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Chau A, Markley JC. Re-attempting the procedure after an accidental dural puncture during an epidural blood patch: is there a hole in the plan? Int J Obstet Anesth 2024; 57:103953. [PMID: 37989614 DOI: 10.1016/j.ijoa.2023.103953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 10/21/2023] [Indexed: 11/23/2023]
Affiliation(s)
- A Chau
- University of British Columbia, Vancouver, BC, Canada.
| | - J C Markley
- University of California San Francisco, San Francisco, CA, USA
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2
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Liu M, Mitchell A, Palanisamy A, Singh PM. Role of cosyntropin in the prevention of post-dural puncture headache: a propensity-matched retrospective analysis. Int J Obstet Anesth 2023; 56:103922. [PMID: 37651920 DOI: 10.1016/j.ijoa.2023.103922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 05/08/2023] [Accepted: 07/30/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Post-dural puncture headache (PDPH) is a well-documented complication of accidental dural puncture in obstetric patients. Reports have shown successful treatment with adrenocorticotropic hormone (ACTH) but evidence remains low and limited. In this retrospective analysis, we assessed whether prophylactic administration of cosyntropin, a synthetic derivative of ACTH, reduced the incidence of PDPH after accidental dural puncture in parturients. METHOD The study population included 132 women with an accidental dural puncture over a three-year period (June 1, 2018 to Oct 31, 2021) at a large tertiary-care center. Patient electronic medical records were reviewed for patient characteristics, prophylactic administration of cosyntropin, PDPH diagnosis, and need for epidural blood patch. Typically, 1 mg of cosyntropin was administered as an intravenous bolus or infusion post-delivery. The propensity score was calculated based on the following factors: age, body mass index, and placement of an intrathecal catheter. Patients were matched allowing 10% variation in scores to reduce potential treatment assignment bias. RESULTS A total of 115 patients were included in the final analysis. Intravenous cosyntropin was administered to 65 patients (55.6%). Among those who received cosyntropin, 37 (56.9%) developed PDPH compared with 29 patients (58%) in the no-cosyntropin group (P = 0.08). Epidural blood patch was performed in 21 patients (56.8%) who received cosyntropin and 13 patients (61.7%) who did not (P = 0.70). CONCLUSION Prophylactic administration of cosyntropin is not associated with a reduced incidence of PDPH.
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Affiliation(s)
- M Liu
- Division of Obstetrical Anesthesiology, Department of Anesthesiology, Washington University in St. Louis, St. Louis, MO, USA
| | - A Mitchell
- Division of Obstetrical Anesthesiology, Department of Anesthesiology, Washington University in St. Louis, St. Louis, MO, USA
| | - A Palanisamy
- Division of Obstetrical Anesthesiology, Department of Anesthesiology, Washington University in St. Louis, St. Louis, MO, USA
| | - P M Singh
- Division of Obstetrical Anesthesiology, Department of Anesthesiology, Washington University in St. Louis, St. Louis, MO, USA.
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3
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Broom MA. Accidental dural puncture during epidural blood patch: a narrative review. Int J Obstet Anesth 2023; 55:103900. [PMID: 37302183 DOI: 10.1016/j.ijoa.2023.103900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 01/30/2023] [Accepted: 05/22/2023] [Indexed: 06/13/2023]
Abstract
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.
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Affiliation(s)
- M A Broom
- Glasgow Royal Infirmary/Princess Royal Maternity Hospital, Glasgow, UK.
