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.     

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.     

Sequential higher epidural catheter re-insertion after accidental dural puncture ameliorates the frequency and severity of post-dural puncture headache

ObjectivesThis cohort study aimed to evaluate the outcome of a hypothesis to use higher level for epidural catheter insertion and activation when an epidural tap was encountered at a lower level during epidural analgesia for labor pain.MethodsEpidural analgesia for labor pain was conducted using a mixture of 0.125% bupivacaine and fentanyl 5 μg/ml (10–15 ml) in 5-ml increments and maintained using continuous epidural infusion of 0.125% bupivacaine and fentanyl 2 μg/ml at rate of (5–15 ml/h), subsequently adjusted according to the patients needs. All cases had accidental dural puncture (ADP) were managed immediately with re-insertion of the needle at a higher level and completion of the procedure and maintained using continuous epidural infusion of 0.0625% bupivacaine and fentanyl 2 μg/ml at rate of (6–12 ml/h) for 24 h after delivery. Postpartum follow-up was conducted for 30 days to comment on the occurrence and severity of post-dural puncture headache (PDPH). All patients developed PDPH were followed daily until resolution of their headache.ResultsAbout 4800 parturient were enrolled in the study, ADP occurred in 24 patients with a frequency of 0.5%. All cases were immediately managed by re-insertion of the needle at a higher level and the procedure was successfully completed without new dural puncture, with 100% re-insertion success rate, and patients were maintained on continuous epidural infusion for 24 h. Throughout 30-day follow-up; only six of 24 patients developed PDPH with a success rate of re-insertion procedure as a prophylactic modality for PDPH after ADP of 75%. PDPH was relieved with bed rest, liberal fluids and paracetamol for 4 days in four patients, while the 5th patient continued to complain but the patient refused to undergo epidural blood patch (EBP) and headache started to subside and patient stopped to complain by the 10th day, and the last patient agreed to undergo EBP; and headache was relived immediately after 2 h.ConclusionIt could be concluded that re-insertion of epidural catheter at higher level of accidental dural puncture with epidural continuous infusion for 24 h could be considered as an efficient prophylactic modality to safe guard against PDPH with success rate of 75% and minimizes its severity if occurred.     

Obstetric post-dural puncture headache

Post-dural puncture headache (PDPH) is a recognized complication of inadvertent dural puncture (DP) during epidural insertion or the intentional dural puncture following spinal anaesthesia. The resulting headache can be debilitating.     

Temporal trends in the incidence of post-dural puncture headache following labor neuraxial analgesia in the United States, 2006 to 2015

BackgroundLabor neuraxial analgesia utilization has increased in the United States (U.S.) but its impact on maternal safety is unknown. This study analyzed the temporal trends in the incidence of post-dural puncture headache (PDPH) in obstetrics.MethodsData for vaginal or intrapartum cesarean deliveries came from the National Inpatient Sample 2006–2015, a U.S. 20% representative sample of hospital discharge records. The outcome was PDPH (ICD-9-CM codes 349.0 and 03.95) categorized into (1) PDPH coded without epidural blood patch (EBP), and (2) PDPH coded with EBP. Temporal trends in incidence were described using the percent change between 2006 and 2015 and its 95% confidence interval (CI).ResultsOf the 29 011 472 deliveries studied, 86 558 (29.8 per 10 000; 95% CI: 29.3 to 30.2) recorded a diagnosis of PDPH, including 34 019 without EBP (11.7 per 10 000; 95% CI 11.4 to 12.0) and 52 539 with EBP (18.1 per 10 000; 95% CI 17.8 to 18.4). A significant decrease in the incidence of PDPH was observed from 31.5 per 10 000 in 2006 to 29.2 per 10 000 in 2015 (–7.5%; 95% CI −2.2 to −0.5; P=0.001). The decrease in the incidence of PDPH was significant irrespective of the presence of EBP. The decrease was observed in the three categories of hospitals examined (rural, urban non-teaching, and urban teaching).ConclusionsDuring the study period, the reported incidence of PDPH in the U.S. has decreased modestly. Intervention programs are needed to address this persistent and preventable cause of maternal morbidity.     

Successful treatment of a recurrent post-dural puncture headache with an epidural blood patch 18 months after the initial dural puncture

Inadvertent dural puncture is a recognised complication of epidural insertion. Parturients are at increased risk of developing a post-dural puncture headache, which can be debilitating for a mother caring for a newborn infant. Epidural blood patch is an effective treatment in patients presenting acutely with post-dural puncture headaches but its efficacy in those with delayed presentation or with late recurrent post-dural puncture headache is less clear. We present the case of a woman with a recurrent post-dural puncture headache who was successfully treated with an epidural blood patch 18 months after the initial dural puncture. Patients who develop post-dural puncture headaches may remain symptomatic for some time and an epidural blood patch may be beneficial, following appropriate investigation.     

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.     

