The injection of intrathecal normal saline reduces the severity of postdural puncture headache

BACKGROUND AND OBJECTIVES: We investigated whether the injection of 10 mL of normal saline into the subarachnoid space following accidental dural puncture reduced the incidence of postdural puncture headache (PDPH) and the need for epidural blood patch (EBP). METHODS: Twenty-eight patients who experienced accidental dural puncture with an epidural needle had 10 mL of normal saline injected into the subarachnoid space. In 22 patients, the injection was performed immediately through the epidural needle. In 6 patients who had intrathecal catheters placed through the epidural needle, the saline was injected through the catheter before removal. All other patients who experienced wet taps during the same period that the study was in progress but did not receive the saline injection served as a control group, 26 in number. Patients with severe or persistent PDPHs were treated with EBP. RESULTS: Of those patients who received intrathecal normal saline immediately through the epidural needle, 32% developed a headache compared with 62% of controls. Of these, 1 patient who received saline required EBP compared with nine in the control group (P =.004). Of those patients who had intrathecal catheters placed, there were no headaches in the saline group of 6 compared with 3 in the control group of 5, 1 of whom was treated with EBP (P >.05). CONCLUSIONS: The immediate injection of 10 mL intrathecal normal saline after a wet tap significantly reduced the incidence of PDPH and the need for EBP. When an intrathecal catheter had been placed following a wet tap, injection of 10 mL of normal saline before its removal effectively prevented PDPH.     

Accidental dural puncture: Combination of prophylactic methods to avoid post-dural puncture headache

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 24 hours. 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.     

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.     

Decreased incidence of headache after unintentional dural puncture in patients with cesarean delivery administered with postoperative epidural analgesia

Purpose  To investigate how subsequent placement of a catheter into the epidural space after unintentional dural puncture for postoperative analgesia for 36–72 h affected the incidence of post-dural puncture headache (PDPH). Methods  The records of 52 parturients who had had accidental dural puncture in cesarean delivery were reviewed. The parturients were assigned to two groups. Twenty-eight parturients were assigned to the study group, in whom an epidural catheter was inserted and was used for anesthesia and postoperative analgesia. Twenty-four parturients were assigned to the control group, in whom spinal anesthesia (n = 20) or general anesthesia (n = 4) was applied. For postoperative analgesia in patients with incision pain above visual analog scale (VAS) 3, 3 mg morphine in 15 ml saline was administered through the epidural catheter in the study group, while intramuscular meperidine or tramadol was administered in the control group. Once PDPH was observed, conservative treatment was tried first. If the headache persisted despite conservative treatment, an epidural blood patch was applied through the catheter or a reinserted epidural needle. Results  The study group demonstrated significant reduction of the incidence of PDPH and reduction in the indication for an epidural blood patch compared to the control group (7.1% vs 58% [P = 0.000] and 3.6% vs 37.5% [P = 0.002], respectively). Conclusion  Subsequent catheter placement into the epidural space after unintentional dural puncture in cesarean delivery and leaving the catheter for postoperative analgesia for 36–72 h may reduce the incidence of PDPH.     

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.     

Intrathecal catheterization after unintentional dural puncture during orthopedic surgery

Purpose

We investigated whether inserting an intrathecal catheter and leaving it in place for 24 h after an unintentional dural puncture in orthopedic patients reduced the incidence of post-dural puncture headache (PDPH).

Methods

The study consisted of 427 patients in whom a total of 21 unintentional dural punctures had occurred during orthopedic surgery performed between 2002 and 2006. Seven patients (phase I; evaluated retrospectively) each underwent placement of an epidural catheter at another level after dural puncture during the period January 2002 to February 2004. Fourteen patients (phase II; evaluated prospectively) received an epidural catheter through the dural tear after an unintentional dural puncture during the period February 2004–March 2006

Results

In phase I, 5 of the 7 patients experienced PDPH, and one required an epidural blood patch. In phase II, only one of the 14 patients complained of PDPH, which resolved after 48 h of medical therapy. No patient experienced paresthesia, neurologic or hemorrhagic complication, or infection.

Conclusion

Inserting an epidural catheter through the dural tear following an unintentional dural puncture and leaving it in place for 24 h significantly reduces the incidence of PDPH.     