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4
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Creazzola F, Aversano M, Prencipe F, Barelli R, Pasqualetti P, Simonelli I, Frigo MG. Effective prevention of post-dural puncture headache with insertion of an intrathecal catheter in parturients: a retrospective study and meta-analysis. J Anesth Analg Crit Care 2023; 3:22. [PMID: 37475027 DOI: 10.1186/s44158-023-00107-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 07/05/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND Accidental dural puncture is a common complication of labour analgesia. It can trigger post-dural puncture headache, with associated morbidity and increased costs. Intrathecal catheter placement is a prophylactic procedure which can reduce incidence and severity of post-dural puncture headache. METHODS We conducted a retrospective single-centred study to define incidence and risk factors of accidental dural puncture and post-dural puncture headache in an obstetric population. We also evaluated effectiveness of intrathecal catheter placement compared to epidural catheter replacement in reducing incidence of post-dural puncture headache. We then conducted a systematic review and meta-analysis which included all studies comparing intrathecal catheter placement to epidural catheter replacement in obstetric patients with accidental dural puncture assessing the outcome of reduced incidence of post-dural puncture headache as a dichotomous variable. RESULTS Accidental dural puncture had an incidence of 0.25% (60 cases). Of these, 66% developed post-dural puncture headache. A total of 77% (47/60) of patients with accidental dural puncture were treated with an intrathecal catheter placement, while 23% (13/60) had an epidural catheter replacement. Incidence of post-dural puncture headache was lower in the intrathecal catheter group (spinal 26/47, 60.5% epidural 11/13, 84.6%), although not reaching statistical significance (RR 0.71, CI 95%: 0.51-1.00; p = 0.049). The meta-analysis revealed that intrathecal catheter placement significantly reduced incidence of post-dural puncture headache compared to epidural catheter replacement (pooled RR 0.81, 95% CI 0.72-0.91, p < 0.001). CONCLUSIONS Intrathecal catheter placement is a promising measure to prevent post-dural puncture headache, especially if followed by a pain management protocol and a continuous saline infusion.
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Affiliation(s)
- F Creazzola
- Obstetric Anaesthesia, San Camillo Forlanini Hospital, Circonvallazione Gianicolense 87, 00152, Rome, RM, Italy
| | - M Aversano
- Obstetric Anaesthesia and Intensive Care Departmental Unit, Fatebenefratelli Gemelli Isola - Isola Tiberina Hospital, Via Di Ponte Quattro Capi 39, Rome, RM, 00186, Italy.
| | - F Prencipe
- Obstetric Anaesthesia and Intensive Care Departmental Unit, Fatebenefratelli Gemelli Isola - Isola Tiberina Hospital, Via Di Ponte Quattro Capi 39, Rome, RM, 00186, Italy
| | - R Barelli
- Anaesthesia and Intensive Care Unit, Sant'Eugenio Hospital, Piazzale Dell'Umanesimo 10, 00144, Rome, RM, Italy
| | - P Pasqualetti
- Service of Medical Statistics and Information Technology, Fatebenefratelli Foundation for Health Research and Education, Via Di Ponte Quattro Capi 39, 00186, Rome, RM, Italy
| | - I Simonelli
- Service of Medical Statistics and Information Technology, Fatebenefratelli Foundation for Health Research and Education, Via Di Ponte Quattro Capi 39, 00186, Rome, RM, Italy
| | - M G Frigo
- Obstetric Anaesthesia and Intensive Care Departmental Unit, Fatebenefratelli Gemelli Isola - Isola Tiberina Hospital, Via Di Ponte Quattro Capi 39, Rome, RM, 00186, Italy
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Honda J, Yamazaki Y, Yakushiji T, Hirata H, Inoue S. Failed spinal anesthesia due to accidental dural puncture: a case report. JA Clin Rep 2022; 8:89. [PMID: 36308604 PMCID: PMC9617982 DOI: 10.1186/s40981-022-00579-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 10/18/2022] [Accepted: 10/24/2022] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND We present a case of inadequate spinal anesthesia possibly due to cerebrospinal fluid (CSF) leakage into the epidural space caused by accidental dural puncture (ADP). CASE PRESENTATION A 28-year-old woman with twin pregnancy underwent a cesarean section. She was scheduled to undergo combined spinal-epidural anesthesia (CSEA). Hyperbaric bupivacaine 9 mg with fentanyl 15 μg, with an additional bupivacaine 5 mg was administered from the L3/4 interspace for spinal anesthesia after repeated ADP at T12/L1; however, analgesia level was only up to T12. Insufficient analgesia level would be attributed to leakage of bupivacaine into the epidural space with the CSF via the injured dura. Planned surgery was performed under general anesthesia and completed uneventfully. CONCLUSION In spinal anesthesia performed after ADP in pregnant women, the anesthesia level may not increase as expected if there is a large amount of CSF leakage.
