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Uppal V, Russell R, Sondekoppam RV, Ansari J, Baber Z, Chen Y, DelPizzo K, Dirzu DS, Kalagara H, Kissoon NR, Kranz PG, Leffert L, Lim G, Lobo C, Lucas DN, Moka E, Rodriguez SE, Sehmbi H, Vallejo MC, Volk T, Narouze S. Evidence-based clinical practice guidelines on postdural puncture headache: a consensus report from a multisociety international working group. Reg Anesth Pain Med 2024; 49:471-501. [PMID: 37582578 DOI: 10.1136/rapm-2023-104817] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 07/25/2023] [Indexed: 08/17/2023]
Abstract
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.
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Affiliation(s)
- Vishal Uppal
- Department of Anesthesia, Pain Management & Perioperative Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Robin Russell
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Rakesh V Sondekoppam
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Jessica Ansari
- Anesthesia Department, Stanford Health Care, Stanford, California, USA
| | - Zafeer Baber
- Department of Anesthesiology and Perioperative Medicine, Newton-Wellesley Hospital, Newton, Massachusetts, USA
| | - Yian Chen
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California, USA
| | - Kathryn DelPizzo
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA
| | - Dan Sebastian Dirzu
- Anesthesia and Intensive Care, Emergency County Hospital Cluj-Napoca, Cluj-Napoca, Romania
| | - Hari Kalagara
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic in Florida, Jacksonville, Florida, USA
| | - Narayan R Kissoon
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Peter G Kranz
- Depatement of Radiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Lisa Leffert
- Department of Anesthesiology, Yale New Haven Health System; Yale University School of Medicine, New Haven, Connecticut, USA
| | - Grace Lim
- Department of Anesthesiology & Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Obstetrics & Gynecology, Magee Womens Hospital of UPMC, Pittsburgh, Pennsylvania, USA
| | - Clara Lobo
- Anesthesiology Institute, Interventional Pain Medicine Department, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
| | - Dominique Nuala Lucas
- Department of Anaesthesia, London North West Healthcare NHS Trust, Harrow, London, UK
| | - Eleni Moka
- Department of Anaesthesiology, Creta Interclinic Hospital - Hellenic Healthcare Group (HHG), Heraklion, Crete, Greece
| | - Stephen E Rodriguez
- Department of Anesthesia, Walter Reed Army Medical Center, Bethesda, Maryland, USA
| | - Herman Sehmbi
- Department of Anesthesia, Western University, London, Ontario, Canada
| | - Manuel C Vallejo
- Departments of Medical Education, Anesthesiology, Obstetrics & Gynecology, West Virginia University, Morgantown, West Virginia, USA
| | - Thomas Volk
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Germany
| | - Samer Narouze
- Northeast Ohio Medical University, Rootstown, Ohio, USA
- Center for Pain Medicine, Western Reserve Hospital, Cuyahoga Falls, OH, USA
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Bansal V, D'Souza G, Aladade E, McFarlane DM, Agarwal R. Postdural Puncture Headaches in Pediatric Patients: A Review of Options When Repeated Epidural Blood Patches Do Not Work. Cureus 2024; 16:e62833. [PMID: 39040713 PMCID: PMC11260652 DOI: 10.7759/cureus.62833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/20/2024] [Indexed: 07/24/2024] Open
Abstract
We present the case of an adolescent with refractory postdural puncture headache (PDPH), whose symptoms resolved with a sphenopalatine ganglion (SPG) nerve block using a J-tip style catheter. Our patient was treated with multiple modalities, including conservative and medical management, multiple epidural blood patches, and different nerve blocks. We discussed different treatments for the PDPH, why each modality did not work, and why our SPG block with a J-tip catheter possibly provided a better sympathetic block in a patient with intractable PDPH for two weeks.
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Affiliation(s)
- Vipin Bansal
- Anesthesiology, Emory University School of Medicine, Atlanta, USA
| | | | - Emmanuel Aladade
- Anesthesiology, Emory University School of Medicine, Atlanta, USA
| | | | - Rita Agarwal
- Anesthesiology, Stanford University, Stanford, USA
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Chen A, Duan W, Hao R, Wang C, Xu X. Ultrasound-guided dexmedetomidine combination with modified high fascia iliaca compartment block for arthroscopic knee surgery: what is the optimal dose of dexmedetomidine? BMC Anesthesiol 2023; 23:400. [PMID: 38057762 PMCID: PMC10699007 DOI: 10.1186/s12871-023-02361-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 11/27/2023] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND Total knee arthroplasty (TKA) is a common orthopedic procedure for end-stage knee osteoarthritis. Although effective in relieving pain and improving function, postoperative pain is still a common and distressing problem for many patients. This study aims to investigate efficacy of combined administration of dexmedetomidine and modified high fascia iliaca compartment block (H-FICB) in managing acute and chronic pain after TKA, as well as to identify the optimal dosage of dexmedetomidine. METHODS A double-blind, randomized controlled trial was conducted to evaluate the effects of dexmedetomidine in patients undergoing TKA. A total of 96 patients undergoing TKA were randomly assigned to one of three groups, were treated with different doses of dexmedetomidine All groups received H-FIB. Pain scores, opioid consumption, side effects, and quality of life were recorded 48 h postoperatively. RESULTS The intraoperative consumption of remifentanil and propofol in Group Db was significantly reduced compared with that in Group D0 and Da (P < 0.05). Compared with D0 and Da group, Db group had the lowest number of rescue analgesia, analgesia time and morphine accumulative dosage 48 h after operation (P < 0.05). The Db group had the lowest scores on the numerical rating scale at rest (P < 0.05) and during movement (P < 0.01), followed by the Da group and then the D0 group. Additionally, the incidence of nausea and vomiting was significantly reduced in the Db group (P < 0.05). Furthermore, the Db group had the lowest incidence of chronic pain (P < 0.05). DISCUSSION In comparison to the other two groups, the administration of combined dexmedetomidine and H-FIB resulted in a significant reduction in pain scores, opioid consumption, and side effects. The optimal dosage of dexmedetomidine was determined to be 1 μg/kg, which provided the most favorable pain relief with minimal adverse effects.