Post-dural puncture headache in the parturient

Post-dural puncture headache (PDPH) is one of the most common and debilitating complications of neuraxial blockade in the parturient. The obstetric population is at particular risk with up to 80% of women developing symptoms after inadvertent dural puncture during epidural insertion. PDPH typically develops 24–48 hours post-puncture and is classically described as an occipito-frontal headache with postural features. Diagnosis and assessment should include consideration of other potential causes of post-partum headache. At the time of inadvertent dural puncture (IDP) one may insert an intrathecal catheter, re-site the epidural or use alternative analgesia. Initial treatment of a PDPH includes bed rest, adequate hydration and simple analgesics. Epidural blood patch (EBP) remains the gold standard treatment of PDPH.     

Second stage pushing correlates with headache after unintentional dural puncture in parturients

PURPOSE: To determine the association between bearing down, postdural puncture headache (PDPH) and epidural blood patch (EBP) following single 17 gauge unintentional dural puncture (UDP) in parturients. METHODS: The charts of 60 parturients identified with UDP in our institutional database during epidural placement were independently reviewed. Patients were divided into categories based on the anesthetic record: well-documented single punctures; well-documented multiple punctures; catheter-related puncture; unclear category (not clear if more than one puncture occurred or if dural puncture had occurred at all) and no evidence of dural puncture. Patients with single 17 gauge punctures were divided into those who had pushed (Group 1) and those who had not (Group 2). Group 2 patients had undergone Cesarean section before reaching second stage labour. The incidence of PDPH, EBP, and cumulative duration to delivery after UDP were compared between groups. RESULTS: Thirty-three patients with well-documented single punctures were identified: 23 had engaged in active pushing as part of second stage labour (Group 1); 10 had not (Group 2). Seventy-four percent of Group1I developed PDPH compared with 10% in Group 2 (P < 0.002). Fifty-seven percent of Group 1 received an EBP compared with 0% in Group 2 (P < 0.002). Increasing the duration of pushing was associated with an increasing incidence of PDPH; the majority of women who pushed > 30 min developed headache. CONCLUSIONS: An increased incidence of PDPH and EBP after UDP occurs in women bearing down in 2nd stage labour when compared with those who never pushed. There was also an association between the cumulative duration of bearing down and the incidence of PDPH.     

Intrathecal catheter insertion during labour reduces the risk of postdural puncture headache

Purpose

To describe the anaesthetic management and report the incidence of PDPH in three parturients who had experienced accidental durai puncture during labour and the subsequent deliberate intrathecal insertion of an epidural catheter.

Clinical features

Inadvertent durai puncture with a 16-gauge Tuohy needle occurred during the first stage of labour at 3–4 cm cervical dilatation in all three women. The 20-gauge epidural catheter was immediately inserted into the subarachnoid space after accidental durai penetration. Intermittent intrathecal injections of lidocaine or bupivacaine with fentanyl were administered to provide analgesia during labour and delivery. Two of the women had spontaneous vaginal deliveries, whereas Caesarean section was performed in one case due to acute fetal distress during the second stage of labour. The intrathecal catheter was left in-situ for 13–19 hr after delivery and the women were questioned daily for symptoms of PDPH. None of the three women developed PDPH after dural puncture and intrathecal catheterisation with the epidural catheter.

Conclusion

Immediate intrathecal insertion of the epidural catheter after accidental durai puncture during labour proved to be an effective prophylactic technique to prevent PDPH in these three parturients.     

Decreased incidence of headache after accidental dural puncture in caesarean delivery patients receiving continuous postoperative intrathecal analgesia