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Affiliation(s)
- Jun Honda
- grid.471467.70000 0004 0449 2946Department of Anesthesiology, Fukushima Medical University Hospital, 1 Hikarigaoka, Fukushima, Fukushima 960-1295 Japan
| | - Yuki Yamazaki
- grid.471467.70000 0004 0449 2946Department of Anesthesiology, Fukushima Medical University Hospital, 1 Hikarigaoka, Fukushima, Fukushima 960-1295 Japan
| | - Tatsumi Yakushiji
- grid.471467.70000 0004 0449 2946Department of Anesthesiology, Fukushima Medical University Hospital, 1 Hikarigaoka, Fukushima, Fukushima 960-1295 Japan
| | - Hinako Hirata
- Department of Anesthesiology, Iwaki City Medical Center, 16, Kusehara, Mimaya-machi, Uchigo, Iwaki, Fukushima, 973-8555 Japan
| | - Satoki Inoue
- grid.471467.70000 0004 0449 2946Department of Anesthesiology, Fukushima Medical University Hospital, 1 Hikarigaoka, Fukushima, Fukushima 960-1295 Japan
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Nakadate Y, Nakajima E, Ikemoto K, Oguchi T, Matsukawa T. Anesthetic experience does not reduce accidental dural puncture in surgical patients: a retrospective case-controlled study. BMC Anesthesiol 2022; 22:139. [PMID: 35538409 PMCID: PMC9087935 DOI: 10.1186/s12871-022-01657-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 04/11/2022] [Indexed: 11/22/2022] Open
Abstract
Background Accidental dural puncture (ADP), which is a complication of epidural anesthesia, still exists and leads to worse outcomes in surgical patients. While residency training is important for epidural competency, it remains unknown whether anesthetic experience reduces ADP in surgical patients. Using an incident reporting system along with anesthetic records, this case-controlled study retrospectively investigated risk factors associated with ADP in surgical patients. Methods Patients who experienced ADP during epidural anesthesia who were registered in the incident reporting system of our institution between April 2012 and March 2019 were enrolled. Patients with ADP were control-matched with those who without ADP in a 1:3 ratio, to compare the potential risk factors and calculated odds ratios (ORs) for ADP. The primary hypothesis was that anesthesiologists’ experience reduces the incidence of ADP. The secondary hypothesis was that there are risk factors for ADP. Between-group differences in anesthesiologists’ experience were compared using the Mann–Whitney U test. Significance was set at P < 0.05. Results Thirty-five patients who experienced ADP were identified from the incident reporting system. These were matched with 69 patients who did not experience ADP. There was no difference in the years of experience of anesthesiologists between the groups that did and did not experience ADP (8 [3–20] vs. 9 [3–18] years, respectively; P = 0.65). Conclusions Having an experienced anesthesiologist did not guarantee the prevention of ADP. Daily individual training and briefings would be needed to reduce the incidence of ADP.
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Affiliation(s)
- Yosuke Nakadate
- Department of Anesthesiology, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo, Yamanashi, 409-3898, Japan. .,Department of Anesthesiology, University of Tsukuba Hospital, 2-1-1 Amakubo, Tsukuba, Ibaraki, 305-8576, Japan.
| | - Emi Nakajima
- Department of Anesthesiology, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo, Yamanashi, 409-3898, Japan
| | - Kodai Ikemoto
- Department of Anesthesiology, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo, Yamanashi, 409-3898, Japan
| | - Takeshi Oguchi
- Department of Anesthesiology, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo, Yamanashi, 409-3898, Japan
| | - Takashi Matsukawa
- Department of Anesthesiology, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo, Yamanashi, 409-3898, Japan
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Abstract
Purpose of Review This article provides an update of recent practice trends in neuraxial labor analgesia. It reviews available evidence regarding management of labor pain in obstetric patients with COVID-19, serious adverse events in obstetric anesthesia to help inform risk/benefit decisions, and increasingly popular neuraxial labor analgesia techniques and adjuvants. State-of-the-art modes of epidural drug delivery are also discussed. Recent Findings There has recently been a focus on several considerations specific to obstetric anesthesia, such as anesthetic management of obstetric patients with COVID-19, platelet thresholds for the safe performance of neuraxial analgesia in obstetric patients with thrombocytopenia, and drug delivery modes for initiation and maintenance of neuraxial labor analgesia. Summary Neuraxial labor analgesia (via standard epidural, dural puncture epidural, and combined spinal epidural techniques) is the most effective therapy to alleviate the pain of childbirth. SARS-CoV-2 infection is not, in and of itself, a contraindication to neuraxial labor analgesia or cesarean delivery anesthesia. Early initiation of neuraxial labor analgesia in patients with COVID-19 is recommended if not otherwise contraindicated, as it may reduce the need for general anesthesia should emergency cesarean delivery become necessary. Consensus regarding platelet thresholds for safe initiation of neuraxial procedures has historically been lacking. Recent studies have concluded that the risk of spinal epidural hematoma formation after neuraxial procedures is likely low at or above an imprecise range of platelet count of 70–75,000 × 106/L. Thrombocytopenia has been reported in obstetric patients with COVID-19, but severe thrombocytopenia precluding initiation of neuraxial anesthesia is extremely rare. High neuraxial blockade has emerged as one of the most common serious complications of neuraxial analgesia and anesthesia in obstetric patients. Growing awareness of factors that contribute to failed conversion of epidural labor analgesia to cesarean delivery anesthesia may help avoid the risks associated with performance of repeat neuraxial techniques and induction of general anesthesia after failed epidural blockade. Dural puncture techniques to alleviate the pain of childbirth continue to become more popular, as do adjuvant drugs to enhance or prolong neuraxial analgesia. Novel techniques for epidural drug delivery have become more widely disseminated.
