accidental dural puncture in obstetrics: a prospective, multicentre, international cohort study

BACKGROUND

Epidural blood patch is commonly used for management of post-dural puncture headache after accidental dural puncture. The primary aim was to determine factors associated with failed epidural blood patch.

METHODS

In this prospective, multicentre, international cohort study, parturients ≥18 yr receiving an epidural blood patch for treatment of post-dural puncture headache were included. Failed epidural blood patch was defined as headache intensity numeric rating scale (NRS) score ≥7 in the upright position at 4, 24, or 48 h, or the need for a second epidural blood patch, and complete success by NRS=0 at 0-48 h after epidural blood patch. All others were considered partial success. Multinominal logistic regression was used for statistical analyses with P<0.01 considered statistically significant.

RESULTS

In all, 643 women received an epidural blood patch. Complete data to classify failure were available in 591 (91.9%) women. Failed epidural blood patch occurred in 167 (28.3%) patients; 195 (33.0%) were completely successful and 229 (38.7%) partially successful. A total of 126 women (19.8%) received a second epidural blood patch. A statistically significant association with failure was observed in patients with a history of migraine, when the accidental dural puncture occurred between lumbar levels L1/L3 compared with L3/L5 and when epidural blood patch was performed <48 h compared with ≥48 h after accidental dural puncture. In patients having radiological investigations, three intracranial bleeds were diagnosed.

CONCLUSIONS

Failed epidural blood patch occurred in 28.3% of women. Independent modifiable factors associated with failure were higher lumbar level of accidental dural puncture and short interval between accidental dural puncture and epidural blood patch. A history of migraine was associated with a higher risk of second epidural blood patch.

CLINICAL TRIAL REGISTRATION

NCT02362828.

Epidural Blood Patch Performed Immediately After Dural Puncture and Epidural Drug Administration

The epidural blood patch (EBP) is a solution for persistent headaches following an accidental dural puncture. We report three cases where EBP was performed immediately after dural puncture combined with drug administration for lumbago. To the best of our knowledge, no similar cases have been reported in the literature.

The patients provided their informed consent, and all standard protocols were followed. At the moment of the dural puncture, all the patients manifested severe headaches, nausea, vomiting, and profuse sweating. A second epidural puncture was performed at a higher intervertebral space, followed by drug administration and 20 mL of autologous blood. All the patients improved gradually, while their headaches vanished after 30-35 minutes. The patients were kept in for monitoring and released the following day with specific instructions and daily phone contact for a week without any complications. Their lumbago symptoms regressed.

The possibility of pneumocephalus was excluded because of the patients’ symptomatology. The risk of high or total spinal anesthesia due to local anesthetic leakage subarachnoidally was countered with close monitoring of the patients. EBP complications include failure, postdural-puncture headache worsening by an accidental additional dural tear(s), back pain, and infection. All patients were instructed to report any symptoms immediately. EBP executed immediately after dural puncture seems to relieve headache fast and does not appear to impede epidural analgesia.

Systematic review of viscoelastic testing (TEG/ROTEM) in obstetrics and recommendations from the women's SSC of the ISTH

Thromboelastography (TEG) and rotational thromboelastometry (ROTEM) are point-of-care viscoelastic devices that use whole blood samples to assess coagulation and fibrinolysis. These devices have been studied extensively in cardiac surgery, but there is limited robust evidence supporting its use in obstetrics. The hesitancy toward its routine use in obstetrics may be due to the current lack of randomized controlled trials and large observational studies. The study aims to systematically review studies that investigated TEG/ROTEM use in pregnancy or peripartum, and to provide recommendations for future studies to fill current research gaps. We performed a systematic review of studies on viscoelastic testing in obstetrics. Included studies were original research, used TEG or ROTEM during pregnancy or peripartum, and published in English. Ninety-three studies, spanning 31 years from 1989 to 2020 and with a total of 32,817 participants, were included. Sixty-two (66.7%) of the studies used TEG and 31 (33.3%) used ROTEM. To date, there are a total of two randomized controlled trials on TEG/ROTEM use in obstetrics. ROTEM may be used to guide transfusion therapy for postpartum hemorrhage. TEG and ROTEM can detect the hypercoagulable changes associated with pregnancy. Variability between study protocols and results suggests the need for future large prospective high-quality studies with standardized protocols to investigate the utility of TEG/ROTEM in assessing risk for thrombosis and hemorrhage as well as in guiding prophylaxis and treatment in obstetric patients. This review identifies the gaps and provides concrete recommendations for future studies to fill those gaps.

Treatment of obstetric post-dural puncture headache. Part 2: epidural blood patch

The 2009-12 MBRRACE-UK report highlighted the deaths of two women in whom dural puncture had occurred during insertion of a labour epidural catheter. Despite suffering long-term headaches, neither woman was adequately followed-up after discharge from hospital. Death resulted from a cerebral vein thrombosis in one case and a subdural haematoma in the other. Due to significant variation in the treatment of obstetric post-dural puncture headache, an Obstetric Anaesthetists' Association working group was set up to produce evidence-based guidelines to guide clinicians. These guidelines have been condensed into two review articles. In this second review, the role of an epidural blood patch is discussed using a question and answer format.

Obstetric analgesia - update 2016

Neuraxial labor analgesia can be initiated via combined spinal-epidural (CSE) or stand-alone epidural. Pros and cons of these techniques are outlined in this review. In recent years computer-integrated patient-controlled epidural analgesia (CI-PCEA) and programed intermittent epidural boluses (PIEB) have been developed, adding to continuous infusion and PCEA for the maintenance of neuraxial analgesia. Postdural puncture headache (PDPH) and fever can occur secondary to labor epidural that both have clinical relevance for the care givers. Insights into the mechanism of epidural fever and treatment strategies for PDPH are outlined. Due to the increase in obesity the specific considerations for this patient group are discussed. New data have been presented for remifentanil, an ultra-shortly acting opioid, that is used in obstetric analgesia. Without breaking new data, the use of nitrous oxide especially by midwives has a kind of renaissance, and this will be discussed, too.