To examine the effects of prolonged (> 24 h) intrathecal catheterization with the use of postoperative analgesia on the incidence of post–dural puncture headache (PDPH), charts of 45 obstetric patients who had accidental dural puncture following attempts at epidural block were reviewed retrospectively. Three groups were identified: Group I (n = 15) patients had a dural puncture on the first attempt at epidural block, but successful epidural block on a repeated attempt; Group II (n=17) patients had a dural puncture with immediate conversion to continuous spinal anaesthesia with catheterization lasting only for the duration of caesarean delivery; Group III (n= 13) patients had an immediate conversion to spinal anaesthesia and received post–caesarean section continuous intrathecal patient–controlled analgesia consisting of fentanyl 5 (ig'ml^-1 with bupivacaine 0.25 mg·ml^-1 and epinephrine 2 μg·ml^-1 with catheterization lasting >24 h. No parturient in group III developed a PDPH. This was substantially lower ( P < 0.009) than the 33% incidence for group I and the 47% incidence for group II. The incidence of a PDPH did not differ between group I and II. Similarly, there was no difference between group I and II with regard to requests for a blood patch. Patients receiving continuous intrathecal analgesia had excellent pain relief, could easily ambulate and none complained of pruritus, nausea, vomiting, sensory loss or weakness. In conclusion, indwelling spinal catheterization > 24 h with continuous intrathecal analgesia following accidental dural puncture in parturients may for some patients be a suitable method for providing PDPH prophylaxis and postoperative analgesia.     

Lower extremity radicular pain after prophylactic intrathecal saline injection through a subarachnoid catheter following accidental dural puncture

We describe a case in which severe lower extremity radicular pain occurred after administration of 0.9% saline into the subarachnoid space through a catheter that had been left for 20 h following inadvertent dural puncture in an obstetric patient. A 42-year-old (G8P7) woman was admitted for repeat cesarean delivery. Accidental dural puncture occurred during epidural placement. Following a slow 10-mL intrathecal injection of 0.9% normal saline an epidural catheter was advanced into the subarachnoid space. Spinal anesthesia was used for cesarean delivery and the subarachnoid catheter was kept in place for 20 h. Before catheter removal, an additional 10 mL of 0.9% saline was slowly administered into the intrathecal space. Almost instantly, the patient complained of back pain that progressed to lower extremity radicular pain and paresthesia; symptoms began to resolve after 10 min. Subsequently, the patient developed a postdural puncture headache that persisted for three days. The patient’s radiculitis and paresthesia likely resulted from an acute increase in intrathecal pressure after saline administration or from direct catheter irritation. Although both intrathecal saline administration and subarachnoid catheter placement have been previously proposed as ways to prevent postdural puncture headache, their efficacy remains controversial, and we advise caution with these techniques.     

Post dural puncture headache following combined spinal epidural or epidural anaesthesia in obstetric patients.

A retrospective review of obstetric anaesthesia charts was performed for all parturients receiving regional anaesthesia over a 22-month period. The incidence of headache, post dural puncture headache (PDPH) and various other complications of regional anaesthesia that had been prospectively assessed were noted, as was the anaesthetic technique used (epidural or combined spinal epidural (CSE)). PDPH was rare (0.44%) and occurred with similar frequency in those managed with either epidural or CSE anaesthesia or analgesia. The pencil-point spinal needle gauge (27 or 29) did not influence the incidence of PDPH. Following a CSE technique, the epidural catheter more reliably produced effective analgesia/anaesthesia as compared with a standard epidural technique (1.49% versus 3.18% incidence of replaced catheters respectively). We conclude, based on the results of this retrospective review, that CSE is acceptable with respect to the occurrence of PDPH and that it is possible it is advantageous in relation to the correct placement of the epidural catheter     

Accidental dural puncture,postdural puncture headache,intrathecal catheters,and epidural blood patch: revisiting the old nemesis

One of the controversial management options for accidental dural puncture in pregnant patients is the conversion of labor epidural analgesia to continuous spinal analgesia by threading the epidural catheter intrathecally. No clear consensus exists on how to best prevent severe headache from occurring after accidental dural puncture. To investigate whether the intrathecal placement of an epidural catheter following accidental dural puncture impacts the incidence of postdural puncture headache (PDPH) and the subsequent need for an epidural blood patch in parturients. A retrospective chart review of accidental dural puncture was performed at Hutzel Women’s Hospital in Detroit, MI, USA for the years 2002–2010. Documented cases of accidental dural punctures (N = 238) were distributed into two groups based on their management: an intrathecal catheter (ITC) group in which the epidural catheter was inserted intrathecally and a non-intrathecal catheter (non-ITC) group that received the epidural catheter inserted at different levels of lumbar interspaces. The incidence of PDPH as well as the necessity for epidural blood patch was analyzed using two-tailed Fisher’s exact test. In the non-ITC group, 99 (54 %) parturients developed PDPH in comparison to 20 (37 %) in the ITC [odds ratio (OR), 1.98; 95 % confidence interval (CI), 1.06–3.69; P = 0.03]. Fifty-seven (31 %) of 182 patients in the non-ITC group required an epidural blood patch (EBP) (data for 2 patients of 184 were missing). In contrast, 7 (13 %) of parturients in the ITC group required an EBP. The incidence of EBP was calculated in parturients who actually developed headache to be 57 of 99 (57 %) in the non-ITC group versus 7 of 20 (35 %) in the ITC group (OR, 2.52; 95 % CI, 0.92–6.68; P = 0.07). The insertion of an intrathecal catheter following accidental dural puncture decreases the incidence of PDPH but not the need for epidural blood patch in parturients.     

