Efficacy of a prophylactic epidural blood patch in preventing post dural puncture headache in parturients after inadvertent dural puncture

BACKGROUND: Postdural puncture headache (PDPH) occurs in up to 80% of parturients who experience inadvertent dural puncture during epidural catheter placement. The authors performed a randomized double blind study to assess the effect of prophylactic epidural blood patch on the incidence of PDPH and the need for therapeutic epidural blood patch. METHODS: Sixty-four parturients who incurred inadvertent dural puncture were randomized to receive a prophylactic epidural blood patch with 20 ml autologous blood (prophylactic epidural blood patch group) or a sham patch (sham group). Subjects were evaluated daily for development of PDPH for a minimum of 5 days after dural puncture. Those who developed a PDPH were followed daily for a minimum of 3 days after resolution of the headache. Subjects with moderate headaches who reported difficulties performing childcare activities and all those with severe headaches were advised to receive a therapeutic epidural blood patch. RESULTS: Eighteen of 32 subjects in each group (56%) developed PDPH. Therapeutic blood patch was recommended in similar numbers of patients in each group. The groups had similar onset time of PDPH, median peak pain scores, and number of days spent unable to perform childcare activities as a result of postural headache. The median duration of PDPH, however, was shorter in the prophylactic epidural blood patch group. CONCLUSIONS: A decrease in the incidence of PDPH or the need for criteria-directed therapeutic epidural patch was not detected when a prophylactic epidural blood patch was administered to parturients after inadvertent dural puncture. However, prophylactic epidural blood patch did shorten the duration of PDPH symptoms.     

Efficacy of a Prophylactic Epidural Blood Patch in Preventing Post Dural Puncture Headache in Parturients after Inadvertent Dural Puncture

Background: Postdural puncture headache (PDPH) occurs in up to 80% of parturients who experience inadvertent dural puncture during epidural catheter placement. The authors performed a randomized double blind study to assess the effect of prophylactic epidural blood patch on the incidence of PDPH and the need for therapeutic epidural blood patch.

Methods: Sixty-four parturients who incurred inadvertent dural puncture were randomized to receive a prophylactic epidural blood patch with 20 ml autologous blood (prophylactic epidural blood patch group) or a sham patch (sham group). Subjects were evaluated daily for development of PDPH for a minimum of 5 days after dural puncture. Those who developed a PDPH were followed daily for a minimum of 3 days after resolution of the headache. Subjects with moderate headaches who reported difficulties performing childcare activities and all those with severe headaches were advised to receive a therapeutic epidural blood patch.

Results: Eighteen of 32 subjects in each group (56%) developed PDPH. Therapeutic blood patch was recommended in similar numbers of patients in each group. The groups had similar onset time of PDPH, median peak pain scores, and number of days spent unable to perform childcare activities as a result of postural headache. The median duration of PDPH, however, was shorter in the prophylactic epidural blood patch group.     

The effects of ropivacaine hydrochloride on platelet function: an assessment using the platelet function analyser (PFA-100)

Amide local anaesthetics impair blood clotting in a concentration-dependent manner by inhibition of platelet function and enhanced fibrinolysis. We hypothesised that the presence of ropivacaine in the epidural space could decrease the efficacy of an epidural blood patch, as this technique requires that the injected blood can clot in order to be effective. Ropivacaine is an aminoamide local anaesthetic used increasingly for epidural analgesia during labour. The concentration of local anaesthetic in blood achieved in the epidural space during the performance of an epidural blood patch is likely to be the greatest which occurs (intentionally) in any clinical setting. This study was undertaken to investigate whether concentrations of ropivacaine in blood, which could occur: (i) clinically in the epidural space and (ii) in plasma during an epidural infusion of ropivacaine, alter platelet function. A platelet function analyser (Dade PFA-100, Miami) was employed to assess the effects of ropivacaine-treated blood on platelet function. The greater concentrations of ropivacaine studied (3.75 and 1.88 mg x ml(-1)), which correspond to those which could occur in the epidural space, produced significant inhibition of platelet aggregation. We conclude that the presence of ropivacaine in the epidural space may decrease the efficacy of an early or prophylactic epidural blood patch.     