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Affiliation(s)
- An Chen
- Department of Anesthesiology, Affiliated Hospital of Nantong University, Nantong, 226001, China
| | - Wanqing Duan
- Department of Anesthesiology, Affiliated Hospital of Nantong University, Nantong, 226001, China
| | - Ruijinlin Hao
- Department of Anesthesiology, Affiliated Hospital of Nantong University, Nantong, 226001, China
| | - Chen Wang
- Department of Anesthesiology, Affiliated Hospital of Nantong University, Nantong, 226001, China
| | - Xingguo Xu
- Department of Anesthesiology, Affiliated Hospital of Nantong University, Nantong, 226001, China.
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Wilcox JA, Estrera R, Boire A. The Spectrum of Headache in Leptomeningeal Metastases: A Comprehensive Review with Clinical Management Guidelines. Curr Pain Headache Rep 2023; 27:695-706. [PMID: 37874457 PMCID: PMC10713777 DOI: 10.1007/s11916-023-01180-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2023] [Indexed: 10/25/2023]
Abstract
PURPOSE OF REVIEW Headaches are a common, oftentimes debilitating symptom in patients with leptomeningeal metastases. RECENT FINDINGS The third edition of the International Classification of Headache Disorders provides a useful diagnostic framework for headaches secondary to leptomeningeal metastases based on the temporal relationship of headache with disease onset, change in headache severity in correlation with leptomeningeal disease burden, and accompanying neurologic signs such as cranial nerve palsies and encephalopathy. However, headaches in patients with leptomeningeal metastases can be further defined by a wide range of varying cancer- and treatment-related pathophysiologies, each requiring a tailored approach. A thorough review of the literature and expert opinion on five observed headache sub-classifications in patients with leptomeningeal metastases is provided, with attention to necessary diagnostic testing, recommended first-line treatments, and prevention strategies.
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Affiliation(s)
- Jessica A Wilcox
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Rachel Estrera
- Human Oncology and Pathogenesis Program, Brain Tumor Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Adrienne Boire
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
- Human Oncology and Pathogenesis Program, Brain Tumor Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Shrestha IK, Chalise R, Poudel S, Regmi A, Ghimire A, Khadka B, Khanal K. Neostigmine and atropine as a treatment for postdural puncture headache after spinal anesthesia in cesarean section: A case report. Clin Case Rep 2023; 11:e8132. [PMID: 37927977 PMCID: PMC10622397 DOI: 10.1002/ccr3.8132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 10/16/2023] [Accepted: 10/17/2023] [Indexed: 11/07/2023] Open
Abstract
Key Clinical message Neostigmine and atropine offer a promising treatment option for postdural puncture headache (PDPH) following spinal anesthesia in cesarean section, providing effective relief with a favorable risk-benefit profile. Abstract Postdural puncture headache (PDPH) is a common consequence of cesarean section surgeries after spinal anesthesia. This case study describes the successful treatment of PDPH with intravenous neostigmine and atropine. A 31 years female who underwent elective cesarean section with spinal anesthesia developed a severe headache on the 6th postoperative day and was diagnosed to have PDPH. PDPH failed to respond to conventional treatment modalities like hydration, a Non-steroidal anti-inflammatory drug, and sphenopalatine ganglion block. Epidural blood patch could not be performed due to lack of consent. A trial dose of intravenous neostigmine (20 mcg/kg) along with atropine (10 mcg/kg) successfully provided symptomatic and clinical relief. The combination of neostigmine and atropine demonstrates a rapid onset of action, providing patients with effective analgesia while avoiding the need for invasive procedures such as epidural blood patches and offers quicker pain relief. This promising result warrants additional research.
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Affiliation(s)
| | | | - Saroj Poudel
- Critical Care MedicineNepal MedicitiLalitpurNepal
| | - Ashim Regmi
- Critical Care MedicineNepal MedicitiLalitpurNepal
| | - Anup Ghimire
- Critical Care MedicineNepal MedicitiLalitpurNepal
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Poma S, Bonomo MC, Gazzaniga G, Pizzulli M, De Silvestri A, Baldi C, Broglia F, Ciceri M, Fuardo M, Morgante F, Pellicori S, Roldi EM, Delmonte MP, Mojoli F, Locatelli A. Complications of unintentional dural puncture during labour epidural analgesia: a 10-year retrospective observational study. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2023; 3:42. [PMID: 37880725 PMCID: PMC10601237 DOI: 10.1186/s44158-023-00127-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 10/14/2023] [Indexed: 10/27/2023]
Abstract
INTRODUCTION Unintentional dural puncture (UDP) occurs in 0.5-1.5% of labour epidural analgesia cases. To date, little is known about evidence of UDP-related complications. This work aimed to assess the incidence of intrapartum and postpartum complications in parturients who experienced UDP. METHODS This is a 10-year retrospective observational study on parturients admitted to our centre who presented UDP. Data collection gathered UDP-related complications during labour and postpartum. All women who displayed UDP received medical therapy and bed rest. An epidural blood patch (EBP) was not used in this population. Once asymptomatic, patients were discharged from the hospital. RESULTS Out of 7718 neuraxial analgesia cases, 97 cases of UDP occurred (1.25%). During labour, complications appeared in a small percentage of analgesia procedures performed, including total spinal anaesthesia (1.0%), extended motor block (3%), hypotension (4.1%), abnormal foetal heart rate (2%), inadequate analgesia (14.4%), and general anaesthesia following neuraxial anaesthesia failure (33.3% of emergency caesarean sections). During the postpartum period, 53.6% of parturients exhibited a postdural puncture headache, 13.4% showed neurological symptoms, and 14.4% required neurological consultation and neuroimaging. No patient developed subdural hematoma or cerebral venous sinus thrombosis; one woman presented posterior reversible encephalopathy syndrome associated with eclampsia. Overall, 82.5% of women experienced an extension of hospital stay. CONCLUSION Major complications occurred in a small percentage of patients during labour. However, since they represent high-risk maternal and neonatal health events, a dedicated anaesthesiologist and a trained obstetric team are essential. No major neurological complications were registered postpartum, and EBP was not performed. Nevertheless, all patients with UDP were carefully monitored and treated until complete recovery before discharge, leading to an extension of their hospitalization.
