Insertion of an intrathecal catheter following accidental dural puncture: a meta-analysis

BackgroundInserting an intrathecal catheter after accidental dural puncture in parturients to prevent postdural puncture headache is becoming increasingly popular. We aimed to identify relevant published articles investigating this intervention and subject data to a meta-analysis.MethodsA systematic literature search was performed, paralleled by a hand search of abstract publications. Studies that reported the dichotomous outcome parameters postdural puncture headache or need for an epidural blood patch were considered eligible. Risk ratios with 95% confidence intervals were calculated.ResultsWe identified nine reports investigating placement of intrathecal catheters after accidental dural puncture. The risk ratio for an epidural blood patch after intrathecal catheter insertion was 0.64 (95% CI 0.49–0.84, P = 0.001). The risk ratio for postdural puncture headache was 0.82 (95% CI 0.67–1.01, P = 0.06).DiscussionInserting an intrathecal catheter significantly reduced the risk for an epidural blood patch; the incidence of postdural puncture headache was reduced but not significantly. Accidental dural puncture is a rare complication and therefore trials on intervention need to include a large number of patients which is time-consuming and costly. Intrathecal catheterisation is a promising approach for the prevention of postdural puncture headache and should be evaluated further. This intervention has additional benefits including a reduced risk of repeat dural puncture, rapid onset of action and use for anaesthesia.     

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.     

Intrathecal catheterisation after observed accidental dural puncture in labouring women: update of a meta-analysis and a trial-sequential analysis

BackgroundOur 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).MethodsA 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.ResultsOur 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.ConclusionsConventional 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.     

The management of accidental dural puncture during labour epidural analgesia: a survey of UK practice

The management of accidental dural puncture and postdural puncture headache in obstetric practice continues to be of great interest. This survey aims to explore the current management of this complication in the United Kingdom and compares the findings to a similar survey undertaken in 1993. A postal questionnaire was sent to all maternity units (n = 248). The return rate was 71%. Of these, 144 units (85%) now have written guidelines for the management of accidental dural puncture compared to 58% in 1993. In 47 units (28%), the epidural catheter is now routinely placed intrathecally following accidental dural puncture; in 69 units (41%) the catheter is re-sited and in the remaining 53 units (31%) either option is allowed. This is in contrast to the previous survey, which found that catheters were re-sited in 99% of units. Only 31 units (18%) now limit the second stage of labour and 19 (11%) avoid pushing and deliver by ventouse or forceps, whilst 116 units (69%) allow labour to take place without any intervention. Only 44 units (26%) now treat postdural puncture headache with an epidural blood patch as soon as it is diagnosed, whereas in 120 units (71%) the blood patch is performed only after failure of conservative measures. Due to the large increase in the use of the intrathecal catheter following this complication, a follow-up questionnaire was posted 5 months later to those units (n = 99) that reported this practice in the initial survey, with a 94% response rate. The two most commonly cited reasons for intrathecal catheterisation were to avoid further dural puncture (76%) and to allow immediate analgesia for labour (75%).     

Persistent headache and low back pain after accidental dural puncture in the obstetric population: a prospective,observational, multicentre cohort study

Accidental dural puncture following epidural insertion can cause a post-dural headache that is defined by the International Headache Society as self-limiting. We aimed to confirm if accidental dural puncture could be associated with persistent headache and back pain when compared with matched control parturients. We performed a prospective multicentre cohort study evaluating the incidence of persistent headache following accidental dural puncture at nine UK obstetric units. Parturients who sustained an accidental dural puncture were matched with controls who had undergone an uneventful epidural insertion. Participants were followed-up at six-monthly intervals for 18 months. Primary outcome was the incidence of persistent headache at 18 months. Ninety parturients who had an accidental dural puncture were matched with 180 controls. The complete dataset for primary analysis was available for 256 (95%) participants. Incidence of persistent headache at 18 months was 58.4% (52/89) in the accidental puncture group and 17.4% (29/167) in the control group, odds ratio (95%CI) 18.4 (6.0–56.7), p < 0.001, after adjustment for past history of headache, Hospital Anxiety and Depression Scale (depression) and Hospital Anxiety and Depression Scale (anxiety) scores. Incidence of low back pain at 18 months was 48.3% (43/89) in the accidental puncture group and 17.4% (29/167) in the control group, odds ratio (95%CI) 4.14 (2.11–8.13), with adjustment. We have demonstrated that accidental dural puncture is associated with long-term morbidity including persistent headache in parturients. This challenges the current definition of post-dural puncture headache as a self-limiting condition and raises possible clinical, financial and medicolegal consequences.     