Prophylactic vs therapeutic blood patch for obstetric patients with accidental dural puncture – a randomised controlled trial

Epidural blood patch is a standard treatment for obstetric patients experiencing a severe post‐dural puncture headache. Patients who sustained an accidental dural puncture during establishment of epidural analgesia during labour or at caesarean delivery were randomly assigned to receive a prophylactic epidural blood patch or conservative treatment with a therapeutic epidural blood patch if required. Eleven of 60 (18.3%) patients in the prophylactic epidural blood patch group developed a post‐dural puncture headache compared with 39 of 49 (79.6%) in the therapeutic epidural blood patch group (p < 0.0001). A blood patch was performed in 36 (73.4%) of patients in the therapeutic group. The number of patients who needed a second blood patch did not differ significantly between the two groups: 6 (10.0%) for prophylactic epidural blood patch and 4 (11.1%) for therapeutic epidural blood patch. We conclude that prophylactic epidural blood patch is an effective method to reduce the development of post‐dural puncture headache in obstetric patients.     

Post dural puncture headache in a pediatric patient with idiopathic intracranial hypertension

We describe the occurrence of postdural puncture headache (PPDH) in an adolescent with idiopathic intracranial hypertension (IIH) and its successful management with an epidural blood patch. PPDH is a very rare occurrence in patients with intracranial hypertension and is described as a paradoxical situation in the literature. There are only two previous case reports (in adults) of the possible association. A 15-year-old obese patient with a diagnosis of IIH had an uneventful diagnostic spinal tap using a 22G Quincke needle in the pediatric emergency department but returned 24 h later with PPDH. After a failed trial of conservative management, she had an uneventful but curative epidural blood patch with 15 ml of autologous venous blood and was able to return to school the day after the blood patch. Follow-up review by her neuro-ophthalmologist shows resolution of her headaches, considerable improvement in her visual field defect and resolution of papilledema. This is the first report of PPDH and its successful management with an epidural blood patch in a pediatric patient with IIH.     

Epidural blood patch for intracranial hypotension with closed system in a Jehovah's Witness

We report a case of treating intracranial hypotension with an epidural blood patch using closed system that allows blood collection and epidural injection without loss of continuity. The patient was a 34-year-old woman with severe headache for several months. The headache failed to respond to conservative management. By radioisotope cisternography, it was diagnosed as intracranial hypotension. Epidural blood patch was planned for intracranial hypotension. We used the method of epidural blood patch in a closed venous blood transfusion system to the epidural space, because she is a member of the Jehovah's Witness. Twenty five ml of blood was drawn into the syringe and injected into the epidural space with closed system. The patient was discharged home after 3 days with dramatically reduced symptons. Epidural blood patching with closed system is a safe, and effective procedure that is acceptable to a Jehovah's Witness.     

Epidural anesthesia and analgesia are not impaired after dural puncture with or without epidural blood patch.

Previous reports have noted a decrease in the success of subsequent epidural anesthesia and analgesia in patients who have undergone prior dural puncture with or without an epidural blood patch. Our retrospective study evaluated the success of epidural anesthesia and analgesia in all patients at the Mayo Clinic who had received a prior epidural blood patch over a 12-yr period. Each epidural blood patch patient was matched to two patients undergoing epidural anesthesia after previous dural puncture (without epidural blood patch) and to two patients undergoing epidural anesthesia after previous epidural anesthetic (without dural puncture/blood patch). These patients were matched for the duration of time between the initial procedure and subsequent epidural anesthetic and the indication (surgery, labor analgesia, postoperative analgesia) for which the subsequent epidural was performed. Subsequent epidural anesthesia was successful in 28 of 29 (96.6%, exact 95% CI 82.2%-99.9%) patients who had undergone prior blood patch, 55 of 58 (94.8%, 85.6%-98.9%) patients with a history of dural puncture, and 55 of 58 (94.8%, 85.6%-98.9%) patients who had had previous epidural anesthesia. There was no significant difference in the success rate of subsequent epidural anesthesia among groups. We conclude that prior dural puncture, with or without epidural blood patch, does not affect the success rate of subsequent epidural anesthesia. Implications: Patients with postdural puncture headache should not be denied the benefits of an epidural blood patch because of concerns about the impairment of subsequent epidural anesthetics. The success rate of subsequent epidural anesthesia and analgesia in patients who have undergone dural puncture with or without epidural blood patch is similar to that of patients who have undergone two prior epidural anesthetics.     

Epidural blood patch using a catheter. Diagnosis of an unrecognised dural tap

Twenty five patients were treated with an epidural blood patch for persistent headache, following a known or suspected dural puncture. Fifteen to 20 ml blood was injected into the epidural space through a catheter inserted one space away from the dural puncture. The catheter technique was useful in confirming the clinical diagnosis of previously unrecognised dural tap in six patients with severe headache. It was possible to perform the blood patch single-handed.     

