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.     

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%).     

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.     

Subarachnoid catheter placement after wet tap for analgesia in labor: influence on the risk of headache in obstetric patients

BACKGROUND AND OBJECTIVES: The incidence of postdural puncture headache (PDPH) after epidural wet tap for obstetric patients may be as high as 75%. We have studied how subsequent placement of a subarachnoid catheter immediately after confirmation of a wet tap, and leaving the catheter in place for 24 hours affects the incidence of PDPH. METHODS: Over a 5-year interval, 115 consecutive patients who had unintentional dural puncture were divided into 3 groups by consecutive assignment. Group A had an epidural catheter placed at another interspace. Group B had a subarachnoid catheter placed for labor analgesia that was removed immediately after delivery. Group C had a subarachnoid catheter that was left in place for 24 hours after delivery. Data were collected retrospectively. The incidence of PDPH and blood patch was compared between groups. RESULTS: The overall incidence of PDPH was 46.9% and need for blood patch 36.5%, significantly less in both subarachnoid catheter groups, 31% in B and 3% in group C, compared with group A (PDPH 81%) (P <.001). CONCLUSION: Subarachnoid catheter placement after wet tap in obstetric patients reduces the PDPH rate and does so to a greater extent if left in place for 24 hours after delivery.     

Injection of intrathecal normal saline in decreasing postdural puncture headache

Purpose

Postdural puncture headache (PDPH) is the most common and still unresolved postoperative complication of spinal anesthesia. Although there are several positive results of intrathecal saline injection for the treatment of PDPH and prophylaxis after accidental dural puncture, the effect of deliberate intrathecal saline injection before spinal anesthesia has not been examined. The objective of our study was to evaluate the effect of prophylactic administration of intrathecal normal saline in decreasing PDPH.

Methods

One hundred healthy women (ASA physical status I) of age between 18 and 35 years scheduled for elective term cesarean delivery under spinal anesthesia were included. Patients were randomly divided into two equal groups. Group C received 2.5 ml (12.5 mg) hyperbaric bupivacaine 0.5 % as a control, and group S received intrathecal normal saline 5 ml before intrathecal injection of 2.5 ml (12.5 mg) hyperbaric bupivacaine 0.5 %. The incidence and severity of PDPH were assessed after 48 h and again 3–7 days after operation.

Results

Basal characteristics were statistically similar in both groups (P > 0.05). The incidences of moderate and severe PDPH during first postoperative 48 h were not different between the groups (P = 0.24). However, the frequency of PDPH after 3–7 days was statistically higher in group C in compared with group S (16 vs. 2 %, P = 0.03). Totally the frequency of PDPH was higher in group C (24 vs. 2 %, P = 0.002).

Conclusion

Administration of normal saline (5 ml) before intrathecal administration of hyperbaric bupivacaine as a preventive approach is an effective and simple way to minimize PDPH in patients undergoing cesarean section.     

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.     

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.     

Prevention strategy for post dural puncture headache

We report the anesthetic management of a parturient after an unintentional dural puncture while performing epidural anaesthesia for caesarean section and the strategy to prevent postdural puncture headache (PDPH). We injected the cerebrospinal fluid (CSF) back into the subarachnoid space and then administered intrathecal 1.5 mL 0.5% hyperbaric bupivacaine and fentanyl 20 microg to maintain CSF volume via epidural needle. The epidural catheter was inserted following re-identification of the epidural space for possible epidural top-up requirement and postoperative pain relief. After adding 3 mL of 0.5% isobaric bupivacaine via epidural catheter, sensory block level reached at T4 bilaterally. No PDPH was observed.     

Epidural blood patch in a patient with multiple sclerosis: is it safe?

Purpose

Multiple sclerosis (MS) is a chronic inflammatory and degenerative disease of the central nervous system resulting in demyelination and axonal injury. Epidural blood patch (EBP) to treat postdural puncture headache (PDPH) in an MS patient may be of concern because of the potential for this to interfere with axonal conduction. Even with normal axons, pressure can interfere with impulse conduction, and it is unknown whether affected axons of the MS patient are particularly vulnerable to the increase in epidural pressure that occurs as a consequence of the EBP. We describe our experience with EBP in an MS patient. While peridural pressure changes were not measured, we attempted to quantify any pressure-induced interference with axonal conduction by measuring changes in somatosensory evoked responses.