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Affiliation(s)
- Roulhac D. Toledano
- NYU Langone Health, Department of Anesthesiology, Perioperative Care & Pain Medicine, NYU Langone Hospital, Brooklyn, USA
| | - Lisa Leffert
- Department of Anesthesia, Critical Care & Pain Medicine, Harvard Medical School, Boston, USA
- Obstetric Anesthesia Division, Massachusetts General Hospital, Boston, MA USA
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8
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Song LL, Zhou Y, Geng ZY. Epidural analgesia followed by epidural hydroxyethyl starch prevented post-dural puncture headache: Twenty case reports and a review of the literature. World J Clin Cases 2021; 9:1946-1952. [PMID: 33748246 PMCID: PMC7953408 DOI: 10.12998/wjcc.v9.i8.1946] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 11/27/2020] [Accepted: 12/16/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Accidental dural puncture (ADP) and subsequent post-dural puncture headache (PDPH) remain common complications of epidural procedures for obstetric anesthesia and analgesia. No clear consensus exists on the best way to prevent PDPH after ADP.
CASE SUMMARY We report our findings in twenty parturients who underwent an incorporated strategy of epidural analgesia followed by epidural hydroxyethyl starch (HES) to prevent PDPH after ADP with a 16-gauge Tuohy needle during epidural procedures. ADP with a 16-gauge Tuohy needle occurred in nine parturients undergoing a cesarean section (CS) and in eleven parturients receiving labor analgesia. An epidural catheter was re-sited at the same or adjacent intervertebral space in all patients. After CS, the epidural catheter was used for postoperative pain relief over a 48-h period. After delivery in eleven cases, epidural infusion was maintained for 24 h. Thereafter, 15 mL of 6% HES 130/0.4 was administered via the epidural catheter immediately prior to catheter removal. None of the parturients developed PDPH or neurologic deficits over a follow-up period of at least two months to up to one year postpartum.
CONCLUSION An incorporated strategy of epidural analgesia followed by epidural hydroxyethyl starch may have great efficacy in preventing PDPH after ADP.
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Affiliation(s)
- Lin-Lin Song
- Department of Anesthesiology, Peking University First Hospital, Beijing 100034, China
| | - Yin Zhou
- Department of Anesthesiology, Peking University First Hospital, Beijing 100034, China
| | - Zhi-Yu Geng
- Department of Anesthesiology, Peking University First Hospital, Beijing 100034, China
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9
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Abela GP, Tan T. Accidental dural puncture and post-dural puncture headache: a retrospective review in an Irish maternity hospital. Ir J Med Sci 2020; 189:657-60. [PMID: 31760551 DOI: 10.1007/s11845-019-02139-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 11/12/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Accidental dural puncture (ADP) during epidural catheter insertion and the possible consequent post-dural puncture headache (PDPH) remain challenging complications in obstetric anaesthesia. ADP/PDPH can represent a considerable degree of morbidity for the parturient and require immediate diagnosis and appropriate management to ensure recovery and avoid complications. AIM This retrospective audit was carried out to identify the accidental dural puncture and post-dural puncture headache rates at the Coombe Women and Infant University Hospital in Dublin. METHODS Cases of ADP and PDPH were identified retrospectively from a register used to record these cases. Demographic and obstetric data was retrieved using the patients' medical records. Analysis was carried using MS Excel. RESULTS In 1 year (June 1, 2018 to June 1, 2019), there were 25 cases of ADP during epidural catheter insertion and this is 0.78% of epidurals done in this period. Seventeen of these (68%) subsequently developed PDPH. In total, there are 32 cases of PDPH: 27 after epidural analgesia using an 18G Touhy needle and 5 after a spinal anaesthetic using a 25G Whitacre needle. All PDPH cases received first-line conservative treatment and 9 (28.1%) required an epidural blood patch (EBP). No-one required a second EBP. DISCUSSION The incidence of ADP at our hospital (0.78%) is within the range quoted in the literature (0.1-1.5%) and below the UK standard of 1%. The incidence of PDPH after recognized ADP (68%) is also consistent with other published reports.