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Affiliation(s)
- S Poma
- Anaesthesia and Postoperative Intensive Care, Department of Anaesthesia and Intensive Care 3, I.R.C.C.S. Policlinic San Matteo Hospital Foundation, Pavia, 27100, Italy.
| | - M C Bonomo
- Department of Anaesthesia and Intensive Care, ASST Bergamo EST, Seriate Hospital, Seriate, Italy
| | - G Gazzaniga
- Department of Anaesthesia and Intensive Care 1, I.R.C.C.S. Policlinic San Matteo Hospital Foundation, Pavia, Italy
| | - M Pizzulli
- Anaesthesia and Postoperative Intensive Care, Department of Anaesthesia and Intensive Care 3, I.R.C.C.S. Policlinic San Matteo Hospital Foundation, Pavia, 27100, Italy
| | - A De Silvestri
- Clinical Epidemiology and Biostatistics, Scientific Direction, I.R.C.C.S. Policlinic San Matteo Hospital Foundation, Pavia, Italy
| | - C Baldi
- Anaesthesia and Postoperative Intensive Care, Department of Anaesthesia and Intensive Care 3, I.R.C.C.S. Policlinic San Matteo Hospital Foundation, Pavia, 27100, Italy
| | - F Broglia
- Anaesthesia and Postoperative Intensive Care, Department of Anaesthesia and Intensive Care 3, I.R.C.C.S. Policlinic San Matteo Hospital Foundation, Pavia, 27100, Italy
| | - M Ciceri
- Anaesthesia and Postoperative Intensive Care, Department of Anaesthesia and Intensive Care 3, I.R.C.C.S. Policlinic San Matteo Hospital Foundation, Pavia, 27100, Italy
| | - M Fuardo
- Anaesthesia and Postoperative Intensive Care, Department of Anaesthesia and Intensive Care 3, I.R.C.C.S. Policlinic San Matteo Hospital Foundation, Pavia, 27100, Italy
| | - F Morgante
- Anaesthesia and Postoperative Intensive Care, Department of Anaesthesia and Intensive Care 3, I.R.C.C.S. Policlinic San Matteo Hospital Foundation, Pavia, 27100, Italy
| | - S Pellicori
- Anaesthesia and Postoperative Intensive Care, Department of Anaesthesia and Intensive Care 3, I.R.C.C.S. Policlinic San Matteo Hospital Foundation, Pavia, 27100, Italy
| | - E M Roldi
- Anaesthesia and Postoperative Intensive Care, Department of Anaesthesia and Intensive Care 3, I.R.C.C.S. Policlinic San Matteo Hospital Foundation, Pavia, 27100, Italy
| | - M P Delmonte
- Anaesthesia and Postoperative Intensive Care, Department of Anaesthesia and Intensive Care 3, I.R.C.C.S. Policlinic San Matteo Hospital Foundation, Pavia, 27100, Italy
| | - F Mojoli
- Department of Anaesthesia and Intensive Care 1, I.R.C.C.S. Policlinic San Matteo Hospital Foundation, Pavia, Italy
| | - A Locatelli
- Anaesthesia and Postoperative Intensive Care, Department of Anaesthesia and Intensive Care 3, I.R.C.C.S. Policlinic San Matteo Hospital Foundation, Pavia, 27100, Italy
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Uppal V, Russell R, Sondekoppam R, Ansari J, Baber Z, Chen Y, DelPizzo K, Dîrzu DS, Kalagara H, Kissoon NR, Kranz PG, Leffert L, Lim G, Lobo CA, Lucas DN, Moka E, Rodriguez SE, Sehmbi H, Vallejo MC, Volk T, Narouze S. Consensus Practice Guidelines on Postdural Puncture Headache From a Multisociety, International Working Group: A Summary Report. JAMA Netw Open 2023; 6:e2325387. [PMID: 37581893 DOI: 10.1001/jamanetworkopen.2023.25387] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/16/2023] Open
Abstract
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.