Clinical features

A 50-yr-old female MS patient required an EBP for a PDPH after a diagnostic lumbar puncture. The first EBP (20 mL autologous blood, L3-4 interspace) was followed by a transient improvement in PDPH and then a worsening with increased lower-extremity weakness. A second EBP was performed (12 mL autologous blood, L3-L4 interspace) with concomitant evoked potential recordings (stimulating electrodes over the left posterior tibial nerve and recording electrodes at CZ-FZ coordinates). Postdural puncture headache symptoms were permanently relieved, and the effects of the EBP on evoked P40 latency responses (39.7 msec and 44.3 msec pre- and post-EBP, respectively) were considered to be physiologically insignificant.

Conclusion

A report of EBP to treat PDPH in an MS patient is presented. We postulate that this type of patient may be at risk for impaired conduction of impulses in affected axons due to the increase in pressure produced by epidural injection of blood. Literature review indicates that pressure increases may be reduced by injecting the blood slowly. When EBP is considered in patients with axon conduction deficits, consideration should be given to concomitant monitoring of somatosensory evoked responses to help quantify interference with axonal conduction as a consequence of injection of blood into the epidural space.     

Dural tears in primary decompressive lumbar surgery. Is primary repair necessary for a good outcome?

Study design

Case control series with prospective data collection.

Objective

To establish whether incidental durotomy treated without primary suture repair adversely affects the outcome following lumbar surgery in the longer term.

Method

Outcome scores from a prospective database were used for an audit of dural tears in primary lumbar decompressive surgery. Outcome data collected includes the Short Form 36 General Health Questionnaire (SF36), the Oswestry Disability Index (ODI) and Visual Analogue Scores for leg pain (VAL) and back pain (VAB).

Results

Out of 200 consecutive procedures, a dural tear occurred in 19 (9.5 %) patients. Of 19 patients with a dural tear, data was incomplete in 4 patients, and 1 further patient who had their dural tear sutured was excluded, leaving 14 patients to be studied. There were seven males and seven females, with an average age of 50.8 years (31–69). These 14 patients (group 1) were compared to a matched group (age, sex, surgical diagnosis and duration of follow-up) of 14 patients (group 2) with no tear. Both groups had similar pre-operative scores. At 6-month follow-up, both groups had significant improvements in all outcomes measures except for the general health domain of the SF-36. At final follow-up, patients with dural tears appeared to have better improvements in outcome measures amongst the VAB, VAL and ODI with similar scores in the SF-36 domains.

Conclusion

Our study demonstrates that incidental durotomy in primary lumbar decompressive surgery can be successfully managed without primary suture repair with no adverse effect on surgical outcome in the longer term.     

Hématome sous durai bilatéral après analgesie péridurale

Purpose

The authors report a case of bilateral subdural hematoma (SDH) which occurred following epidural analgesia for labour, complicated by post durai puncture headache (PDPH). Physiopathological mechanisms are discussed.

Clinical features

A 27-yr-old woman displayed typical PDPH following epidural anaesthesia. On the fifth day she was given a blood patch (BP) which proved immediately effective. Further developments were marked by late recurrence of PDPH and by administration of a second BP on the 24th day. With the aggravation of the headaches, the disapearance of their postural nature and with the appearance of transitory focal neurological signs on the 30th day, a CT-Scan was done and showed bilateral subdural haematoma. Following surgical drainage, the patient made an uneventful recovery.

Conclusion

The presence of PDPH complicated by a typical neurological deterioration should prompt the anaesthetist to seek an immediate clinical and x-ray diagnosis in order to look for the existence of intracranial complications.     

Continuous spinal anaesthesia using a standard epidural set for extracorporeal shockwave lithotripsy

Purpose

Continuous spinal anaesthesia (CSA) offers considerable advantages over “single shot” spinal or epidural anaesthesia since it allows titration of anaesthesia using small doses of local anaesthetics (LA). We evaluated the feasibility of CSA using a standard epidural set for extracorporeal shockwave lithotnpsy (ESWL).

Methods

Charts of 100 consecutive CSAs for ESWL were retrospectively reviewed. Lumbar CSA was performed using a 20G epidural catheter through an 18G Tuohy needle. The CSA was preplanned, or followed inadvertent dural puncture. Small LA boluses were injected to achieve the desired sensory level of anaesthesia. Demographic data, anaesthetic duration, LA doses, the most cephalad sensory level to pinprick, arterial blood pressure, heart rate, use of systemic sympathomimetics and complications were recorded.

Results

Mean age was 66.2 ± 9.9 (SD). The ASA status was III–IV in 54.1 % and 5.5% of the preplanned and inadvertent patients, respectively. In 85 anaesthetics, hyperbanc bupivacaine 0.1% (9.7 ± 7.5 mg) was used as the sole anaesthetic. Sensory level was T₄-T₈. Maximal decrease in systolic and diastolic blood pressures and heart rate was 19.0 ± 9.8%, 13.4 ± 13.3%, and 7.2 ± 11.7 respectively. Intravenous sympathomimetics were used in nine of 82 (11.0%) preplanned, and in six of 18 (33.3%) inadvertent anaesthetics. Post dural puncture headache appeared following two of 82 (2.5%) preplanned, and four of 18 (22.2%) inadvertent anaesthetics. No postanaesthetic neurological deficit was detected.

