Prophylactic cosyntropin after unintentional dural puncture and incidence of post-dural puncture headache and epidural blood patch use: A retrospective cohort study (2019-2022)

BACKGROUND

Cosyntropin has been suggested to decrease the incidence of post-dural puncture headache (PDPH) by increasing the production of cerebrospinal fluid. This study examined the association of prophylactic cosyntropin administration with the incidence of PDPH and its management with an epidural blood patch after an unintentional dural puncture (UDP).

METHODS

We conducted a retrospective cohort study of cases with UDP during placement of neuraxial labor analgesia. Per institutional practice and at the discretion of the anesthesiologist, intravenous cosyntropin 1 mg may be administered for PDPH prophylaxis. PDPH, time from UDP to cosyntropin administration, time to development of PDPH, and management with epidural blood patch(es) were recorded.

RESULTS

Cosyntropin was administered in 164 of 234 (70%) cases with UDP. PDPH occurred 98/164 (60%) with cosyntropin and 45/70 (64%) without cosyntropin (p = 0.66). The PDPH adjusted incidence was 53% with cosyntropin and 62% without cosyntropin, difference 9% (95% CI -6% to 24%, p = 0.25). The adjusted epidural blood patch rate was 66% with cosyntropin and 78% without cosyntropin, difference of 12% (95% CI -5% to 28%, p = 0.17).

CONCLUSIONS

Prophylactic cosyntropin following UDP was not associated with a significant decrease in PDPH rate or use of epidural blood patch for management of PDPH. There was no significant difference in the rate of adverse hyperglycemic or hypertensive events amongst those who did or did not receive cosyntropin.

The Prophylactic Effect of Acetaminophen and Caffeine on Post Dural Puncture Headache after Spinal Anesthesia for Cesarean Section: A Randomized Double-Blind Clinical Trial

Background

Post-dural puncture headache (PDPH) is the most common complication following spinal anesthesia among parturients undergoing cesarean section surgery. The purpose of this study was to evaluate the effectiveness of acetaminophen and caffeine in preventing PDPH.

Methods

This double-blind, randomized clinical trial was conducted on 96 obstetric women, who were candidates for elective cesarean section. Following the randomization of participants into two groups, participants in the intervention group received tablets of acetaminophen (500 mg)+caffeine (65 mg), and participants in the control group received placebo tablets orally 2 hours before spinal anesthesia induction and then every 6 hours after surgery up to 24 hours. All parturients were evaluated for frequency and intensity of PDPH every 6 hours until 24 hours after surgery and then 48 and 72 hours after surgery. Overall satisfaction during the first 72 hours of postpartum was evaluated. The data were analyzed using SPSS software. P<0.05 was considered statistically significant.

Results

Participants in the intervention group were 70% less likely to experience PDPH after spinal anesthesia (OR=0.31 P=0.01, 95% CI [0.12-0.77]). They also experienced significantly milder headaches 18 hours, 48 hours, and 72 hours later. Participants in the intervention group reported higher levels of satisfaction at the end of the study (P=0.01). No side effects related to the intervention were reported.

Conclusion

Prophylactic administration of acetaminophen+caffeine decreases 70% the risk of PDPH and significantly attenuates pain intensity in obstetric patients who underwent spinal anesthesia for cesarean section.

Lumbar Puncture Complications: A Review of Current Literature

PURPOSE OF REVIEW

This paper reviews the complications of lumbar puncture with a focus on post-dural puncture headache including pathophysiology, risk factors, prevention, and treatment.

RECENT FINDINGS

Recent research has focused on understanding the multifactorial mechanisms of post-dural puncture headache and improving prevention and treatment strategies. Small caliber, pencil-point type needles are encouraged to minimize the risk of post-dural puncture headaches, especially in populations that are at higher risk for complication. While new medications and procedures show promise in small cohorts, conservative medical management and epidural blood patch are still the first and second-line treatments for PDPH. Post-dural puncture headache is the most frequent complication of lumbar puncture. There are both modifiable and nonmodifiable risk factors to consider when performing this procedure. Conservative medical management and procedure-based therapies exist for when complications of lumbar puncture arise.

Evidence-based clinical practice guidelines on postdural puncture headache: a consensus report from a multisociety international working group

INTRODUCTION

Postdural puncture headache (PDPH) can follow unintentional dural puncture during epidural techniques or intentional dural puncture during neuraxial procedures such as a lumbar puncture or spinal anesthesia. Evidence-based guidance on the prevention, diagnosis or management of this condition is, however, currently lacking. This multisociety guidance aims to fill this void and provide practitioners with comprehensive information and patient-centric recommendations to prevent, diagnose and manage patients with PDPH.

METHODS

Based on input from committee members and stakeholders, the committee cochairs developed 10 review questions deemed important for the prevention, diagnosis and management of PDPH. A literature search for each question was performed in MEDLINE (Ovid) on 2 March 2022. The results from each search were imported into separate Covidence projects for deduplication and screening, followed by data extraction. Additional relevant clinical trials, systematic reviews and research studies published through March 2022 were also considered for the development of guidelines and shared with contributors. Each group submitted a structured narrative review along with recommendations graded according to the US Preventative Services Task Force grading of evidence. The interim draft was shared electronically, with each collaborator requested to vote anonymously on each recommendation using two rounds of a modified Delphi approach.