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Affiliation(s)
- Vishal Uppal
- Department of Anesthesia, Perioperative Medicine and Pain Management, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Robin Russell
- Nuffield Department of Anaesthetics, Oxford University Hospitals National Health Service (NHS) Foundation Trust, Oxford, England
| | - Rakesh Sondekoppam
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City
| | - Jessica Ansari
- Anesthesia Department, Stanford Health Care, Stanford, California
| | - Zafeer Baber
- Department of Anesthesiology and Perioperative Medicine, Newton-Wellesley Hospital, Tufts University School of Medicine, Boston, Massachusetts
| | - Yian Chen
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California
| | - Kathryn DelPizzo
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York
| | - Dan Sebastian Dîrzu
- Department of Anaesthesia and Intensive Care, Emergency County Hospital, Cluj-Napoca, Romania
| | - Hari Kalagara
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida
| | - Narayan R Kissoon
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Peter G Kranz
- Department of Radiology, Duke University Medical Center, Durham, North Carolina
| | - Lisa Leffert
- Yale University School of Medicine, Yale New Haven Hospital and Bridgeport Hospital, New Haven, Connecticut
| | - Grace Lim
- Department of Anesthesiology and Perioperative Medicine, Department of Obstetrics and Gynecology, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center Magee Hospital, Pittsburgh, Pennsylvania
| | - Clara A Lobo
- Anesthesiology Institute, Interventional Pain Medicine Department, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Dominique Nuala Lucas
- Department of Anaesthesia, London Northwest University Healthcare NHS Trust, London, England
| | - Eleni Moka
- Anaesthesiology Department, Creta Interclinic Hospital-Hellenic Healthcare Group, Heraklion, Crete, Greece
| | | | - Herman Sehmbi
- Department of Anesthesia, University of Western Ontario, London, Ontario, Canada
| | - Manuel C Vallejo
- Medical Education, Anesthesiology, Obstetrics and Gynecology, West Virginia University, Morgantown
| | - Thomas Volk
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Medical Center and Saarland University Faculty of Medicine, Saarbrücken, Germany
| | - Samer Narouze
- Rootstown and Center for Pain Medicine, Western Reserve Hospital, Cuyahoga Falls, Ohio
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Zetlaoui PJ, Buchheit T, Benhamou D. Epidural blood patch: A narrative review. Anaesth Crit Care Pain Med 2022; 41:101138. [DOI: 10.1016/j.accpm.2022.101138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 04/01/2022] [Accepted: 04/01/2022] [Indexed: 11/24/2022]
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Southerland WA, Hasoon J, Urits I, Viswanath O, Simopoulos TT, Imani F, Karimi-Aliabadi H, Aner MM, Kohan L, Gill J. Dural Puncture During Spinal Cord Stimulator Lead Insertion: Analysis of Practice Patterns. Anesth Pain Med 2022; 12:e127179. [PMID: 36158140 PMCID: PMC9364517 DOI: 10.5812/aapm-127179] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 04/29/2022] [Indexed: 12/16/2022] Open
Abstract
Background Spinal cord stimulation (SCS) is an important modality for intractable pain not amenable to less conservative measures. During percutaneous SCS lead insertion, a critical step is safe access to the epidural space, which can be complicated by a dural puncture. Objectives In this review, we present and analyze the practices patterns in the event of a dural puncture during a SCS trial or implantation. Methods We conducted a survey of the practice patterns regarding spinal cord stimulation therapy. The survey was administered to members of the Spine Intervention Society and American Society of Regional Anesthesia specifically inquiring decision making in case of inadvertent dural puncture during spinal cord stimulator lead insertion. Results A maximum of 193 responded to a question regarding dural punctures while performing a SCS trial and 180 responded to a question regarding dural punctures while performing a SCS implantation. If performing a SCS trial and a dural puncture occurs, a majority of physicians chose to continue the procedure at a different level (56.99%), followed by abandoning the procedure (27.98%), continuing at the same level (10.36%), or choosing another option (4.66%). Similarly, if performing a permanent implantation and a dural puncture occurs, most physicians chose to continue the procedure at a different level (61.67%), followed by abandoning the procedure (21.67%), continuing at the same level (10.56%), or choosing another option (6.11%). Conclusions Whereas the goals of the procedure would support abandoning the trial but continuing with the permanent in case of inadvertent dural puncture, we found that decision choices were minimally influenced by whether the dural puncture occurred during the trial or the permanent implant. The majority chose to continue with the procedure at a different level while close to a quarter chose to abandon the procedure. This article sets a time stamp in practice patterns from March 20, 2020 to June 26, 2020. These results are based on contemporary SCS practices as demonstrated by this cohort, rendering the options of abandoning or continuing after dural puncture as reasonable methods. Though more data is needed to provide a consensus, providers can now see how others manage dural punctures during SCS procedures.
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Affiliation(s)
- Warren A. Southerland
- Department of Anesthesia, Beth Israel Deaconess Medical Center, Critical Care, and Pain Medicine; Harvard Medical School, Boston, MA, USA
| | - Jamal Hasoon
- Department of Anesthesia, Beth Israel Deaconess Medical Center, Critical Care, and Pain Medicine; Harvard Medical School, Boston, MA, USA
- Department of Anesthesia and Pain Medicine, University of Texas Medical Branch, Galveston, TX, USA
- Pain Specialists of America, Austin, TX, USA
- Corresponding Author: Department of Anesthesia, Beth Israel Deaconess Medical Center, Critical Care, and Pain Medicine; Harvard Medical School, Boston, MA, USA.
| | - Ivan Urits
- Department of Anesthesia, Beth Israel Deaconess Medical Center, Critical Care, and Pain Medicine; Harvard Medical School, Boston, MA, USA
- Department of Anesthesia and Pain Management, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Omar Viswanath
- Department of Anesthesia and Pain Management, Louisiana State University Health Sciences Center, Shreveport, LA, USA
- Valley Anesthesiology and Pain Consultants, Envision Physician Services, Phoenix, AZ, USA
- Department of Anesthesiology, Phoenix, University of Arizona College of Medicine–Phoenix, AZ, USA
| | - Thomas T. Simopoulos
- Department of Anesthesia, Beth Israel Deaconess Medical Center, Critical Care, and Pain Medicine; Harvard Medical School, Boston, MA, USA
| | - Farnad Imani
- Pain Research Center, Department of Anesthesiology and Pain Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Hakimeh Karimi-Aliabadi
- Department of Anesthesiology, Kerman University of Medical Sciences, Kerman, Iran
- Corresponding Author: Department of Anesthesiology, Kerman University of Medical Sciences, Kerman, Iran.