Diagnosis of intracranial hypotension syndrome by a bolus or continuous epidural injection of normal saline solution

A 75-year-old man had neck sprain by traffic accident. He had headache but not orthostatic at first. He also had dysesthesia and pain of upper limbs, neck pain, and nausea. His symptoms vanished immediately after 10 ml bolus thoracic epidural injection of normal saline for about one hour. Succeeding continuous epidural injection of normal saline (10 ml x h(-1)) made him symptom free until stopping injection. If headache of a patient vanished after epidural normal saline injection, a diagnosis of intracranial hypotension syndrome can be made. This patient became pain free after one trial of cervical epidural blood patch of 12 ml. Quantity of blood to be injected into the cervical epidural space can be decided by flood of injected blood from thoracic epidural vent tapped in advance.     

Utility of ultrasound imaging for epidural blood patch in postdural puncture headache patients after caesarean section

Although epidural blood patch (EBP) is an effective treatment for postdural puncture headache (PDPH), the adequate blood volume has not been determined. We reported two cases of EBP for PDPH after caesarean section with spinal anesthesia using ultrasound imaging with a 2-5 MHz convex probe. In case 1, the dura mater was expanded and subarachnoid space was compressed by 8 ml of autologous blood with paresthesia at bilateral L5 area during EBP and blood infusion was finished at 10 ml. In case 2, although the area of the epidural space was unchanged by 17 ml of EBP, contrast of the epidural space was altered in as a mosaic pattern. We conclude that ultrasound imaging is useful to confirm the adequate blood infusion during EBP Therefore, there is a possibility of estimating the optimal blood volume by ultrasound imaging.     

产科患者硬膜外血补丁的适宜容量：一项随机、盲法的临床试验

背景本研究为一项多国家、多中心的随机、单盲试验,目的是在3个容量中确定自体血硬膜外血补丁（epidural blood patch,EBP）的最适容量。方法选择硬膜外穿刺时意外导致硬脊膜穿破的产科患者,随机注射15ml、20ml或30ml自体血。分层设计EBP操作的时间及中心。参与研究的患者随访5天。主要的研究指标是头痛完全或部分缓解率,次要研究指标包括头痛完全缓解率、部分缓解率、持续头痛的严重程度、在EBP治疗当时及随后的腰背疼情况。结果120例女性患者完成了研究。注射量的中位数（四分位距）是15ml（15）、20ml（20）和30ml（22～30）。在15ml、20ml、30ml组分别有98％、81％和54％的患者接受预定的注射容量。3组中分别有61％、73％、67％的患者完全或部分头痛缓解,分别有10％、32％、26％的患者头痛完全缓解。根据头痛评分与时间曲线,可见15ml组0～48小时的曲线下面积最大。虽然15ml组在EBP后腰背痛的评分最高,但3组在行EBP当时及术后的腰背痛有相似的较低发生率,均无严重并发症报道。结论虽然最适的EBP注射容量仍待确定,但本研究的结果支持20ml自体血补丁治疗适合发生硬膜穿破后头痛（postdural puncture headache,PDPH）的产科患者。     

Post-dural puncture headache: pathophysiology, prevention and treatment

Post-dural puncture headache (PDPHA) has been a vexing problem for patients undergoing dural puncture for spinal anaesthesia, as a complication of epidural anaesthesia, and after diagnostic lumbar puncture since Bier reported the first case in 1898. This Chapter discusses the pathophysiology of low-pressure headache resulting from leakage of cerebrospinal fluid (CSF) from the subarachnoid to the epidural spaces. Clinical and laboratory research over the last 30 years has shown that use of small-gauge needles, particularly of the pencil-point design, is associated with a lower risk of PDPHA than traditional cutting point needle tips (Quincke-point needles). A careful history can rule out other causes of headache. A positional component of headache is the sine qua non of PDPHA. In high-risk patients (e.g. age < 50 years, post-partum, large-gauge-needle puncture), patients should be offered early (within 24-48 h of dural puncture) epidural blood patch. The optimum volume of blood has been shown to be 12-20 ml for adult patients. Complications of autologous epidural blood patch are rare.     