Postdural puncture headache: a randomized comparison of five spinal needles in obstetric patients

This prospective, blinded, randomized study compares the incidence of postdural puncture headache (PDPH) and the epidural blood patch (EBP) rate for five spinal needles when used in obstetric patients. One thousand two women undergoing elective cesarean delivery under spinal anesthesia were recruited. We used two cutting needles: 26-gauge Atraucan and 25-gauge Quincke, and three pencil-point needles: 24-gauge Gertie Marx (GM), 24-gauge Sprotte, and 25-gauge Whitacre. The needle for each weekday was chosen randomly. Cutting needles were inserted parallel to the dural fibers. The incidences of PDPH were, respectively, 5%, 8.7%, 4%, 2.8%, and 3.1% for Atraucan, Quincke, GM, Sprotte, and Whitacre needles (P = 0.04, chi(2) analysis), and the corresponding EBP rates in those with PDPH were 55%, 66%, 12.5%, 0%, and 0% (P = 0.000). The Quincke needle had a more frequent PDPH rate than the Sprotte or the Whitacre needle (P = 0.02) and a more frequent EBP rate than the GM, Sprotte, or the Whitacre needle (P = 0.01). The Atraucan needle had a more frequent EBP rate than the Sprotte or Whitacre needle (P = 0.05). Neither the PDPH rate nor the EBP rates differed among the pencil-point needles. The cost of EBP must be taken into consideration when choosing a spinal needle. We conclude that pencil-point spinal needles should be used for subarachnoid anesthesia in obstetric patients.     

Post-dural puncture headache in the parturient

Post-dural puncture headache (PDPH) is a common and debilitating complication of central neuraxial blockade in the parturient. The obstetric population is at particular risk with up to 80% of women developing symptoms after accidental dural puncture (ADP) during labour epidural insertion. PDPH typically develops 24–48 hours post puncture and is classically described as an occipito-frontal headache with postural features. Diagnosis and assessment should include consideration of other potential causes of post-partum headache. Initial treatment of PDPH includes adequate hydration and analgesics. Epidural blood patch (EBP) remains the gold standard treatment. It is more successful if performed over 24–48 hours after the development of symptoms. Complete and permanent relief of symptoms following a single EBP occurs in up to one third of cases where headache follows ADP with an epidural needle. Complete or partial relief may be seen in 50–80% overall. Higher success rates are achieved following a second EBP. There is now UK national guidance on the treatment of post dural puncture headache published by the Obstetric Anaesthetists Association (OAA).     

An audit of accidental dural puncture during epidural insertion of a Tuohy needle in obstetric patients

We report a prospective audit of 100 parturients who experienced accidental dural puncture by a Tuohy needle, while attending a tertiary referral obstetric unit during the period 1993-1999. The post dural puncture headache rate was 81% and the diagnosis of dural puncture was delayed until presentation of the headache in 27% of these cases. The incidence of unrecognised dural puncture was not influenced by the technique used for identification of the epidural space. Intraspinal opioid administration after dural puncture was associated with a significant reduction in the incidence of headache (P < 0.04). There was no association between mode of delivery and post dural puncture headache. Deliberate cannulation of the subarachnoid space with an epidural catheter at the time of dural puncture, for continuous spinal analgesia or anaesthesia, did not affect the incidence of post dural puncture headache but was associated with a significantly reduced rate of epidural blood patch (43% versus 80%, P < 0.01). Of those who developed post dural puncture headache, 48% were classified 'severe' and in 49% the headache presented within 24 h of dural puncture. There was a trend to earlier onset of headache (either immediate or within 24 h) when the epidural identification technique was loss-of-resistance to air rather than saline (54% versus 33%, P = 0.07). Twenty-eight percent of those suffering from post dural puncture headache were treated expectantly and 72% received a therapeutic blood patch. Of seven parturients who received sumatriptan, six found it ineffective and five subsequently received a blood patch.     