| | - Musa M Aner
- Dartmouth-Hitchcock Medical Center, Center for Pain and Spine, Geisel School of Medicine, Lebanon, NH, USA
| | - Lynn Kohan
- Pain Management Center; University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Jatinder Gill
- Department of Anesthesia, Beth Israel Deaconess Medical Center, Critical Care, and Pain Medicine; Harvard Medical School, Boston, MA, USA
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Oh AR, Park J, Jeong JS, Lee JY, Choi JW, Kim H, Sim WS. Risk factors associated with repeated epidural blood patches using autologous blood. Korean J Pain 2022; 35:224-230. [PMID: 35354685 PMCID: PMC8977201 DOI: 10.3344/kjp.2022.35.2.224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 02/16/2022] [Accepted: 02/20/2022] [Indexed: 11/05/2022] Open
Abstract
Background An epidural blood patch (EBP) is a procedure to treat intracranial hypotension that does not respond to conservative treatment. EBPs are commonly repeated when the symptoms persist. In this study, we used a large single-center retrospective cohort and evaluated the factors associated with repeated EBPs. Methods From January 2010 to December 2020, a total of 596 patients were treated with EBPs for intracranial hypotension. We evaluated the factors associated with repeated EBPs in the entire population, in patients with spontaneous intracranial hypotension (SIH), and in those with available myelographies. Results In a total of 596 patients, 125 (21.1%) patients required repeated EBPs, and 96/278 (34.5%) in SIH and 29/314 (9.2%) in iatrogenic population. In patients with SIH, international normalized ratio (INR) and cerebrospinal fluid (CSF) leakage on myelographies consistently exhibited significant associations (odds ratio [OR], 1.38; 95% confidence interval [CI], 1.02-1.87; P = 0.043 and OR, 2.18; 95% CI, 1.28-3.69; P = 0.004). In patients with iatrogenic injury, INR and CSF leakage on myelogram did not show difference in repeated EBPs. Conclusions Repeated EBPs may be more frequently required in patients with SIH. Prolonged INR and CSF leakage were associated with repeated EBPs in patient with SIH. Further studies are needed to determine factors associated with repeated EBP requirements.
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Affiliation(s)
- Ah Ran Oh
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jungchan Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji Seon Jeong
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin Young Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji Won Choi
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hara Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Woo Seog Sim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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11
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Huo CW, King J, Goldschlager T, Dixon B, Chen Zhao Y, Uren B, Wang YY. The effects of cerebrospinal fluid (CSF) diversion on post-operative CSF leak following extended endoscopic anterior skull base surgery. J Clin Neurosci 2022; 98:194-202. [PMID: 35189544 DOI: 10.1016/j.jocn.2022.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 01/18/2022] [Accepted: 02/04/2022] [Indexed: 11/24/2022]
Abstract
There is a paucity of high quality evidence regarding the routine placement of lumbar drain (LD) in reducing post-operative (op) cerebrospinal fluid (CSF) leak after extended endoscopic trans-sphenoidal resection of anterior skull base lesions. In this study, we sought to compare the incidence of post-op CSF leak between patients with upfront LD insertion and those without it. This was a prospective randomized controlled trial conducted over a period of 5 years with patients undergoing extended endoscopic trans-sphenoidal surgery randomly assigned to either LD insertion at the time of surgery, or no LD placement. Thirty-eight patients with anterior skull base tumors were accrued from three tertiary hospitals of Melbourne. Post-op leak was confirmed by β2-transferrin-positive rhinorrhea, and/or worsening pneumocephalus on brain imaging. Skull base defect size and pedicled nasoseptal flap viability were assessed on post-op CT and MRI, respectively. There was no significant difference in post-op CSF leak incidence between the two subgroups (12.50% in LD arm vs. 9.10% in no LD arm). Patients with LD insertion however, demonstrated substantially raised complication rates, longer hospital lengths of stay and lower subjective quality of life measures at 12 months compared with those without LD. In conclusion, routine placement of LD at the time of surgery for extended anterior skull base trans-nasal approach did not reduce the risk of post-op CSF leak. Discretion is warranted when using LD as an adjunct due to its associated morbidities, prolonged hospital stay and adverse effect on patients' subjective outcome measures.
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Affiliation(s)
- Cecilia W Huo
- Department of Neurosurgery, St Vincent's Hospital Melbourne, VIC 3065, Australia.
| | - James King
- Department of Neurosurgery, The Royal Melbourne Hospital, VIC 3050, Australia
| | - Tony Goldschlager
- Department of Neurosurgery, Monash Medical Centre, VIC 3168, Australia
| | - Benjamin Dixon
- The Head and Neck/ENT Unit, St Vincent's Hospital Melbourne, VIC 3065, Australia
| | - Yi Chen Zhao
- The Head and Neck/ENT Unit, The Royal Melbourne Hospital, VIC 3050, Australia
| | - Brent Uren
- The Head and Neck/ENT Unit, Monash Medical Centre, VIC 3168, Australia
| | - Yi Yuen Wang
- Department of Neurosurgery, St Vincent's Hospital Melbourne, VIC 3065, Australia; Department of Surgery, The University of Melbourne, VIC Australia
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12
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Alizadeh R, Aghsaeifard Z, Fereydoonnia B, Hashemi M, Mostafazadeh M. Prone position: A possible method to decrease post dural puncture headache (PDPH) during surgery. Ann Med Surg (Lond) 2022; 74:103277. [PMID: 35145664 PMCID: PMC8802042 DOI: 10.1016/j.amsu.2022.103277] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 01/09/2022] [Accepted: 01/23/2022] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVES Postdural puncture headache (PDPH) is a complication associated with spinal and epidural anesthesia, characterized by a very severe dull, non-throbbing positional headache along with nausea, vomiting and other symptoms. The aim of this study was to compare positional character of PDPH, where the effects of prone and supine positions during surgery were compared for the risk of the headache. METHODS This cohort study, was carried out at (XXX) University of Medical Sciences from June 2019 to June 2020 after the approval from the Ethical Committee. 1416 patients participated in this study among whom either supine or prone positions were used for the surgery, based on the type of surgical requirements. All patients received spinal where, 18-gauge cannula was inserted and lactated ringer 4 mL per Kg per hour was used for the administration. Using an aseptic technique, a 26-gauge Quincke needle was inserted intrathecally via a midline approach into the L3-L4 or L4-L5 interspace with the patient in the sitting position. Patients received 10 mg 0.5% hyperbaric bupivacaine. 444 patients were operated in the prone position during surgery (P group) and the 972 patients were in the supine position (S group). RESULTS We compared the rate of PDPH between the two groups. 3 (0.68%) patients with pilonidal sinus were operated in prone position experienced headache and 87 of those operated in supine position (8.95%) had headache (P < 0.001); and the odds ratio of developing headache when operated in supine position was 13.16. CONCLUSIONS Prone position during surgery appears to be a reliable way to reduce PDPH following spinal or epidural anesthesia.