RESULTS

Based on contemporary evidence and consensus, the multidisciplinary panel generated 50 recommendations to provide guidance regarding risk factors, prevention, diagnosis and management of PDPH, along with their strength and certainty of evidence. After two rounds of voting, we achieved a high level of consensus for all statements and recommendations. Several recommendations had moderate-to-low certainty of evidence.

CONCLUSIONS

These clinical practice guidelines for PDPH provide a framework to improve identification, evaluation and delivery of evidence-based care by physicians performing neuraxial procedures to improve the quality of care and align with patients' interests. Uncertainty remains regarding best practice for the majority of management approaches for PDPH due to the paucity of evidence. Additionally, opportunities for future research are identified.

Long-term effects of neuraxial analgesia

PURPOSE OF REVIEW

This review article explores the potential longer-term implications of neuraxial analgesia in labour for both the mother and her child.

RECENT FINDINGS

Neuraxial techniques for labour analgesia are well tolerated and effective, and long-term adverse sequelae are rare. Labour epidural analgesia is not independently associated with long-term headache, backache, postnatal depression or anal sphincter injury, and evidence supports that epidurals may offer protection against severe maternal morbidity, particularly in women at a higher risk of complications. However, there is an increasing awareness that postdural puncture headache may be associated with chronic headache, back pain and postnatal depression, emphasizing the need for adequate follow-up until symptoms resolve.For the neonate, a growing body of evidence refutes any association between epidural analgesia in labour and the later development of autism spectrum disorder. The clinical significance of epidural related maternal fever remains uncertain and is a research priority.

SUMMARY

Women should continue to access the significant benefits of neuraxial analgesia in labour without undue concern about adverse sequelae for themselves or their offspring. Measures to prevent, appropriately manage and adequately follow-up women who have suffered complications of neuraxial analgesia, such as postdural puncture headache, are good practice and can mitigate the development of long-term sequelae.

Efficacy of therapies for post dural puncture headache

PURPOSE OF REVIEW

Clinical management of postdural puncture headache (PDPH) remains an interdisciplinary challenge with significant impact on both morbidity and quality of life. This review aims to give an overview of the most recent literature on prophylactic and therapeutic measures and to discuss novel findings with regard to currently published consensus practice guideline recommendations.

RECENT FINDINGS

Although current evidence does not support a recommendation of any specific prophylactic measure, new data is available on the use of intrathecal catheters to prevent PDPH and/or to avoid invasive procedures. In case of disabling or refractory symptoms despite conservative treatments, the epidural blood patch (EBP) remains the therapeutic gold standard and its use should not be delayed in the absence of contraindications. However, recent clinical studies and meta-analyses provide additional findings on the therapeutic use of local anesthetics as potential noninvasive alternatives for early symptom control.

SUMMARY

There is continuing research focusing on both prophylactic and therapeutic measures offering promising data on potential alternatives to invasive procedures, although there is currently no treatment option that comes close to the effectiveness of an EBP. A better understanding of PDPH pathophysiology is not only necessary to identify new therapeutic targets, but also to recognize patients who benefit most from current treatments, as this might enhance their therapeutic efficacy.

Neuraxial Anesthesia during the COVID-19 Pandemic: Report from a Large Academic Medical Center

OBJECTIVE

Three primary neuraxial techniques reduce labor pain: epidural, dural puncture epidural (DPE), and combined spinal-epidural (CSE). This study aims to determine whether neuraxial analgesia techniques changed after the onset of the coronavirus disease 2019 (COVID-19) pandemic. Given that a dural puncture confirms neuraxial placement, we hypothesized that DPE was more frequent in women with concerns for COVID-19.

STUDY DESIGN

A single-center retrospective cohort study comparing neuraxial analgesia techniques for labor and delivery pain management before and after the onset of the COVID-19 pandemic and in patients with and without SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) at a maternity hospital in Dallas, Texas, with a large delivery service. Statistical analyses included the Chi-square test for categorical and Kruskal-Wallis test for nonparametric ordinal comparisons. The Cochran-Mantel-Haenszel test was used to assess the association between neuraxial technique and accidental dural puncture or postdural puncture headache.

RESULTS

Of 10,971 patients who received neuraxial analgesia for labor, 5,528 were delivered in 2019 and 5,443 in 2020. Epidural analgesia was the most common neuraxial technique for labor pain in 2019 and 2020. There was no difference in the frequency of neuraxial analgesia techniques or the rates of accidental dural puncture or postdural puncture headaches comparing all deliveries in 2019 to 2020. Despite a significant increase in DPEs relative to epidurals in the SARS-CoV-2-positive group compared with the SARS-CoV-2-negative group in 2020, there was no significant difference in postdural puncture headaches or accidental dural punctures.