Decrease in the incidence of post-dural puncture headache: maintaining CSF volume

The incidence of epidural needle-induced post-dural puncture headache (PDPH) in parturients following dural puncture with a large bore (18-gauge) needle has been reported to range 76-85%. We describe seven cases in which the performance of epidural anesthesia in parturients was complicated by an unintentional dural puncture with an 18-gauge epidural needle. In all seven cases, the unintentional dural puncture was followed by (i) injection of the CSF in the glass syringe back into the subarachnoid space through the epidural needle, (ii) insertion of a epidural catheter into the subarachnoid space (now referred to as an intrathecal catheter), (iii) injection of a small amount of preservative free saline (3-5 ml) into the subarachnoid space through the intrathecal catheter, (iv) administration of bolus and then continuous intrathecal labor analgesia through the intrathecal catheter and then (v) leaving the intrathecal catheter in-situ for a total of 12-20 h. PDPH occurred in only one of these cases (14%).     

The management of accidental dural puncture and postdural puncture headache: a North American survey

Study Objective

To evaluate the management of accidental dural puncture (ADP) and postdural puncture headache (PDPH) among obstetric anesthesiologists practicing in North America.

Design

Questionnaire survey of individual members of the Society for Obstetric Anesthesia and Perinatology (SOAP).

Setting

University hospital.

Measurements

In June 2008, a 4-part, 83-item electronic survey was distributed to all North American members of SOAP. It contained questions about respondent demographics, epidural catheter and intrathecal catheter management after ADP, PDPH management, epidural blood patch (EBP) management, and patient follow-up.

Main Results

Of the 843 United States and Canadian members of SOAP who were surveyed, 160 responses were collected. Respondents reported placing an epidural 75% of the time and an intrathecal catheter 25% of the time following ADP. Common prophylactic and conservative treatment strategies included hydration, caffeine, and opioids by mouth; 76% of respondents leave an intrathecal catheter in place for 24 hours to reduce the frequency of headache. Epidural blood patches are placed by 81% of practitioners less than 24 hours after headache onset.

Conclusions

Protocols for ADP management are rare. There is wide variation in catheter management after dural puncture, measures used to prevent and treat a resultant headache, and EBP management.     

Treatment of accidental dural puncture during obstetric epidural analgesia

OBJECTIVE: To assess the effectiveness of continuous intrathecal analgesia as prophylaxis for postdural puncture headache (PDPH) and for analgesia during labor in 12 patients who suffered accidental dural puncture. PATIENTS AND METHODS: A total of 920 patients who received spinal analgesia during labor were enrolled. Group A (no accidental dural puncture) received a single dose of 10 mL of 0.2% ropivacaine, and 5 minutes later continuous epidural infusion of 0.125% ropivacaine and 3 micromg mL(-1) was started at a rate of a 5 mL h(-1); a 5 mL bolus dose was allowed every 20 minutes if needed. In patients who suffered accidental dural puncture (Group B) we inserted an intrathecal catheter to administer an initial dose of 3 mL of 0.2% ropivacaine and the same analgesic mixture at the same dose as was administered in Group A. Patient characteristics, analgesic efficacy, duration of labor and delivery, motor blockade, analgesic volume, and incidence of PDPH were recorded. The Student t test was used for statistical comparisons. RESULTS: No significant differences in duration of labor and delivery, analgesic efficacy, or motor blockade were observed. The incidence of PDPH was 16.6% in Group B and 0.33% in Group A. The patients in Group B required more additional bolus doses: 10 (SD, 2) in Group B and 3 (1.25) in Group A (P<0.01). CONCLUSIONS: Continuous intrathecal analgesia after accidental dural puncture was a safe way to provide analgesia during labor and to reduce the expected incidence of PDPH.