Conclusion

Continuous spinal anaesthesia, using a standard epidural set and hyperbaric bupivacaine is feasible for ESWL in high risk patients. Inadvertent dural puncture does not preclude CSA under these circumstances.     

Epidural needle insertion

Background

Dural puncture, paraesthesia and vascular puncture are the most common complications of epidural catheter insertion. Their association with variation in midline needle insertion depth is unknown.

Objective

This study evaluated the risk of dural and vascular punctures and the unwanted events paraesthesia and multiple skin punctures related to midline needle insertion depth.

Material and methods

A total of 14,503 epidural catheter insertions including lumbar (L1–L5; n?=?5367), low thoracic (T7–T12, n?=?8234) and upper thoracic (T1–T6, n?=?902) insertions, were extracted from the German Network for Regional Anaesthesia registry between 2007 and 2015. The primary outcomes were compared with logistic regression and adjusted (adj) for confounders to determine the risk of complications/events. Results are presented as odds ratios (OR, [95% confidence interval]).

Main results

Midline insertion depth depended on body mass index, sex, and spinal level. After adjusting for confounders increased puncture depth (cm) remained an independent risk factor for vascular puncture (adjOR 1.27 [1.09–1.47], p?=?0.002) and multiple skin punctures (adjOR 1.25 [1.21–1.29], p?<?0.001). In contrast, dural punctures occurred at significantly shallower depths (adjOR 0.73 [0.60–0.89], p?=?0.002). Paraesthesia was unrelated to insertion depth. Body mass index and sex had no influence on paraesthesia, dural and vascular punctures. Thoracic epidural insertion was associated with a lower risk of vascular puncture than at lumbar sites (adjOR 0.39 [0.18–0.84], p?=?0.02).

Conclusion

Variation in midline insertion depth is an independent risk factor for epidural complications; however, variability precludes use of depth as a reliable guide to insertion in individual patients.

     

Bilateral interhemispheric subdural hematoma after inadvertent lumbar puncture in a parturient

Purpose

Interhemispheric subdural hematomas (ISH) are rare in adults and occur most often after cranial trauma. We describe a parturient who developed bilateral acute ISH after inadvertent dural puncture associated with placement of an epidural catheter for labour analgesia. We discuss the features, pathophysiology, and management of this type of subdural hematoma.

Clinical features

A 38-yr-old woman requested epidural analgesia for relief of labour pain. An inadvertent dural puncture occurred during placement of a 17G Tuohy needle. After labour and delivery, the patient developed symptoms of a postdural puncture headache, which responded only partially to an epidural blood patch. The patient??s headache subsequently became less position-dependent and was associated with episodes of sharp pain radiating down her legs and paresthesias on the left side of her body. A computed tomography (CT) scan showed right frontal and left parietal acute ISH without an intracranial mass effect. The patient was monitored in the intensive care unit and treated conservatively because of the relatively small size of the ISH and the absence of progressive neurological deficits on serial examinations. Daily CT scans showed gradual decreases in the size of the ISH concomitant with improvement of the headache.

Conclusions

Rupture of bridging veins between the cerebral cortex and the superior sagittal sinus is the usual mechanism by which ISH occur. Nearly one-quarter of patients with ISH do not survive, although those with smaller hematomas have a better outcome. If the hematoma is?相似文献   

Reversal of high spinal anesthesia with cerebrospinal lavage after inadvertent intrathecal injection of local anesthetic in an obstetric patient

Purpose

High or total spinal anesthesia commonly results from accidental placement of an epidural catheter in the intrathecal space with subsequent injection of excessive volumes of local anesthetic. Cerebrospinal lavage has been shown to be effective at reversing the effects of high/total spinal anesthesia but is rarely considered in obstetric cases. Here, we describe the use of cerebrospinal lavage to prevent potential complications from high/total spinal anesthesia after unintentional placement of an intrathecal catheter in a labouring obstetric patient.

Clinical features

A 34-yr-old female presented to the labour and delivery unit in active labour. Epidural anesthesia was initiated, and after the first bolus dose, the patient experienced lower extremity motor block and shortness of breath. A high spinal was confirmed, and cerebrospinal lavage was performed. In total, 40 mL of cerebrospinal fluid (CSF) were exchanged for an equal volume of normal saline. The patient’s breathing difficulties and motor block resolved quickly, and a new epidural catheter was placed after removal of the spinal catheter. Pain control was effective, and the patient delivered a healthy baby.