CONCLUSION

The advantages of a DPE, specifically the ability to confirm epidural placement using a small gauge spinal needle, likely led to an increase in the placement of this neuraxial in SARS-CoV-2-positive patients. There was no effect on the frequency of postdural puncture headaches or accidental dural punctures within the same period.

KEY POINTS

· Epidural analgesia was the most common neuraxial technique for labor pain management.. · Dural puncture epidural placements increased in SARS-CoV-2-positive patients.. · Rates of postdural puncture headaches and accidental dural puncture after neuraxial placement did not change..

Prophylactic effect of chamomile on post-dural puncture headache in women undergoing elective cesarean section: A randomized, double blind, placebo-controlled clinical trial

BACKGROUND

Post-dural puncture headache (PDPH) is a common complication after spinal anesthesia, affecting patient recovery. This study evaluated the prophylactic effect of topical chamomile ointment on PDPH in women undergoing elective cesarean section.

METHODS

In a randomized, double-blind, placebo-controlled clinical trial 148 pregnant women were randomized into two parallel groups and received 3cc of the chamomile or the placebo ointment on the forehead of the participants 20 minutes before the start of spinal anesthesia, and then 2 and 4 hours after that. The primary outcomes were the incidence rate of headache, and its severity assessed by a numeric rating scale (NRS), while secondary outcomes included analgesic consumption, frequency of nausea/vomiting, and adverse events.

RESULTS

Chamomile ointment exhibited significant preventive effects on PDPH incidence compared to placebo. The chamomile group demonstrated lower rates of PDPH at 6 hours (3.5% vs. 7.18%, p = 0.021) and 12 hours (7.6% vs. 20%, p = 0.028) after spinal anesthesia. Analgesic consumption, frequency of nausea/vomiting, and adverse events were comparable between the groups.

CONCLUSION

Topical chamomile ointment demonstrated significant preventive effects on PDPH incidence compared to placebo. Chamomile ointment could be a promising adjunctive approach to prevent PDPH, enhancing patient comfort and potentially reducing the need for analgesics. Further investigation is needed to explore its mechanisms and broader applications.

Prophylactic Epidural Blood Patch or Prophylactic Epidural Infusion of Hydroxyethyl Starch in Preventing Post-Dural Puncture Headache - A Retrospective Study

BACKGROUND

Post-dural puncture headache (PDPH) is particularly likely to happen in patients under obstetric care due to an unintentional dural puncture (UDP). There is as yet no ideal strategy for preventing UDP-induced PDPH.

OBJECTIVES

The primary objective of this study was to assess whether a prophylactic epidural blood patch (EBP) or prophylactic epidural infusion of hydroxyethyl starch (HES) is effective in preventing PDPH for parturients with UDP compared with conservative treatments.

STUDY DESIGN

Retrospective analysis from a single center's inpatient data.

SETTING

Department of Anesthesiology at a single center.

METHODS

A retrospective study was conducted of a single center's inpatient data from January 2017 through March 2020. The study included parturients with UDP during neuraxial anesthesia. The interventions of UDP included conservative treatment, prophylactic EBP, and prophylactic epidural infusion of HES. The incidence of PDPH, the use of intravenous aminophylline, therapeutic EBP, symptom onset, duration of headache, and duration of hospital stay were compared.

RESULTS

A total of 85 patients were analyzed. The incidences of PDPH were 84%, 52.6% and 54.5% with conservative, prophylactic EBP, and prophylactic epidural HES treatments, respectively. Compared with the conservative treatment, prophylactic EBP and prophylactic epidural HES treatment significantly reduced the incidence of PDPH (P < 0.05). No significant difference was found between the prophylactic EBP and prophylactic epidural HES groups. Compared with the conservative treatment group, therapeutic EBP was significantly less used in the prophylactic EBP and prophylactic epidural HES groups (P < 0.05). Prophylactic EBP shortened the length of hospital stay of parturients with UDP (P < 0.05) while prophylactic epidural HES showed no statistical difference compared with conservative treatment. No severe complications, such as central nervous system and puncture site infection or nerve injury, were found in those patients.

LIMITATIONS

Retrospective nature and single center data with a relatively small sample size.

CONCLUSIONS

Prophylactic management with EBP and epidural infusion of HES has an effect in preventing the occurrence of PDPH; prophylactic EBP significantly shortened hospital stay length in parturients with UDP.

KEY WORDS

Unintentional dural puncture, epidural blood patch, hydroxyethyl starch, post-dural puncture headache, parturient.

Consensus Practice Guidelines on Postdural Puncture Headache From a Multisociety, International Working Group: A Summary Report

Importance

Postdural puncture headache (PDPH) can follow unintentional dural puncture during epidural techniques or intentional dural puncture during neuraxial procedures, such as a lumbar puncture or spinal anesthesia. Evidence-based guidance on the prevention, diagnosis, and management of this condition is, however, currently lacking.

Objective

To fill the practice guidelines void and provide comprehensive information and patient-centric recommendations for preventing, diagnosing, and managing PDPH.