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Heesen M, Hilber N, Rijs K, van der Marel C, Rossaint R, Schäffer L, Klimek M. Intrathecal catheterisation after observed accidental dural puncture in labouring women: update of a meta-analysis and a trial-sequential analysis. Int J Obstet Anesth 2019; 41:71-82. [PMID: 31522933 DOI: 10.1016/j.ijoa.2019.08.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 07/11/2019] [Accepted: 08/05/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Our meta-analysis from 2013 showed that inserting a catheter intrathecally after an observed accidental dural puncture can reduce the need for epidural blood patch in labouring women requesting epidural analgesia. We updated our conventional meta-analysis and added a trial-sequential analysis (TSA). METHODS A systematic literature search was conducted to identify studies that compared inserting the catheter intrathecally with an epidural catheter re-site or with no intervention. The extracted data were pooled and the risk ratio (RR) and 95% confidence interval (95%CI) for the incidence of post-dural puncture headache (PDPH) was calculated, using the random effects model. A contour-enhanced funnel plot was constructed. A TSA was performed and the cumulative Z score, monitoring and futility boundaries were constructed. RESULTS Our search identified 13 studies, reporting on 1653 patients, with a low risk of bias. The RR for the incidence of PDPH was 0.82 (95%CI 0.71 to 0.95) and the RR for the need for epidural blood patch was 0.62 (95%CI 0.49 to 0.79); heterogeneity of both analyses was high. The TSA showed that the monitoring or futility boundaries were not crossed, indicating insufficient data to exclude a type I error of statistical analysis. Contour-enhanced funnel plots were symmetric, suggesting no publication bias. CONCLUSIONS Conventional meta-analyses showed for the first time that intrathecal catheterisation can reduce the incidence of PDPH. However, TSA did not corroborate this finding. Despite increasing use in clinical practice there is no firm evidence on which to base a definite conclusion.
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Affiliation(s)
- M Heesen
- Department of Anaesthesia, Kantonsspital Baden, Baden, Switzerland.
| | - N Hilber
- Department of Anaesthesia, Kantonsspital Baden, Baden, Switzerland
| | - K Rijs
- Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - C van der Marel
- Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - R Rossaint
- Department of Anaesthesiology, University Hospital RWTH Aachen, Aachen, Germany
| | - L Schäffer
- Department of Obstetrics, Kantonsspital Baden, Baden, Switzerland
| | - M Klimek
- Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
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Abstract
Subdural hematoma (SDH) following labor epidural analgesia is a rare neurological complication. SDH is a late complication of this procedure; it is caused by a leak of cerebrospinal fluid that may damage the vascular structures of the brain. Persistent headache in the days after labor epidural analgesia is a nonspecific clinical symptom caused by hematoma. Preexisting vascular malformations can be a concomitant cause of headache. Clinical cases have been reported even after epidural anesthesia. The differential diagnosis includes unspecified headache, sinusitis headache, drug-induced headache, cortical vein thrombosis, fistula of the dura mater, and bacterial, viral, and aseptic meningitis.