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.     

The association between labour epidural case volume and the rate of accidental dural puncture

Accidental dural puncture is a recognised complication of labour epidural placement and can cause a debilitating headache. We examined the association between labour epidural case volume and accidental dural puncture rate in specialist anaesthetists and anaesthesia trainees. We performed a retrospective cohort study of labour epidural and combined spinal-epidural nerve blocks performed between 1 July 2013 and 31 December 2017 at Waitemata District Health Board, Auckland, New Zealand. The mean (SD) annual number of obstetric epidural and combined spinal-epidural procedures for high-case volume specialists was 44.2 (15.0), and for low-case volume specialists was 10.0 (6.8), after accounting for caesarean section combined spinal-epidural procedures. Analysis of 7976 labour epidural and combined spinal-epidural procedure records revealed a total of 92 accidental dural punctures (1.2%). The accidental dural puncture rate (95%CI) in high-case volume specialists was 0.6% (0.4–0.9%) and in low-case volume specialists 2.4% (1.4–3.9%), indicating probable skill decay. The odds of accidental dural puncture were 3.77 times higher for low- compared with high-case volume specialists (95%CI 1.72–8.28, p = 0.001). Amongst trainees, novices had a significantly higher accidental dural puncture complication rate (3.1%) compared with registrars (1.2%), OR (95%CI) 0.39 (0.18–0.84), p = 0.016, or fellows (1.1%), 0.35 (0.16–0.76), p = 0.008. Accidental dural puncture complication rates decreased once trainees progressed past the ‘novice’ training stage.     

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.     

Intrathecal catheter use after accidental dural puncture in obstetric patients: literature review and clinical management recommendations

If an accidental dural puncture occurs, one option is to insert a catheter and use it as an intrathecal catheter. This avoids the need for a further injection and can rapidly provide labour analgesia and anaesthesia for caesarean section. However, there are no recommendations for managing intrathecal catheters and, therefore, significant variation in clinical practice exists. Mismanagement of the intrathecal catheter can lead to increased motor block, high spinal anaesthesia, drug error, hypotension and fetal bradycardia. Care must be taken with an intrathecal catheter to adhere to strict aseptic technique, meticulous labelling, cautious administration of medications and good communication with the patient and other staff. Every institution considering the use of intrathecal catheters should establish a protocol. For labour analgesia, we recommend the use of dilute local anaesthetic agents and opioids. For caesarean section anaesthesia, gradual titration to the level of the fourth thoracic dermatome, with full monitoring, in a facility equipped to manage complications, should be performed using local anaesthetics combined with lipophilic opioids and morphine or diamorphine. Although evidence of the presence and duration of intrathecal catheters on the development of post-dural puncture headache and need for epidural blood patch is limited, we suggest considering leaving the intrathecal catheter in for 24 hours to reduce the chance of developing a post-dural puncture headache while maintaining precautions to avoid drug error and cerebrospinal fluid leakage. Injection of sterile normal saline into the intrathecal catheter may reduce post-dural puncture headache. The level of evidence for these recommendations was low.     

Nine-year audit of post-dural puncture headache in a tertiary obstetric hospital in Singapore

BackgroundThe KK Women’s and Children’s Hospital is a tertiary obstetric unit with approximately 11 000 deliveries per year. Epidural analgesia is used in about 40% of laboring women. We reviewed the incidence and management of post-dural puncture headache over a nine-year period.MethodsA retrospective audit of labor epidural analgesia database records from 1 June 2005 to 31 May 2014 was conducted, identifying an “event” as an accidental dural puncture, an inadvertent intrathecal catheter insertion and/or development of a post-dural puncture headache.ResultsA total of 43 434 epidural records were reviewed. Sixty-three events were identified (an incidence of 0.15%). Women had median age of 30 years and median body mass index of 27.6 kg/m²; 69.8% (44/63) delivered vaginally. Procedures performed by less experienced anesthesiologists and those performed outside office hours were associated with a higher incidence of accidental dural puncture. An intrathecal catheter was inserted in 52 of 58 women (89.7%). Headache developed in 24 of 38 (63.1%) women in whom there was a witnessed accidental dural puncture. Most women who developed post-dural puncture headache presented during the primary admission (36/39; 92.3%). Paracetamol and non-steroidal anti-inflammatory drugs were the most commonly prescribed medications. Six women (9.5%) received an epidural blood patch which led to resolution of headache.ConclusionA retrospective audit over a nine-year period at a tertiary teaching hospital found the overall incidence of post-dural puncture headache and associated events to be 0.15%, with a decreasing trend coinciding with improvement in the teaching and supervision of trainees in labor epidural procedures.     