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Affiliation(s)
- Reza Alizadeh
- Department of Anesthesiology and Intensive Care, School of Medicine, AJA University of Medical Sciences, Tehran, Iran
| | - Ziba Aghsaeifard
- Department of Internal Medicine, School of Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Bahar Fereydoonnia
- Department of Anesthesiology and Intensive Care, School of Medicine, AJA University of Medical Sciences, Tehran, Iran
| | - Masoud Hashemi
- Anesthesiology Research Center, Akhtar Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mojtaba Mostafazadeh
- Department of Anesthesiology and Intensive Care, School of Medicine, AJA University of Medical Sciences, Tehran, Iran
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13
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Efficacy and safety of prophylactic intrathecal normal saline for prevention of Post Dural Puncture Headache among women undergoing cesarean section under spinal anesthesia: A randomized controlled trial. INTERNATIONAL JOURNAL OF SURGERY OPEN 2021. [DOI: 10.1016/j.ijso.2021.100396] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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14
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Galanou P, Tsoleridis T, Tsoleridis S. Epidural Blood Patch Performed Immediately After Dural Puncture and Epidural Drug Administration. Cureus 2021; 13:e16634. [PMID: 34462675 PMCID: PMC8386135 DOI: 10.7759/cureus.16634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2021] [Indexed: 11/18/2022] Open
Abstract
The epidural blood patch (EBP) is a solution for persistent headaches following an accidental dural puncture. We report three cases where EBP was performed immediately after dural puncture combined with drug administration for lumbago. To the best of our knowledge, no similar cases have been reported in the literature. The patients provided their informed consent, and all standard protocols were followed. At the moment of the dural puncture, all the patients manifested severe headaches, nausea, vomiting, and profuse sweating. A second epidural puncture was performed at a higher intervertebral space, followed by drug administration and 20 mL of autologous blood. All the patients improved gradually, while their headaches vanished after 30-35 minutes. The patients were kept in for monitoring and released the following day with specific instructions and daily phone contact for a week without any complications. Their lumbago symptoms regressed. The possibility of pneumocephalus was excluded because of the patients’ symptomatology. The risk of high or total spinal anesthesia due to local anesthetic leakage subarachnoidally was countered with close monitoring of the patients. EBP complications include failure, postdural-puncture headache worsening by an accidental additional dural tear(s), back pain, and infection. All patients were instructed to report any symptoms immediately. EBP executed immediately after dural puncture seems to relieve headache fast and does not appear to impede epidural analgesia.
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Affiliation(s)
- Polymnia Galanou
- Anesthesia and Pain Treatment Unit, General Hospital of Rhodes, Greece, Rhodes, GRC
| | - Theofilos Tsoleridis
- Anesthesia and Pain Treatment Unit, General Hospital of Rhodes, Greece, Rhodes, GRC
| | - Savvas Tsoleridis
- Anesthesia and Pain Treatment Unit, General Hospital of Rhodes, Greece, Rhodes, GRC
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15
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Mushtaq U, Massolini G, Nahid S. P.94 Post-dural puncture headache: four year review of a tertiary maternity hospital in Qatar. Int J Obstet Anesth 2021. [DOI: 10.1016/j.ijoa.2021.103092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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16
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Mustafa R, Barman RA, Kurian EB, Eldrige J, Frank R, Kissoon N, Garza I, Whealy MA, Cutsforth-Gregory JK, Olatoye O. Characterizing the need for multiple epidural blood patches in the treatment of postdural puncture headache: an observational study. Reg Anesth Pain Med 2021; 46:1110-1112. [PMID: 33952685 DOI: 10.1136/rapm-2021-102692] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 04/22/2021] [Accepted: 04/25/2021] [Indexed: 11/03/2022]
Affiliation(s)
- Rafid Mustafa
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ross A Barman
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Emil B Kurian
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jason Eldrige
- Department of Pain Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Ryan Frank
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Narayan Kissoon
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ivan Garza
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mark A Whealy
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Oludare Olatoye
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
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17
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Shiwlochan D, Ohanyan S, Rajput K. It Is Just a Blood Patch: Considerations for Patients with Preexisting Intracranial Hypertension. Case Rep Anesthesiol 2020; 2020:8365296. [PMID: 33274080 PMCID: PMC7676938 DOI: 10.1155/2020/8365296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 10/25/2020] [Accepted: 10/28/2020] [Indexed: 11/17/2022] Open
Abstract
Epidural blood patches are routine procedures interventional pain physicians perform for postdural puncture headaches (PDPH), whether it be due to the inadvertent wet tap from an epidural or a diagnostic lumbar puncture. Typically, these patients are relatively healthy and an epidural is relatively straightforward. However, there are cases complicated by a neurologic history such as benign intracranial hypertension. Here, we present a case of a patient with benign intracranial hypertension (BIH) that suffered a postdural puncture headache after a diagnostic lumbar puncture, with no documented opening pressure, continued on acetazolamide. There have only been a small number of documented cases of BIH complicated by PDPH. We discuss the medical management of BIH, how it can exacerbate a postdural puncture headache, our definitive management with an epidural blood patch, and our concerns of rebound intracranial hypertension. We demonstrate that treatment of PDPH in BIH is best managed with image-guided blood patches, with smaller volume of autologous blood, and at a slower rate.