Evidence Review

With input from committee members and stakeholders of 6 participating professional societies, 10 review questions that were deemed important for the prevention, diagnosis, and management of PDPH were developed. A literature search for each question was performed in MEDLINE on March 2, 2022. Additional relevant clinical trials, systematic reviews, and research studies published through March 2022 were also considered for practice guideline development and shared with collaborator groups. Each group submitted a structured narrative review along with recommendations that were rated according to the US Preventive Services Task Force grading of evidence. Collaborators were asked to vote anonymously on each recommendation using 2 rounds of a modified Delphi approach.

Findings

After 2 rounds of electronic voting by a 21-member multidisciplinary collaborator team, 47 recommendations were generated to provide guidance on the risk factors for and the prevention, diagnosis, and management of PDPH, along with ratings for the strength and certainty of evidence. A 90% to 100% consensus was obtained for almost all recommendations. Several recommendations were rated as having moderate to low certainty. Opportunities for future research were identified.

Conclusions and Relevance

Results of this consensus statement suggest that current approaches to the treatment and management of PDPH are not uniform due to the paucity of evidence. The practice guidelines, however, provide a framework for individual clinicians to assess PDPH risk, confirm the diagnosis, and adopt a systematic approach to its management.

Epidural hydroxyethyl starch ameliorating postdural puncture headache after accidental dural puncture

BACKGROUND

No convincing modalities have been shown to completely prevent postdural puncture headache (PDPH) after accidental dural puncture (ADP) during obstetric epidural procedures. We aimed to evaluate the role of epidural administration of hydroxyethyl starch (HES) in preventing PDPH following ADP, regarding the prophylactic efficacy and side effects.

METHODS

Between January 2019 and February 2021, patients with a recognized ADP during epidural procedures for labor or cesarean delivery were retrospectively reviewed to evaluate the prophylactic strategies for the development of PDPH at a single tertiary hospital. The development of PDPH, severity and duration of headache, adverse events associated with prophylactic strategies, and hospital length of stay postpartum were reported.

RESULTS

A total of 105 patients experiencing ADP received a re-sited epidural catheter. For PDPH prophylaxis, 46 patients solely received epidural analgesia, 25 patients were administered epidural HES on epidural analgesia, and 34 patients received two doses of epidural HES on and after epidural analgesia, respectively. A significant difference was observed in the incidence of PDPH across the groups (epidural analgesia alone, 31 [67.4%]; HES-Epidural analgesia, ten [40.0%]; HES-Epidural analgesia-HES, five [14.7%]; P <0.001). No neurologic deficits, including paresthesias and motor deficits related to prophylactic strategies, were reported from at least 2 months to up to more than 2 years after delivery. An overall backache rate related to HES administration was 10%. The multivariable regression analysis revealed that the HES-Epidural analgesia-HES strategy was significantly associated with reduced risk of PDPH following ADP (OR = 0.030, 95% confidence interval: 0.006-0.143; P < 0.001).

CONCLUSIONS

The incorporated prophylactic strategy was associated with a great decrease in the risk of PDPH following obstetric ADP. This strategy consisted of re-siting an epidural catheter with continuous epidural analgesia and two doses of epidural HES, respectively, on and after epidural analgesia. The efficacy and safety profiles of this strategy have to be investigated further.

Opioids for the Prevention of Post-dural Puncture Headache in Obstetrics: A Systematic Review and Meta-analysis of Efficacy and Safety

BACKGROUND

Post-dural puncture headache (PDPH), or spinal headache, is the most common serious complication resulting from iatrogenic puncture of the dura during epidural or spinal anesthesia and cerebrospinal fluid (CSF) leak in pregnant women.

OBJECTIVE

To analyze the effectiveness and safety of opioids as a prophylaxis approach in treating obstetric patients who underwent unintentional dural puncture during the initiation of neuraxial anesthesia.

STUDY DESIGN

A systematice review and meta-analysis.

SETTING

No restriction regarding study type.

METHODS

PubMed, Embase, and the Cochrane library were searched for available papers published up to September 2020.

RESULTS

According to the eligibility criteria, 10 studies were included with post-dural puncture headache (PDPH) incidence as the primary outcome and the number of epidural blood patch (EBP) required as the second outcome. The risk estimates of each study were reported as odds ratios (ORs). The results showed morphine does not decrease the incidence of PDPH (OR = 0.45, 95% CI: 0.15 - 1.34, P = 0.153, I2 = 74.4%, Pheterogeneity = 0.004) and the use of EBP (OR = 0.40, 95% CI: 0.08 - 1.95, P = 0.259, I2=73.7%, Pheterogeneity = 0.004). Fentanyl does not decrease the incidence of PDPH (OR = 0.35, 95% CI: 0.01-13.77, P = 0.576, I2 = 81.0%, Pheterogeneity = 0.022).

LIMITATIONS

The small number of included studies, high heterogeneity, and variety in study designs.

CONCLUSIONS

Exposure to opioids for any reason after the diagnosis of unintentional dural puncture is not associated with a reduced risk of PDPH and does not decrease the need for therapeutic EBP.