Chronic adhesive arachnoiditis after repeat epidural blood patch

Epidural blood patching is an effective treatment for postdural puncture headache but has potential risks. Arachnoiditis is a very rare disabling condition and few cases have been described following an epidural blood patch. We present a case of chronic adhesive arachnoiditis in a parturient treated with a repeat epidural blood patch. A healthy 29-year-old woman had an accidental dural puncture following epidural insertion during labour. Initial treatment of postdural puncture headache with an epidural blood patch was ineffective and was therefore repeated. She gradually developed severe neurological symptoms consistent with arachnoiditis confirmed with magnetic resonance imaging. Despite intensive multimodal treatment with analgesics and physiotherapy, her neurological condition remains unresolved two years later. This serious but rare complication should encourage caution when treating parturients with postdural puncture headache with a repeat epidural blood patch.     

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.     

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.     

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.     

Repetitive hearing loss following dural puncture treated with autologous epidural blood patch

A case of repetitive hearing loss following an otherwise uncomplicated diagnostic dural puncture is presented. The patient developed severe postdural puncture headache (PDPH) and three episodes of pronounced vestibulocochlear disturbances within five weeks after only one dural puncture. On all three occasions the headache and the associated symptoms were treated with an autologous epidural blood patch (AEBP) resulting in the immediate disappearance of all the subjective complaints of postdural puncture headache and the normalization of an audiological test within minutes.     

Management of accidental dural puncture in labour with intrathecal catheters: an analysis of 10 years' experience

The records of 15030 labour epidural blocks were analysed. Seventy-two accidental dural punctures (ADP) were recognised at the time of the procedure. In 34 women an epidural catheter was inserted intrathecally through the Tuohy needle and continuous spinal analgesia provided. In a further 37 women the primary management of ADP was to resite an epidural catheter. One woman who received a microspinal catheter later in labour was excluded from analysis. There were no significant differences in maternal characteristics, quality of labour analgesia and anaesthesia, or mode of delivery between the groups. Three repeat ADPs occurred during attempts to resite the epidural. Two women developed high blocks after epidural resiting, one of whom required intubation and ventilation. There was one high block in the intrathecal catheter group. The incidence of postdural puncture headache was 71% in the intrathecal catheter group compared with 81% in the non-intrathecal catheter group (P = 0.45). Epidural blood patch was performed on 50% of women managed with intrathecal catheters compared with 73% of those managed without (P = 0.08). Following ADP in labour an intrathecal catheter is a simple and effective alternative to resiting an epidural. Recognition of ADP is important as it allows appropriate management avoiding possible complications of administering epidural top-ups in the presence of a dural tear.     

Effect of neuraxial technique after inadvertent dural puncture on obstetric outcomes and anesthetic complications

BackgroundThe aim of this study was to evaluate labor and delivery outcomes in parturients with inadvertent dural puncture managed by either insertion of an intrathecal catheter or a resited epidural catheter.MethodsThis was a retrospective cohort review of 235 parturients who had an inadvertent dural puncture during epidural placement over a six-year period. The primary outcome was the proportion of women with a delayed second stage of labor. Secondary outcomes were the proportion of cesarean deliveries, the proportion of cases resulting in post-dural puncture headache, and the incidence of failed labor analgesia.ResultsBaseline characteristics such as age, body mass index and parity were similar between the two groups. Among the 236 cases of inadvertent dural puncture, 173 women (73%) had an intrathecal catheter placed while 63 women (27%) had the epidural catheter resited. Comparing intrathecal with epidural catheters, there was no observed difference in the proportion of cases of prolonged second stage of labor (13% vs. 16%, P=0.57) and the overall rate of cesarean deliveries (17% vs. 16%, P=0.78). However, we observed a lower rate of post-dural puncture headache in women who had cesarean delivery compared to vaginal delivery (53% vs. 74%, P=0.007). A greater proportion of failed labor analgesia was observed in the intrathecal catheter group (14% vs. 2%, P=0.005).ConclusionThe choice of neuraxial technique following inadvertent dural puncture does not appear to alter the course of labor and delivery. Cesarean delivery decreased the incidence of post-dural puncture headache by 35%. Intrathecal catheters were associated with a higher rate of failed analgesia.     