Conclusion

We show that exchange of CSF for normal saline can be used successfully to manage a high spinal in an obstetric patient. Our results suggest that CSF lavage could potentially be an important and helpful adjunct to the conventional supportive management of obstetric patients in the event of inadvertent high or total spinal anesthesia.     

Time spent per patient in lumbar spinal stenosis surgery

Purpose

To examine the time needed from a surgeon’s viewpoint to treat a patient operated for lumbar spinal stenosis. We firstly aimed to give evidence of the wide ranging duration of standardized procedure. Secondly, we investigated factors affecting the time allocated to each patient.

Methods

438 medical records of patients operated on for lumbar decompression without fusion (2005–2011) were retrospectively examined. Primary data were operative time (OT, min), length of stay (LoS, days) and number of postoperative visits. A fourth parameter was calculated, the time spent per patient (TSPP, min) by summing the time spent in surgery, during inpatient and outpatient follow-up visits. Factors that influenced these medical resources were examined.

Results

Median (5th–95th percentile) LoS was 5 days (2–15), OT 106 min (60–194), number of medical visits 5 (2–11) and TSPP 329 min (206–533). In descending order, factors predicting LoS were age, no. of levels, sex, operative technique, cardiovascular risk index, dural tear and haematoma. Factors predicting OT were number of levels, dural tear, foraminotomy, synovial cyst and body mass index. The statistical model could predict 36 % of the TSPP variance. We recommend that surgeons add 35 min for each level, 29 min for patients over 65 years, 30 min for women, 132 min for dural tear and 108 min for epidural haematoma.

Conclusion

TSPP treated for lumbar spinal stenosis is highly variable, yet partially predictable. These data may help individual surgeons or heads of departments to plan their activities.     

Management of postdural puncture headache

Postdural puncture headache (PDPH), a complication of regional anesthesia, is not infrequently seen in parturients because of their inherent risk from young age and female gender. With spinal anesthesia, the risk of PDPH is mainly dependent on the size and type of needle and can be reduced with the use of small-gauge, pencilpoint spinal needles. For unintentional dural puncture with epidural needles, a prophylactic epidural blood patch can reduce the risk of PDPH. Other potentially efficacious maneuvers include insertion of an intrathecal catheter and avoidance of second- stage pushing. Treatment of PDPH includes the use of caffeine or an epidural blood patch. Other pharmacologic interventions (eg, theophylline, sumatriptan, adrenocorticotropic hormone) and epidural administration of saline or dextran 40 await further investigation. The evidence for these interventions is discussed in this review. Copyright © 2001 by W.B. Saunders Company     

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.     

Continuous spinal anesthesia for Cesarean hysterectomy and massive hemorrhage in a parturient with placenta increta

Purpose

We present anesthetic management using a continuous spinal anesthesia (CSA) technique in a patient with placenta increta who underwent elective Cesarean hysterectomy with massive postpartum hemorrhage.

Clinical features

A 34-yr-old parturient (G3P2) was scheduled for Cesarean delivery and possible hysterectomy at 35⁺³ weeks due to suspected placenta accreta. Her body mass index was 21?kg·m^?2 and she had a reassuring airway. Inadvertent dural puncture occurred during combined spinal-epidural (CSE) placement, and a decision was made to thread the epidural catheter and utilize a CSA technique. Following delivery of a healthy infant, morbid adherence of the placenta to the myometrium was confirmed, and a supracervical hysterectomy was performed. Eight litres of blood loss occurred postpartum requiring resuscitation with crystalloid 3,800?mL, colloid 1,500?mL, red blood cells 16 units, fresh frozen plasma 16 units, platelets 4 units, and cryoprecipitate 1 unit. The patient developed pulmonary edema requiring conversion to general anesthesia. The patient??s cardiovascular status was stable throughout surgery, and her lungs were mechanically ventilated for 18 hr postoperatively in the intensive care unit. The intrathecal catheter was removed 24 hr after placement. She developed no adverse neurological sequelae and reported no postdural puncture headache. The pathology report confirmed placenta increta.

Conclusion

A CSA technique may be a viable option in the event of inadvertent dural puncture during planned CSE or epidural placement in patients with a reassuring airway undergoing Cesarean delivery. Although a catheter-based neuraxial technique is appropriate for Cesarean hysterectomy for abnormal placentation, conversion to general anesthesia may be required in the event of massive perioperative hemorrhage and fluid resuscitation.     

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.