Preventing Post Dural Puncture Headache after Intrathecal Drug Delivery System Implantation Through Preventive Fibrin Glue Application: A Retrospective Study

BACKGROUND

Cerebrospinal fluid (CSF) leakage resulting in post dural puncture headache (PDPH) is a frequent adverse effect observed after intrathecal drug delivery system (IDDS) implantation. CSF leakage symptoms negatively affect patient quality of life and can result in additional complications. Fibrin glue was used to treat CSF leakage syndrome. We developed a procedure to reduce the incidence of PDPH by preventing CSF leakage with the use of fibrin glue during surgery.

OBJECTIVES

The main outcome criterion for this study was the incidence of PDPH syndrome after IDDS implantation with or without preventive fibrin glue application during the procedure.

STUDY DESIGN

We designed a monocentric retrospective cohort study to compare the incidence of PDPH due to CSF leakage syndrome after lumbar puncture in patients with an implanted intrathecal pump, with or without preventive fibrin glue application during the procedure.

SETTING

The study was held in the Anesthesiology and Pain department of the  Integrative Cancer Institute (ICO), Angers - France.

METHODS

The study compared 2 patient cohorts over 2 successive periods. Fibrin glue was injected into the introducer needle puncture pathway after placement of the catheter immediately following needle removal.

RESULTS

The no-glue group included 107 patients, whereas the glue group included 92 patients.Two application failures were observed (2.04%). Fibrin glue application results in a significant decrease in PDPH incidence, from 32.7% in the no-glue group to 10.92 % (P < 0.001) in the glue group. In regard to severity, in the no-glue group, 37.1% of PDPH syndromes were mild, 34.3% were moderate, and 28.6% were severe. In the fibrin glue group, 80% of PDPH syndromes were mild, and 20% were moderate. No severe PDPHs were reported after fibrin glue application. Duration of symptoms was also statistically shorter in the fibrin glue group (maximum of 3 days vs. 15 days in the no-glue group). In a univariate analysis, preventive fibrin glue application and age are significant to prevent PDPH. In multivariate analysis, only fibrin glue application was statistically significant (odds ratio, 0.26; P = 0.0008). No adverse effects linked to fibrin glue were observed.

LIMITATIONS

The main limitation of this study is its retrospective nature. In addition, this study is from a single center with a potential selection bias and a center effect.

CONCLUSIONS

The novel use of fibrin glue is promising in terms of its effect on PDPH and its safety profile. Its moderate cost and reproducibility make it an affordable and efficient technique.

A nudge towards better lumbar puncture practice

BACKGROUND

Despite a body of evidence demonstrating reduced incidence of post-lumbar puncture headache associated with pencil-point (vs bevelled-edge) needles, their use remains variable in the UK.

METHODS

A multimodal longitudinal intervention was performed over a 12-month period at a tertiary neurology referral centre. In addition to simulation training using pencil-point needles and an electronic documentation pro forma, a change in the default needles presented in clinical environments was performed.

RESULTS

Prior to the intervention, pencil-point needle usage was minimal. Documentation significantly improved throughout the intervention period. Simulation training interventions only resulted in transient, moderate improvements in pencil-point needle usage. However, changing the default produced a marked increase in use that was sustained. No significant changes in operator success rate were found.

CONCLUSIONS

In the context of wider literature on the power of default options in driving behavioural choices, changing defaults may be an effective, inexpensive and acceptable intervention to improve lumbar puncture practice.

Optimal management after paediatric lumbar puncture: a randomized controlled trial

BACKGROUND

To evaluate whether a shorter time of lying supine without a pillow and fasting for solids and liquids (LSFSL) after a lumbar puncture (LP) is associated with a higher risk of post-lumbar puncture headache (PLPH) and post-lumbar puncture lower back pain (PLPBP) in a randomized, assessor-blinded, controlled trial.

METHODS

Paediatric patients who underwent their first LP after hospital admission were randomly allocated to either the group with half an hour of LSFSL (0.5 h LSFSL) or 4 h of LSFSL (4 h LSFSL) immediately after LP. The primary outcome is PLPH after LP. The incidence of PLPH, PLPBP, and vomiting; vital signs (respiratory rate, heart rate, blood pressure); and other post-procedure conditions after LP were measured as the outcomes. The Non-inferiority test and Wilcoxon rank-sum test were used to analyse the outcome data.

RESULTS

In total, 400 patients (201 in the 0.5-h LSFSL group and 199 in the 4-h LSFSL group) were included in this trial. Twelve (5.97%) of 201 patients experienced PLPH in the 0.5 h LSFSL group versus 13 (6.53%) of 199 patients in the 4 h LSFSL group (difference 0.56, 95% CI -4.18 to 5.31; p = 0·0108 for the non-inferiority test). Fourteen (6.97%) of 201 patients experienced PLPBP in the 0.5 h LSFSL group versus 17 (8.54%) of 199 patients in the 4 h LSFSL group (difference 1.57, 95% CI -3.66 to 6.82; p = 0.007 for the non-inferiority test). The changes in heart rate (HR), respiratory rate (RP) and systolic blood pressure (SBP) before and after the LP were not different between the 0.5-h LSFSL group and the 4-h LSFSL group. No other adverse events were reported.