Impact of obesity on post-dural puncture headache

IntroductionPrevious studies have suggested an inverse relationship between obesity and development of post-dural puncture headache following spinal anesthesia. However, few have investigated the relationship between obesity and headaches after accidental dural puncture with an epidural needle. This study explored whether obesity has any association with headaches following an accidental dural puncture.MethodsRecords of patients who received epidural analgesia for labor and vaginal delivery between January 2011 and June 2015 were reviewed. Body mass index, American Society of Anesthesiologists Physical Status and age were analyzed. Chi-squared analysis was performed to determine the relationship between the incidence and severity of post-dural puncture headaches and body mass index.ResultsA total of 17 497 epidurals were placed for vaginal deliveries. Of these, 164 patients met our criteria for accidental dural puncture, of whom 51.2% developed post-dural puncture headaches. Of patients who developed a post-dural puncture headache 35.7% required an epidural blood patch. Data analysis showed no significant relationship between body mass index and incidence of post-dural puncture headaches regardless of body mass index classification (P>0.05). There was no association between body mass index and the intensity of post-dural puncture headache (P=0.29).ConclusionPatients with a high body mass index do not appear to be protected from experiencing a post-dural puncture headache after an accidental dural puncture during placement of labor epidural analgesia. Additionally, the intensity of post-dural puncture headache does not vary with body mass index.     

Post-dural puncture headache,intracranial air and obstetric anesthesia

Recently, a controversy has arisen as to whether air or saline should be recommended for the correct localization of the epidural space with the loss of resistance technique. I report a case of a previously healthy parturient who developed pneumocephalus and severe headache following the use of the loss of resistance to air (LORA) technique to identify the epidural space. This case report raises one more time the question about the safety of the LORA technique for labor analgesia.     

Tonic-clonic seizure after unrecognized unintentional dural puncture

Patients who suffer an unintentional dural puncture have a high risk of developing a post-dural puncture headache. Other neurologic complications have been reported, but seizure is rarely seen. We present a case of a 21-year-old primigravida who experienced an unrecognized unintentional dural puncture that ultimately resulted in a tonic-clonic seizure from intracranial hypotension one week following the dural breach. Her trachea was intubated and she was transferred to the intensive care unit. Two epidural blood patches, performed by neuroradiologists, were needed before the patient experienced complete resolution of her headache. During the re-admission, she also experienced a pulmonary embolus which further lengthened her hospital stay.     

Post-delivery postural headache: not always a classical post-dural puncture headache

We report a parturient complaining of headache after spinal and epidural labour analgesia with neurological deterioration following an epidural blood patch. Further investigation revealed a medulloblastoma within the fourth ventricle. The patient underwent an operation 4 days after the diagnosis, but died 2 years later. The consequences of the use of neuraxial analgesia and epidural blood patch in the treatment of post-dural puncture headache in this kind of pathology are discussed.     

All patients with a postdural puncture headache should receive an epidural blood patch

Postdural puncture headache (PDPH) is an important complication of obstetric epidural anaesthesia and analgesia. Though often self-limiting, PDPH is unpleasant, at times incapacitating, and associated with complications, some of which are serious. Despite this, treatment options are few and of limited efficacy. The epidural blood patch (EBP) has been used for PDPH treatment for over 50 years.¹ It is probably the most efficacious of therapies, although this is unproven, and plays an important part in the management of this condition.² However, PDPH is often complex, of variable severity and duration, and merits a cautious and individualized approach to its diagnosis and treatment. An EBP may be part of that treatment but administering it to all women with PDPH is not the optimal management approach.     

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

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

Management of persistent post-dural puncture headache after repeated epidural blood patch

We report a case of persistent post-dural puncture headache (PDPH) in a patient despite two epidural blood patches (EBPs). Successful resolution of headache was achieved with a third EBP performed under computed tomography (CT) guidance. A 38-year-old female had a total abdominal hysterectomy under combined spinal-epidural anesthesia with no complications. After surgery, she developed a postural headache consistent with PDPH. The first EBP was performed by injecting autologous blood through the epidural catheter that was in situ. The second EBP was performed under fluoroscopy. The patient continued to have a persistent headache. A computed tomography (CT) myelogram demonstrated cerebrospinal fluid (CSF) leak at L3-4 level. A "directed" CT-guided blood patch was then performed successfully with resolution of the headache.     

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.     

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.     

The management of a postdural puncture headache in a child

We present a case of an 11-year old girl who underwent an elective pyeloplasty and had an epidural catheter placed for per- and postoperative analgesia. Postoperatively she developed a postural headache and severe nausea, and a diagnosis of postdural puncture headache (PDPH) was made. Her symptoms failed to respond to conservative management. An epidural blood patch was performed with immediate and complete resolution of her symptoms. We present this case to highlight the occurrence of PDPH in children and to outline the considerations for management.     

硬膜穿破后头痛的研究进展

硬膜穿破是硬膜外麻醉常见的并发症,可能导致阻滞平面过高甚至全脊麻.但是硬膜穿破后最常见的并发症是头痛,称为硬膜穿破后头痛(post-dural puncture headache,PDPHA).头痛的程度与患者的性别和年龄、穿刺针类型和粗细等因素相关.硬膜外血补片以及生理盐水注入是最常用也是最有效的治疗PDPHA的方法.     

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).