Atypical headache following dural puncture in obstetrics

BackgroundIn obstetrics, post-dural puncture headache is a well-recognised complication. Typical symptoms include fronto-temporal or occipital headache, worsening with ambulation and improving in the decubitus position. Occasionally, patients present with non-postural headache, although relatively little is known about this atypical presentation. The purpose of this study was to determine the incidence, associated signs and risk factors for this atypical manifestation of post-dural puncture headache.MethodsWe analysed a series of 27 064 parturients having a neuraxial procedure between January 2001 and December 2010. Using data from electronic anaesthesia patient records, medical charts and a postpartum quality audit, we identified all parturients with atypical post-dural puncture headache. We assessed the incidence and used uni- and multivariate analysis to identify associated risk factors.ResultsAmongst 142 parturients with post-dural puncture headache, eight (5.6%, 95% CI 1.7–9.4%) had atypical non-postural headache. Associated symptoms were stiffness and pain in the cervical, thoracic or lumbar vertebral area, visual disturbances and vertigo. Significant risk factors for developing atypical signs were previous migraine, odds ratio 6.1 (95% CI 1.2–28.7), a more cephalad level of needle insertion, odds ratio 17.2 (95% CI 1.4–210.1) and identification of dural puncture by aspiration of cerebrospinal fluid from the epidural catheter, odds ratio 5.5 (95% CI 1.2–24.4). Following multivariate analysis, recognition of dural puncture by aspiration of cerebrospinal fluid from the epidural catheter was the most significant predictor of non-orthostatic postdural puncture headache.ConclusionAnaesthetists should be aware of this atypical clinical presentation, particularly if there is a past history of migraine, a more cephalad level of needle insertion or identification of dural puncture by aspiration of cerebrospinal fluid from the epidural catheter.     

A prospective controlled study of continuous spinal analgesia versus repeat epidural analgesia after accidental dural puncture in labour

BackgroundAfter accidental dural puncture in labour it is suggested that inserting an intrathecal catheter and converting to spinal analgesia reduces postdural puncture headache and epidural blood patch rates. This treatment has never been tested in a controlled manner.MethodsThirty-four hospitals were randomised to one of two protocols for managing accidental dural puncture during attempted labour epidural analgesia: repeating the epidural procedure or converting to spinal analgesia by inserting the epidural catheter intrathecally. Hospitals changed protocols at six-month intervals for two years.ResultsOne hundred and fifteen women were recruited but 18 were excluded from initial analysis because of practical complications which had the potential to affect the incidence of headache and blood patch rates. Of the remaining 97 women, 47 were assigned to the repeat epidural group and 50 to the spinal analgesia group. Conversion to spinal analgesia did not reduce the incidence of postdural puncture headache (spinal 72% vs. epidural 62%, P = 0.2) or blood patch (spinal 50% vs. epidural 55%, P = 0.6). Binary logistic analysis revealed the relative risk of headache increased with 16-gauge vs. 18-gauge epidural needles (RR = 2.21, 95% CI 1.4–2.6, P = 0.005); anaesthetist inexperience (RR = 1.02 per year difference in experience, 95% CI 1.001–1.05, P = 0.043), and spontaneous vaginal compared to caesarean delivery (RR = 1.58, 95% CI 1.14–1.79, P = 0.02). These same factors also increased the risk of a blood patch: 16-gauge vs. 18-gauge needles (RR = 2.92, 95% CI 1.37–3.87, P = 0.01), anaesthetist inexperience (RR = 1.06 per year difference in experience, 95% CI 1.02–1.09, P = 0.006), spontaneous vaginal versus caesarean delivery (RR = 2.22, 95% CI 1.47–2.63, P = 0.002). When all patients were included for analysis of complications, there was a significantly greater requirement for two or more additional attempts to establish neuraxial analgesia associated with repeating the epidural (41% vs. 12%, P = 0.0004) and a 9% risk of second dural puncture.ConclusionsConverting to spinal analgesia after accidental dural puncture did not reduce the incidence of headache or blood patch, but was associated with easier establishment of neuraxial analgesia for labour. The most significant factor increasing headache and blood patch rates was the use of a 16-gauge compared to an 18-gauge epidural needle.     

Epidural blood patch for postdural puncture headache in a five-year-old child

A case was presented of a 5-year-old girl who suffered an accidental dural puncture during placement of an epidural catheter under general anesthesia for orthopedic surgery. She complained of headache 4 days after the operation, which was relieved on supine position but became worse on sitting position. Her symptoms failed to respond to conservative management. An epidural blood patch was performed under general anesthesia and completely resolved her symptoms. The reported incidence of epidural blood patch for post dural puncture headache following accidental dural puncture in children is low. We outline this case and the consideration for management for epidural blood patch in pediatric patients.