CONCLUSIONS

Compared with 4 h of LSFSL after LP, 0.5 h of LSFSL was not associated with a higher risk of PLPH, PLPBP or other adverse events. In conclusion, 0.5 h of LSFSL is sufficient for children undergoing LP.

TRIAL REGISTRATION

Clinical trial NCT02590718 . The date of registration was 08/25/2015.

Impact of spinal needle type on postdural puncture headache among women undergoing Cesarean section surgery under spinal anesthesia: A meta-analysis

OBJECTIVE

Spinal anesthesia is the most frequently performed anesthesia for cesarean section. The American Society of Anesthesiology recommends using pencil-point spinal needles (SNs) over cutting-bevel SNs to reduce postdural puncture headache (PDPH) in their practice guidelines for obstetric anesthesia. However, there is no meta-analysis addressing the impact of the type of SNs on PDPH among women undergoing Cesarean section surgery.

METHODS

We conducted a systematic review and meta-analysis including randomized controlled trials comparing the incidence of PDPH of pencil-point SNs with cutting-bevel SNs in patients undergoing Cesarean section with spinal anesthesia. A comprehensive search of PubMed, Cochrane Library, EMBASE, and CINAHL without using any language and time restrictions were performed.

RESULTS

A total of 4936 patients from 20 studies (31 comparisons) were included. Pencil-point SN leads to reduced PDPH (risk ratio [RR] 0.33, 95% confidence intervals [CI] 0.25 to 0.45) and reduced requirement of epidural blood patch (RR = 0.21, 95% CI 0.09 to 0.51) compared to cutting-bevel SN. The incidence of anesthesia failure, non-PDPH, backache, and other adverse effects was not statistically significantly difference between the two SNs. Overall quality of evidence was moderate to low.

CONCLUSIONS

Using pencil-point SN appears to be beneficial for preventing PDPH in patients undergoing Cesarean section without increasing any potential adverse effects. Further research addressing the specific gauge of pencil-point SNs, which might further reduce the incidence of PDPH is highly desired.

Effect of 24-Hour Bed Rest versus Early Ambulation on Headache after Spinal Anesthesia: Systematic Review and Meta-analysis

OBJECTIVES

We performed a systematic review of the evidence for the effectiveness of bed rest after dural puncture to update current evidence on the topic.

DESIGN

The design was a systematic review and meta-analysis.

DATA SOURCES

We searched 10 electronic databases in English (Medline, CINAHL, EMBASE, and the Cochrane Controlled Trial Register) and Korean (KISS, KMBASE, NDSL, and RISS) using the terms "post-dural puncture headache," "spinal anesthesia," "epidural anesthesia," and "bed rest" to identify reports discussing the effectiveness of bed rest in preventing post-dural puncture headache (PDPH) after spinal anesthesia from 1980 to 2014. Review/Analysis Methods: Original studies such as randomized and nonrandomized controlled trials, where participants were allocated to an intervention or control group, were included. A total of eight studies that met the inclusion criteria were independently reviewed and encoded by two review authors. To ensure the quality of the eight studies, levels of risk of bias were assessed by two different researchers. The main outcome was the prevalence of PDPH.

RESULTS

The included studies indicated that PDPH prevalence did not differ between the group assigned to 24 hours of bed rest and the group assigned to early ambulation. In subgroup analysis, the effect size of clinical factors (severity of headache, day of onset, and needle gauge) and the study characteristics (language and sample size) did not differ between groups.

CONCLUSION

This meta-analysis of studies suggested that long-term bed rest after spinal anesthesia may not be effective in preventing PDPH.

Effect of Posture on Post Lumbar Puncture Headache after Spinal Anesthesia: A Prospective Randomized Study

Background Headache after lumbar puncture has long been attributed to early mobilization, and hence prophylactic bed rest had been standard protocol to prevent spinal headache after lumbar puncture. However, trend has been changing towards early mobilization to no need of bed rest at all after lumbar puncture. Objective To study the influence of posture in the incidence of post lumbar puncture headache in patients undergoing spinal anesthesia. Method In a prospective randomized study, patients undergoing various surgical procedures under spinal anesthesia from February 2013 to January 2014 were included. They were randomly allocated into two groups; group A, no restriction of position and group B, 24 hours bed rest after spinal anesthesia. Two groups were compared with regards to spinal anesthesia complications such as headache, backache, urinary retention, nausea and vomiting. Result Total of 112 patients, 58 in group A and 54 in group B, were enrolled in the study. The mean age was 40.13±17.4 years and male: female ratio was 2.5:1. Post spinal headache was observed in 13(22.4%) patients in group A and 13 (24.0%) patients in group B which was statistically not significant (p=0.755). Similarly, there was no significant difference of headache score, and the incidence of other complications like backache, nausea, vomiting and urinary retention between two groups. Conclusion There is no significant influence in the incidence of post lumbar puncture headache by early mobilization after spinal anesthesia. Hence, prophylactic bed rest following spinal anesthesia is of no benefit.