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Affiliation(s)
- Luca De Lipsis
- Department of Anesthesia, Sacred Heart of Jesus Hospital, Benevento, Italy
| | - Rossella Belmonte
- Department of Anesthesia, Sacred Heart of Jesus Hospital, Benevento, Italy
| | - Maria Cusano
- Department of Anesthesia, Sacred Heart of Jesus Hospital, Benevento, Italy
| | | | | | - Mauro Mancinelli
- Department of Radiology, Sacred Heart of Jesus Hospital, Benevento, Italy
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12
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Rana K, Jenkins S, Rana M. Insertion of an intrathecal catheter following a recognised accidental dural puncture reduces the need for an epidural blood patch in parturients: an Australian retrospective study. Int J Obstet Anesth 2018; 36:11-16. [PMID: 30245259 DOI: 10.1016/j.ijoa.2018.08.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 08/04/2018] [Accepted: 08/08/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND There is no clear consensus about how best to prevent post-dural puncture headache (PDPH) following an accidental dural puncture in parturients. Our primary objective was to investigate whether the insertion of an intrathecal catheter following accidental dural puncture reduces the incidence of PDPH and therapeutic epidural blood patch. METHODS Anaesthetic records from January 2009 to December 2015 were reviewed retrospectively and parturients who had an accidental dural puncture and/or PDPH were identified. Data from those with a recognised dural puncture in whom an intrathecal catheter was inserted at the time of accidental dural puncture (ITC group) were compared to those without an intrathecal catheter (non-ITC group), as were outcomes of patients with an intrathecal catheter for ≥24 hours compared to <24 hours. RESULTS Of 94 recognised accidental dural punctures, 66 were in the ITC group (37 for ≥24 h) and 28 in the non-ITC group. In the ITC group, 22 (33.3%) required an epidural blood patch in comparison to 19 (67.9%) in the non-ITC group (P <0.01, 95% CI 12.5 to 52.0). In the ITC group, 62 (93.9%) developed PDPH in comparison to 28 (100%) in the non-ITC group (P=0.186, 95% CI -6.55 to 14.57). Intrathecal catheter insertion for ≥24 h obviated the need for an epidural blood patch in 28 (75.7%) parturients, compared to 13 (59.1%) if <24 h (P=0.184, 95% CI -7.08 to 39.72). CONCLUSION Inserting an intrathecal catheter after a recognised accidental dural puncture significantly reduced the need for an epidural blood patch.
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Affiliation(s)
- K Rana
- Medical School, The University of Adelaide, Australia.
| | - S Jenkins
- Department of Anaesthesia, Lyell McEwin Hospital, Haydown Rd, Elizabeth Vale, South Australia, Australia
| | - M Rana
- Medical School, The University of Adelaide, Australia; Department of Anaesthesia, Lyell McEwin Hospital, Haydown Rd, Elizabeth Vale, South Australia, Australia
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Bakshi SG, Gehdoo RSP. Incidence and management of post-dural puncture headache following spinal anaesthesia and accidental dural puncture from a non-obstetric hospital: A retrospective analysis. Indian J Anaesth 2018; 62:881-886. [PMID: 30532325 PMCID: PMC6236776 DOI: 10.4103/ija.ija_354_18] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background and Aims Post-dural puncture headache (PDPH) is one of the complications following spinal anaesthesia (SA) and accidental dural puncture (ADP). In our institute, we routinely practice epidural analgesia (EA) for supra-major surgeries. Our previous audit on EA revealed 4% incidence of ADP. This lead us to a clinical initiative to follow-up patients with dural puncture (DP) to note the incidence, presentation, associated symptoms and treatment of PDPH. Herewith, we present the retrospective analysis over a 2-year period. Methods Following institutional review board approval, the follow-up notes of patients who had DP from May 2011 to April 2013 were analysed retrospectively (using SPSS 20 version) with respect to the needle size, level of DP, reinsertion of epidural catheter, details of ongoing analgesics, incidence and severity of PDPH and treatment received. Results In 2 years, we found that the incidence of PDPH in the patients who received SA was 3.9% and 25% in the ADP group. There was a positive association between needle size, type and PDPH, and it was seen more in the 20-40 age group. The commonest presentation of PDPH was occipital/frontal headache within 96 h and lasted for a mean of 3 days. All patients received pharmacological treatment. Seventy-one per cent of patients (25) were either on coffee or caffeine tablets. One case of intractable PDPH responded well to oral pregabalin 75 mg. Conclusion PDPH severity and incidence following ADP in our centre is lower than the reported incidence from obstetric centres and can be effectively controlled with drug treatment only.