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Affiliation(s)
- Devina Shiwlochan
- Department of Anesthesiology and Pain Medicine, Yale University School of Medicine, 333 Cedar Street, New Haven, CT-06511, USA
| | - Sargis Ohanyan
- Department of Anesthesiology and Pain Medicine, Yale University School of Medicine, 333 Cedar Street, New Haven, CT-06511, USA
| | - Kanishka Rajput
- Department of Anesthesiology and Pain Medicine, Yale University School of Medicine, 333 Cedar Street, New Haven, CT-06511, USA
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18
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Nair A, Diwan S. Treating postdural puncture headache in COVID-19 positive patient- is bilateral greater occipital nerve block the answer? Saudi J Anaesth 2020; 14:566-567. [PMID: 33447220 PMCID: PMC7796769 DOI: 10.4103/sja.sja_383_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 05/10/2020] [Accepted: 05/11/2020] [Indexed: 11/04/2022] Open
Affiliation(s)
- Abhijit Nair
- Department of Anaesthesia, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, Telangana, India
| | - Sandeep Diwan
- Department of Anaesthesia, Sancheti Hospital, Pune, Maharashtra, India
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19
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Cheng WJ, Hung KC, Ho CH, Yu CH, Chen YC, Wu MP, Chu CC, Chang YJ. Satisfaction in parturients receiving epidural analgesia after prenatal shared decision-making intervention: a prospective, before-and-after cohort study. BMC Pregnancy Childbirth 2020; 20:413. [PMID: 32689958 PMCID: PMC7370438 DOI: 10.1186/s12884-020-03085-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 07/01/2020] [Indexed: 11/23/2022] Open
Abstract
Background The explanation of epidural analgesia by anesthesiologist would often begin after the parturient is admitted to the hospital. Because of labor pain, the decision of receiving epidural analgesia would often be made by the family members, instead of the parturient herself. We aimed to test whether earlier prenatal shared decision-making (SDM) interventions increase parturient’s comprehension and satisfaction of epidural labor analgesia, compared to conventional explanation after labor pain begun. Methods During the 28th week of gestation, we provided the SDM parturient health education as well as a leaflet with quick response codes. Scanning the code would link to education videoclips which explained what epidural analgesia is and its advantages and disadvantages. Original routine practice group parturients received explanation of analgesia after admission for delivery. To measure the satisfaction of labor pain service, the accessibility of information, and the communication with medical staff, we designed a questionnaire with reference to (1) Pregnancy and Maternity Care Patients’ Experiences Questionnaire (PreMaPEQ), (2) Preterm Birth Experience and Satisfaction Scale (P-BESS), and (3) Women’s Views of Birth Labor Satisfaction Questionnaire (WOMBLSQ). The questionnaire was amended after a pretest involving 30 parturients who had received epidural analgesia. Scree test analysis and exploratory factor analysis were performed; then, the questionnaire was revised again. A total of 200 valid questionnaires were collected—100 each from the original routine practice group and the SDM group. Results The SDM group reported significantly higher satisfaction with and understanding of epidural analgesia, and a significantly higher satisfaction with the information received, and the quality of pain relief. After SDM intervention, significant increasement of the average satisfaction scores in question “my epidural is effective” (9.10%; mean difference: 0.38; 95% confidence interval, 0.17 ~ 0.59; p < 0.001) and “The effect of epidural is just as what I have expected” (10.41%; mean difference: 0.41; 95% confidence interval, 0.18 ~ 0.64; p < 0.001) was demonstrated. Conclusions An earlier prenatal SDM intervention with sufficient information through videoclips increased parturients’ comprehensions and satisfaction of epidural analgesia service. Trial registration ISRCTN registry, 14,256,563. Registered April 1st, 2020 (10.1186/ISRCTN14256563).
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Affiliation(s)
- Wan-Jung Cheng
- Department of Anesthesiology, Chi Mei Medical Center, 901 Zhonghua Road, Yongkang District, Tainan City, 710, Taiwan
| | - Kuo-Chuan Hung
- Department of Anesthesiology, Chi Mei Medical Center, 901 Zhonghua Road, Yongkang District, Tainan City, 710, Taiwan
| | - Chung-Han Ho
- Department of Medical Research, Chi Mei Medical Center, 901 Zhonghua Road, Yongkang District, Tainan City, 710, Taiwan.,Department of Hospital and Health Care Administration, Chia Nan University of Pharmacy and Science, 901 Zhonghua Road, Yongkang District, Tainan City, 710, Taiwan
| | - Chia-Hung Yu
- Department of Anesthesiology, Chi Mei Medical Center, 901 Zhonghua Road, Yongkang District, Tainan City, 710, Taiwan
| | - Yi-Chen Chen
- Department of Medical Research, Chi Mei Medical Center, 901 Zhonghua Road, Yongkang District, Tainan City, 710, Taiwan
| | - Ming-Ping Wu
- Division of Urogynecology and Pelvic Floor Reconstruction, Department of Obstetrics and Gynecology, Chi Mei Medical Center, 901 Zhonghua Road, Yongkang District, Tainan City, 710, Taiwan.,Center of General Education, Chia Nan University of Pharmacy and Science, 901 Zhonghua Road, Yongkang District, Tainan City, 710, Taiwan
| | - Chin-Chen Chu
- Department of Anesthesiology, Chi Mei Medical Center, 901 Zhonghua Road, Yongkang District, Tainan City, 710, Taiwan. .,Department of Medical Research, Chi Mei Medical Center, 901 Zhonghua Road, Yongkang District, Tainan City, 710, Taiwan. .,Department of Recreation and Health-Care Management, Chia Nan University of Pharmacy and Science, 901 Zhonghua Road, Yongkang District, Tainan City, 710, Taiwan.