Epidural blood patch for the treatment of intracranial hypotension due to cerebrospinal fluid leakage after thoracic spine surgery

We report a case of a 44-year-old woman successfully treated by an epidural blood patch for intracranial hypotension due to cerebrospinal fluid (CSF) leakage into the thoracic cavity after thoracic spine surgery. The patient was admitted to our hospital with the complaint of postural headaches. She had received anterior thoracic instrumentation for thoracic disc herniation four months earlier. Lumbar puncture demonstrated low CSF pressure, and Gd-enhanced MR images displayed diffuse dural enhancement. Accordingly, she was diagnosed as having intracranial hypotension. 111In-DTPA cisternography revealed a CSF leakage into the left thoracic cavity, possibly caused by dural laceration during thoracic spine surgery. To avoid the risk of direct surgery, we performed epidural blood patch; 3 ml of autologous blood was injected into the epidural cavity. Postoperatively postural headaches immediately disappeared. MRI taken one year later revealed disappearance of diffuse dural enhancement, and 111In-DTPA cisternography revealed no CSF fluid leaks. Epidural blood patch seems to be a choice of treatment for CSF leak after spinal surgery.     

The epidural blood patch. Resolving the controversies

PURPOSE: To review the literature regarding epidural blood patch (EBP) to generate conclusions relating to the controversial issues surrounding its application. SOURCE: A Medline search was made for relevant publications using keywords epidural blood patch, prophylactic epidural blood patch, dural puncture, and postdural puncture headache. Bibliographies of retrieved articles were hand-searched for relevant articles. Case series and comparative trials were emphasized in the analyses. These were culled and those deemed relevant were reviewed. PRINCIPAL FINDINGS: The majority of the literature consists of observational reports: there are few comparative studies. Headache most likely results from cerebrospinal fluid (CSF) loss leading to intracranial content shift and traction on pain sensitive structures; cerebrovascular alterations may be implicated. An EBP with 10-15 ml blood is indicated and effective therapy for severe headache after dural puncture. There is conflicting evidence regarding larger volume blood injections or delaying EBP for 24 hr or more after the diagnosis of postdural puncture headache (PDPH). Efficacy of EBP is related to a "patch effect" as well as transmission of increased epidural space pressure to the CSF space. Previous estimates of EBP efficacy were overgenerous; persistent symptomatic relief can be expected in 61-75% of patients with initial EBP. Patching with non-blood solutions, although initially effective, is associated with a high incidence of headache recurrence. Prophylactic injection of saline or blood decreases the incidence of severe headache after dural puncture. CONCLUSION: Blood-patching is an effective treatment of PDPH but further research is required regarding its mechanisms and prophylaxis.     

Epidural morphine injections for prevention of post dural puncture headache

A prospective, randomised, double-blind trial was conducted to study the effect of epidural morphine in prevention of post dural puncture headache in 25 parturients after inadvertent dural puncture. Women were randomly allocated to receive two epidural injections, 24 h apart, of either 3 mg morphine in 10 ml saline (morphine group) or 10 ml saline (saline group). The incidence of headache and need for therapeutic epidural blood patch were reported. There was a significant difference in the incidence of headache between the two groups: 3/25 (12%) in the morphine group and 12/25 (48%) in the saline group (p = 0.014). Therapeutic epidural blood patches were required in six patients in the saline group and none of the patient in the morphine group (p = 0.022). It was concluded that epidural morphine appears to be a simple and effective technique for prevention of post dural puncture headache after accidental dural puncture in high risk obstetric patients.     

Improved spinal MRI findings after epidural blood patch administration: A pediatric case

Orthostatic headache is the leading clinical manifestation of CSF leakage. Anatomic changes due to low CSF pressure can be detected by cranial and spinal magnetic resonance imaging (MRI). We report improved spinal MRI findings in a pediatric case of post-dural puncture headache treated by epidural blood patch administration.In this case, a 7-year-old girl with a history of recurrent lumbar punctures and orthostatic headache for three months is presented. Cerebrospinal fluid (CSF) leak was reported at the level of T5-L1 by magnetic resonance imaging (MRI). An autologous epidural blood patch was performed under sedation with a blood volume of 6?ml. Five days after the procedure MRI showed no CSF signal in the extradural space and dural infolding was found to be disappeared. On the seventh day of the procedure, headache recurred and the procedure was repeated using same amount of blood. After seven months of follow-up, the patient reported no recurrence of headache.To the best of our knowledge, this is the first pediatric case report that presents improved spinal MRI findings following an epidural blood patch. Although MR findings show improvement, it is not a definitive proof of the adequacy of the treatment.     