Insertion of an intrathecal catheter in parturients reduces the risk of post-dural puncture headache: A retrospective study and meta-analysis

This study aimed to determine whether insertion of an intrathecal catheter following accidental dural puncture (ADP) in obstetric patients can reduce the incidence of post-dural puncture headache (PDPH) and the requirement of a therapeutic epidural blood patch (TEBP). This was also compared with relocating the epidural catheter at a different vertebral interspace. A retrospective study was performed, as well as a meta-analysis of the literature to further validate our findings. We reviewed the records of 86 obstetric patients who suffered from ADP during epidural anesthesia or combined spinal-epidural anesthesia from October 2015 to November 2016 at our institution. Although, there was no significant decrease in the incidence of PDPH (P = 0.08), the requirement for a TEBP (P = 0.025) was significantly reduced in the intrathecal catheter group compared with the relocated group. In the meta-analysis, 13 eligible studies including 1044 obstetric patients were finally identified. To estimate the pooled risk ratios (RRs), fixed or random effect models were used depending on the heterogeneity. We initially found that an intrathecal catheter significantly reduced the incidence of PDPH (pooled RR = 0.823; 95% CI = 0.700–0.967; P = 0.018) and the requirement of a TEBP (pooled RR = 0.616; 95% CI = 0.443–0.855; P = 0.004). Our study shows that insertion of an intrathecal catheter following ADP might be an effective and dependable method for reducing the risk of a PDPH and requirement for a TEBP in obstetric patients.

Effectiveness of Lateral Decubitus Position for Preventing Post-Dural Puncture Headache: A Meta-Analysis

BACKGROUND

Post-dural puncture headache (PDPH) is a relatively common complication of lumbar punctures for spinal anesthesia or neurologic diagnosis. For many years, a high number of drugs has been evaluated to treat PDPH, yet there is a minority to prevent this complication. The lateral decubitus position instead of sitting position during lumbar puncture has become an interesting approach because of its feasibility and patient satisfaction.

OBJECTIVES

In this meta-analysis we hypothesized that lateral decubitus position is an effective manner to prophylactically reduce the incidence of PDPH.

STUDY DESIGN

This meta-analysis pooled all data published in randomized controlled trials (RCTs) examining the impact of position (sitting versus lateral decubitus) during lumbar puncture and the incidence of PDPH.

SETTINGS

This work was performed at Universidad del Valle, in Cali, Colombia, in collaboration with the Department of Anesthesiology at The Johns Hopkins Hospital.

METHODS

Our group searched in PubMed, EMBASE, Cochrane Library and Google Scholar for relevant RCTs, dating from 1990 to July 2016, that compared the sitting and lateral decubitus position with regards to the incidence of PDPH in adult patients (age > 18 years) undergoing lumbar puncture for spinal anesthesia or neurologic diagnosis.

RESULTS

Literature search identified 7 eligible RCTs (6 on spinal anesthesia and only one on neurologic diagnosis) with 1,101 patients, of which 557 had lumbar punctures in lateral decubitus position and 544 in sitting position. Only 3 (out of 7) RCTs favored the lateral decubitus position to significantly reduce the PDPH. Meta-analysis showed that the lateral decubitus position was associated with a significant reduction of the incidence of PDPH (risk ratio [RR] = 0.61, 95% confidence interval [CI] = 0.44-0.86, P = 0.004, I2 = 25%, P for heterogeneity = 0.24) compared with the sitting position. Subgroup analysis showed that lateral decubitus position is also associated with reduction of PDPH in spinal anesthesia (RR = 0.69, 95% CI = 0.50-0.95, I2 = 0%, P for heterogeneity = 0.42). We found no statistically significant association between lateral decubitus position and successful placement of spinal needle at first attempt (RR = 1.00, 95% CI = 0.92-1.09, P = 0.94, I2 = 73%, P for heterogeneity = 0.01). There was no evidence of publication bias in our analyses (Egger's bias = -0.05, P = 0.96).

LIMITATIONS

The low number of RCTs might be an important limitation on our results.

CONCLUSION

Our results indicate that lateral decubitus position during lumbar puncture seems to be a good alternative for preventing PDPH. Further research should focus on the new prophylactic alternatives to reduce the incidence of PDPH.

Needle gauge and tip designs for preventing post-dural puncture headache (PDPH)

BACKGROUND

Post-dural puncture headache (PDPH) is one of the most common complications of diagnostic and therapeutic lumbar punctures. PDPH is defined as any headache occurring after a lumbar puncture that worsens within 15 minutes of sitting or standing and is relieved within 15 minutes of the patient lying down. Researchers have suggested many types of interventions to help prevent PDPH. It has been suggested that aspects such as needle tip and gauge can be modified to decrease the incidence of PDPH.