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Affiliation(s)
- Sumitra G Bakshi
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital and Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Raghuveer Singh P Gehdoo
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital and Homi Bhabha National Institute, Mumbai, Maharashtra, India
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Abstract
Headache after dural puncture is a common complication accompanying neuraxial anesthesia. The proposed cause is loss of cerebrospinal fluid through the puncture into the epidural space. Although obstetric patients are at risk for the development of this headache because of female gender and young age, there is a difference in the obstetric population. Women who deliver by cesarean delivery have a lower incidence of headache after dural puncture compared with those who deliver vaginally. Treatment of postdural puncture headache is an epidural blood patch. Departments should develop protocols for management of accidental dural puncture, including appropriate follow-up and indications for further management.
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Affiliation(s)
- Robert R Gaiser
- Department of Anesthesiology, University of Kentucky, Lexington, KY 40506, USA.
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Michaan N, Lotan M, Galiner M, Amzalag S, Many A. Risk factors for accidental dural puncture during epidural anesthesia for laboring women. J Matern Fetal Neonatal Med 2015; 29:2845-7. [PMID: 26593850 DOI: 10.3109/14767058.2015.1107040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND AND OBJECTIVES Accidental dural puncture (ADP) during epidural analgesia is a debilitating complication. Symptoms of ADP post-dural puncture headache (PDPH) are headache while rising from supine to upright position, nausea, and neck stiffness. While age, gender and needle characteristics are established risk factors for ADP, little is known about risk factors in laboring women. METHODS All cases of ADP during epidural analgesia treated with blood-patching during a 3-years period were retrospectively reviewed. Each case was matched to two controls according to delivery period. RESULTS Forty-nine cases of blood patches after ADP out 17 977 epidural anesthesia procedures were identified (0.27%). No differences were found between cases and controls with regards to body mass index, labor stage at time of epidural, length of second stage, location of epidural along the lumbar vertebrae, anesthesiologist's experience or time when epidural was done. In cases of ADP, significantly lower doses of local anesthetics were injected (10.9 versus 13.5 cc, p < 0.001); anesthesiologists reported significantly more trials of epidurals (70 versus 2.8% more than one trial, p < 0.001), more patient movement during the procedure (13 versus 0%, p < 0.001), more intra-procedure suspicion of ADP (69 versus 0%, p < 0.001) and more cases where CSF/blood was drawn with the syringe (57 versus 2.4%, p < 0.001). CONCLUSION ADP during labor is a rare but debilitating complication. Risk factors for this iatrogenic complication include patient movement and repeated epidural trials. Intra-procedure identification of ADP is common, allowing early intervention with blood patching where indicated.
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Affiliation(s)
| | - Michael Lotan
- a Department of Anesthesia , Lis Maternity Hospital, Tel-Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University , Israel
| | | | | | - Ariel Many
- b Department of Obstetrics and Gynecology and
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Ramírez S, Gredilla E, Martínez B, Gilsanz F. Bilateral subdural hematoma secondary to accidental dural puncture. Braz J Anesthesiol 2015; 65:306-9. [PMID: 26123149 DOI: 10.1016/j.bjane.2014.07.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2014] [Accepted: 07/04/2014] [Indexed: 10/23/2022] Open
Abstract
We report the case of a 25-year-old woman, who received epidural analgesia for labor pain and subsequently presented post-dural puncture headache. Conservative treatment was applied and epidural blood patch was performed. In the absence of clinical improvement and due to changes in the postural component of the headache, a brain imaging test was performed showing a bilateral subdural hematoma. The post-dural puncture headache is relatively common, but the lack of response to established medical treatment as well as the change in its characteristics and the presence of neurological deficit, should raise the suspicion of a subdural hematoma, which although is rare, can be lethal if not diagnosed and treated at the right time.
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Affiliation(s)
- Sofía Ramírez
- Servicio de Anestesiología y Reanimación, Hospital Universitario La Paz, Madrid, Spain.