X线引导下硬膜外自体血补丁对自发性颅内低压患者的疗效

于2007年11月至2008年5月本院治疗自发性颅内低压患者6例.男女各3例,年龄33～66岁,病程6～35d.根据脊髓造影CT薄层扫描结果 ,对于单发脑脊液漏患者,选择脑脊液漏点所在脊髓节段以下1-2个椎体间隙为穿刺点,对于多发脑脊液漏患者,选择脑脊液漏较严重的节段.在C形臂X射线引导下硬膜外注射自体血与欧门派克(300g/100 ml)的混合液(容量比为3:1),使混合液覆盖脑脊液漏点所在节段.记录注射自体血过程中及注射自体血后不良反应的发生情况.治疗无效者于治疗后1周行下一次治疗.1例患者接受3次治疗;其余5例患者接受1次治疗.注射自体血过程中发生穿刺部位疼痛5例、上肢放射性疼痛2例、右腿麻木感2例,均自行缓解.注射自体血后未见不良反应发生,全部痊愈,随访2-6月未见复发.     

Evaluation of the effects of levobupivacaine on clotting and fibrinolysis using thromboelastography

Amide local anaesthetics inhibit platelet function. We hypothesized that residual anaesthetic in the epidural space could decrease efficacy of an epidural blood patch in preventing postdural puncture headache. Levobupivacaine has recently been approved for epidural anaesthesia. Its effects on coagulation have not previously been studied. The aim of this study was to determine the effects of levobupivacaine on clotting using thromboelastography. Ten ASA Class I volunteers were studied. Venous blood samples were analysed using a Haemoscope 2000D TEG analyser. Whole blood, a 50% saline control and two levobupivacaine solutions (2.5 mg mL(-1) and 2.5 microg mL(-1) in blood) were compared. The former reproduces that produced in the epidural space by blood (20 mL for an epidural blood patch) and levobupivacaine 0.5% (20 mL). The latter approximates plasma concentrations following epidural injection of levobupivacaine 0.5% (20 mL). P < 0.05 was considered significant. Maximum amplitude (MA), a measure of clot strength, is decreased by levobupivacaine 2.5 mg mL(-1). Levobupivacaine 2.5 mg mL(-1) decreases clot strength and may reduce efficacy of a prophylactic epidural blood patch.     

A retrospective review of an epidural blood patch database: the incidence of epidural blood patch associated with obstetric neuraxial anesthetic techniques and the effect of blood volume on efficacy

BackgroundThe optimal volume of blood required to treat post-dural puncture headache remains in question. In our institution a target volume of 30 mL is used for an epidural blood patch unless the patient experiences pain during injection.MethodsThe institutional database was retrospectively reviewed for epidural blood patch and delivery statistics over a 15-year period to determine if the volume of blood administered during the procedure directly correlated with the number of epidural blood patches administered. The primary endpoint was defined as the need for a repeat epidural blood patch.ResultsThere were 466 epidural blood patches performed on 394 patients, associated with 84 804 obstetric neuraxial procedures. Thirty-two percent (95% CI 28.3 to 34.9%) of patients who had an inadvertent dural puncture with an epidural needle received an epidural blood patch versus 0.19% (0.16% to 0.22%) of patients who received neuraxial anesthesia with no documented dural puncture with an epidural needle. All patients experienced relief of post-dural puncture headache, although 17% required two and 1.5% required three epidural blood patches. The mean ± SD volume of blood administered was 20.5 ± 5.4 mL and only 35 patients (8.9%) received 30 mL.ConclusionIncreasing blood volumes up to 30 mL did not reduce the need for repeat epidural blood patch. Although the optimal volume of blood to administer during epidural blood patch placement remains unknown, our institution will continue to administer up to 30 mL or until the patient experiences pain during epidural injection.     

Fluoroscopically guided epidural blood patch in patients with postdural puncture headache after spinal and epidural anesthesia

Postdural puncture headache (PDPH) is one of the major complications after spinal and epidural anesthesia. An epidural blood patch (EBP) may be applied when PDPH persists regardless of conservative treatment. We describe the results of management including fluoroscopically guided EBP in a series of patients with moderate to severe PDPH. From January 2007 to December 2009, PDPH developed in 15 of 3,381 patients (0.44%) who received epidural or spinal anesthesia: 5 (0.21%) after general anesthesia combined with epidural anesthesia, 8 (0.81%) after spinal anesthesia, and 2 (3.14%) after combined spinal and epidural anesthesia. Of 15 patients, PDPH was relieved without the EBP in 9 patients and 6 patients required the EBP. EBP was performed under fluoroscopy in a prone position; a 4:1 mixture of autologous blood and contrast medium was injected to cover the site of dural puncture. The success rate of fluoroscopically guided EBP was 100% with a mean blood volume of 7.2 ml. No complications were associated with EBP except for a mild backache. Fluoroscopically guided EBP may be successfully and safely performed to treat persistent PDPH with a relatively small volume of blood for epidural injection.