OBJECTIVES

To assess the effects of needle tip design (traumatic versus atraumatic) and diameter (gauge) on the prevention of PDPH in participants who have undergone dural puncture for diagnostic or therapeutic causes.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL and LILACS, as well as trial registries via the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) search portal in September 2016. We adopted the MEDLINE strategy for searching the other databases. The search terms we used were a combination of thesaurus-based and free-text terms for both interventions (lumbar puncture in neurological, anaesthesia or myelography settings) and headache.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) conducted in any clinical/research setting where dural puncture had been used in participants of all ages and both genders, which compared different tip designs or diameters for prevention of PDPH DATA COLLECTION AND ANALYSIS: We used the standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included 70 studies in the review; 66 studies with 17,067 participants were included in the quantitative analysis. An additional 18 studies are awaiting classification and 12 are ongoing. Fifteen of the 18 studies awaiting classification mainly correspond to congress summaries published before 2010, in which the available information does not allow the complete evaluation of all their risks of bias and characteristics. Our main outcome was prevention of PDPH, but we also assessed the onset of severe PDPH, headache in general and adverse events. The quality of evidence was moderate for most of the outcomes mainly due to risk of bias issues. For the analysis, we undertook three main comparisons: 1) traumatic needles versus atraumatic needles; 2) larger gauge traumatic needles versus smaller gauge traumatic needles; and 3) larger gauge atraumatic needles versus smaller gauge atraumatic needles. For each main comparison, if data were available, we performed a subgroup analysis evaluating lumbar puncture indication, age and posture.For the first comparison, the use of traumatic needles showed a higher risk of onset of PDPH compared to atraumatic needles (36 studies, 9378 participants, risk ratio (RR) 2.14, 95% confidence interval (CI) 1.72 to 2.67, I2 = 9%).In the second comparison of traumatic needles, studies comparing various sizes of large and small gauges showed no significant difference in effects in terms of risk of PDPH, with the exception of one study comparing 26 and 27 gauge needles (one study, 658 participants, RR 6.47, 95% CI 2.55 to 16.43).In the third comparison of atraumatic needles, studies comparing various sizes of large and small gauges showed no significant difference in effects in terms of risk of PDPH.We observed no significant difference in the risk of paraesthesia, backache, severe PDPH and any headache between traumatic and atraumatic needles. Sensitivity analyses of PDPH results between traumatic and atraumatic needles omitting high risk of bias studies showed similar results regarding the benefit of atraumatic needles in the prevention of PDPH (three studies, RR 2.78, 95% CI 1.26 to 6.15; I2 = 51%).

AUTHORS' CONCLUSIONS

There is moderate-quality evidence that atraumatic needles reduce the risk of post-dural puncture headache (PDPH) without increasing adverse events such as paraesthesia or backache. The studies did not report very clearly on aspects related to randomization, such as random sequence generation and allocation concealment, making it difficult to interpret the risk of bias in the included studies. The moderate quality of the evidence for traumatic versus atraumatic needles suggests that further research is likely to have an important impact on our confidence in the estimate of effect.

Comparison of cutting and pencil-point spinal needle in spinal anesthesia regarding postdural puncture headache: A meta-analysis

BACKGROUND

Postdural puncture headache (PDPH), mainly resulting from the loss of cerebral spinal fluid (CSF), is a well-known iatrogenic complication of spinal anesthesia and diagnostic lumbar puncture. Spinal needles have been modified to minimize complications. Modifiable risk factors of PDPH mainly included needle size and needle shape. However, whether the incidence of PDPH is significantly different between cutting-point and pencil-point needles was controversial. Then we did a meta-analysis to assess the incidence of PDPH of cutting spinal needle and pencil-point spinal needle.

METHODS

We included all randomly designed trials, assessing the clinical outcomes in patients given elective spinal anesthesia or diagnostic lumbar puncture with either cutting or pencil-point spinal needle as eligible studies. All selected studies and the risk of bias of them were assessed by 2 investigators. Clinical outcomes including success rates, frequency of PDPH, reported severe PDPH, and the use of epidural blood patch (EBP) were recorded as primary results. Results were evaluated using risk ratio (RR) with 95% confidence interval (CI) for dichotomous variables. Rev Man software (version 5.3) was used to analyze all appropriate data.

RESULTS

Twenty-five randomized controlled trials (RCTs) were included in our study. The analysis result revealed that pencil-point spinal needle would result in lower rate of PDPH (RR 2.50; 95% CI [1.96, 3.19]; P < 0.00001) and severe PDPH (RR 3.27; 95% CI [2.15, 4.96]; P < 0.00001). Furthermore, EBP was less used in pencil-point spine needle group (RR 3.69; 95% CI [1.96, 6.95]; P < 0.0001).

CONCLUSIONS

Current evidences suggest that pencil-point spinal needle was significantly superior compared with cutting spinal needle regarding the frequency of PDPH, PDPH severity, and the use of EBP. In view of this, we recommend the use of pencil-point spinal needle in spinal anesthesia and lumbar puncture.