| | - Elena Gredilla
- Servicio de Anestesiología y Reanimación, Hospital Universitario La Paz, Madrid, Spain
| | - Blanca Martínez
- Servicio de Anestesiología y Reanimación, Hospital Universitario La Paz, Madrid, Spain
| | - Fernando Gilsanz
- Servicio de Anestesiología y Reanimación, Hospital Universitario La Paz, Madrid, Spain
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Gobin J, Lonjaret L, Pailhas A, Bayoumeu F, Minville V. Accidental dural puncture: combination of prophylactic methods to avoid post-dural puncture headache. ACTA ACUST UNITED AC 2014; 33:e95-7. [PMID: 24821339 DOI: 10.1016/j.annfar.2014.03.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2013] [Accepted: 03/31/2014] [Indexed: 11/29/2022]
Abstract
Accidental dural puncture (ADP) is a common complication of epidural catheter insertion, and may lead to post-dural puncture headache (PDPH), especially in obstetric patients. Epidural blood patch (BP) is the most effective treatment of PDPH. Prophylactic BP has shown its efficacy to prevent PDPH; nevertheless, this method may be insufficient. We report an ADP case before induction of labor in a 28-year-old parturient. To avoid PDPH, an intrathecal catheter was immediately inserted after ADP and an epidural catheter was also inserted at the interspace above. Catheters were kept in place for more than 24hours. A prophylactic BP was performed immediately after removal of the intrathecal catheter. The patient did not experience any headache. This combination of treatments (intrathecal catheter insertion+prophylactic BP) may be a good alternative approach to prevent PDPH, even if it has to be warranted by other clinical studies.
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Affiliation(s)
- J Gobin
- Département d'anesthésie et réanimation, CHU de Toulouse, université Paul Sabatier, hôpital Purpan, place du Dr-Baylac, 31059 Toulouse cedex 9, France.
| | - L Lonjaret
- Département d'anesthésie et réanimation, CHU de Toulouse, université Paul Sabatier, hôpital Purpan, place du Dr-Baylac, 31059 Toulouse cedex 9, France
| | - A Pailhas
- Département d'anesthésie et réanimation, CHG d'Albi, 22, boulevard Général-Sibille, 81000 Albi, France
| | - F Bayoumeu
- Département d'anesthésie et réanimation, CHU de Toulouse, université Paul Sabatier, hôpital Purpan, place du Dr-Baylac, 31059 Toulouse cedex 9, France
| | - V Minville
- Département d'anesthésie et réanimation, CHU de Toulouse, université Paul Sabatier, hôpital Purpan, place du Dr-Baylac, 31059 Toulouse cedex 9, France
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Jadon A, Chakraborty S, Sinha N, Agrawal R. Intrathecal Catheterization by Epidural Catheter: Management of Accidental Dural Puncture and Prophylaxis of PDPH. Indian J Anaesth 2009; 53:30-4. [PMID: 20640074 PMCID: PMC2900030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2009] [Indexed: 11/25/2022] Open
Abstract
Accidental or inadvertent dural puncture during epidural anaesthesia results in high incidence of post dural puncture headache (PDPH). Spinal or intrathecal catheter in such a situation, provides a conduit for administration of appropriate local anaesthetic for rapid onset of intraoperative surgical anaesthesia and postoperative pain relief. This procedure prevents PDPH if catheter left in situ for > 24 hrs and also avoids the associated risks with a repeat attempts at epidural analgesia. Primary aim of this study was to observe the effect of spinal catheter on incidence of PDPH, and to assess early and delayed complications of spinal catheterization by epidural catheter. In prospective clinical study 34 patients who had accidental dural puncture during epidural anaesthesia were included. The catheter meant for epidural use was inserted in spinal space and used for spinal anaesthesia and postoperative analgesia. Catheter was removed between 24-36hrs after surgery. The incidence of accidental dural puncture was 4%(34/846). Two patients 5.88% (2/34) had transient paresthesia during spinal catheter insertion. Post dural puncture headache occurred in 11.76% (4/34) patients. Two patients required epidural blood patch and two patients were managed with conservative treatment. No patient had any serious intraoperative or postoperative side effects. Epidural catheter can be used as spinal catheter to manage accidental dural puncture without serious complications, and it also prevents PDPH.
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Affiliation(s)
- Ashok Jadon
- Senior Consultant and Head of the Department, Department of Anaesthesia, Tata Motors Hospital, Jamshedpur-831001, Jharkhand, (India),Correspondence to: Ashok Jadon, 44, Beldih Lake Flats, Dhatkidih, Jamshedpur-831001, Jharkhand (India)
| | - Swastika Chakraborty
- Consultant, Department of Anaesthesia, Tata Motors Hospital, Jamshedpur-831001, Jharkhand, (India)
| | - Neelam Sinha
- Senior Registrar, Department of Anaesthesia, Tata Motors Hospital, Jamshedpur-831001, Jharkhand, (India)
| | - Rajiv Agrawal
- Senior Medical Officer, Department of Anaesthesia, Tata Motors Hospital, Jamshedpur-831001, Jharkhand, (India)
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