| | - Ying-Jen Chang
- Department of Anesthesiology, Chi Mei Medical Center, 901 Zhonghua Road, Yongkang District, Tainan City, 710, Taiwan. .,College of Health Sciences, Chang Jung Christian University, Tainan City, Taiwan.
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20
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De Haan JB, Chrisman OM, Lee L, Ge M, Hernandez N. T4 Erector Spinae Plane Block Relieves Postdural Puncture Headache: A Case Report. Cureus 2019; 11:e6237. [PMID: 31807394 PMCID: PMC6881086 DOI: 10.7759/cureus.6237] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Postdural puncture headache (PDPH) is a common complication of neuraxial anesthesia. The gold standard treatment for PDPH is an epidural blood patch (EBP). However, the risks of EBP, and patient willingness to undergo another attempted neuraxial procedure, can prevent patients from receiving this treatment. The erector spinae plane (ESP) block has been used in the treatment of acute postoperative and chronic pain secondary to many indications at many vertebral levels, and a prior case series describes two patients in which ESP block relieved tension headache. In our case report, we describe a novel use of the ESP block at the fourth thoracic vertebral level to relieve PDPH in a super morbidly obese patient with two prior inadvertent dural punctures.
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Affiliation(s)
- Johanna B De Haan
- Anesthesiology, McGovern Medical School University of Texas Health Science Center, Houston, USA
| | - Olga M Chrisman
- Anesthesiology, McGovern Medical School University of Texas Health Science Center, Houston, USA
| | - Linden Lee
- Anesthesiology, McGovern Medical School University of Texas Health Science Center, Houston, USA
| | - Michelle Ge
- Anesthesiology, McGovern Medical School University of Texas Health Science Center, Houston, USA
| | - Nadia Hernandez
- Anesthesiology, McGovern Medical School University of Texas Health Science Center, Houston, USA
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21
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Efficacy of prophylactic epidural saline for reducing postdural puncture headache in patients undergoing caesarean section. JOURNAL OF SURGERY AND MEDICINE 2019. [DOI: 10.28982/josam.604790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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22
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Costerus JM, Brouwer MC, van de Beek D. Technological advances and changing indications for lumbar puncture in neurological disorders. Lancet Neurol 2019; 17:268-278. [PMID: 29452686 DOI: 10.1016/s1474-4422(18)30033-4] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 11/24/2017] [Accepted: 11/28/2017] [Indexed: 01/12/2023]
Abstract
Technological advances have changed the indications for and the way in which lumbar puncture is done. Suspected CNS infection remains the most common indication for lumbar puncture, but new molecular techniques have broadened CSF analysis indications, such as the determination of neuronal autoantibodies in autoimmune encephalitis. New screening techniques have increased sensitvity for pathogen detection and can be used to identify pathogens that were previously unknown to cause CNS infections. Evidence suggests that potential treatments for neurodegenerative diseases, such as Alzheimer's disease, will rely on early detection of the disease with the use of CSF biomarkers. In addition to being used as a diagnostic tool, lumbar puncture can also be used to administer intrathecal treatments as shown by studies of antisense oligonucleotides in patients with spinal muscular atrophy. Lumbar puncture is generally a safe procedure but complications can occur, ranging from minor (eg, back pain) to potentially devastating (eg, cerebral herniation). Evidence that an atraumatic needle tip design reduces complications of lumbar puncture is compelling, and reinforces the need to change clinical practice.
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Affiliation(s)
- Joost M Costerus
- Department of Neurology, Academic Medical Center, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, Netherlands
| | - Matthijs C Brouwer
- Department of Neurology, Academic Medical Center, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, Netherlands
| | - Diederik van de Beek
- Department of Neurology, Academic Medical Center, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, Netherlands.
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23
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Nair AS, Kodisharapu PK, Anne P, Saifuddin MS, Asiel C, Rayani BK. Efficacy of bilateral greater occipital nerve block in postdural puncture headache: a narrative review. Korean J Pain 2018; 31:80-86. [PMID: 29686805 PMCID: PMC5904351 DOI: 10.3344/kjp.2018.31.2.80] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 11/27/2017] [Accepted: 11/28/2017] [Indexed: 11/19/2022] Open
Abstract
The Epidural blood patch is considered the gold standard for managing postdural puncture headache when supportive measures fail. However, it is a procedure which can lead to another inadvertent dural puncture. Other potential adverse events that could occur during a blood patch are meningitis, neurological deficits, and unconsciousness. The bilateral greater occipital nerve block has been used for treating chronic headaches in patients with PDPH with a single injection. This minimally invasive, simple procedure can be considered for patients early, along with other supportive treatment, and an epidural blood patch can be avoided.
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Affiliation(s)
- Abhijit S Nair
- Department of Anesthesiology and Pain Management, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, Telangana, India
| | - Praveen Kumar Kodisharapu
- Department of Anesthesiology and Pain Management, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, Telangana, India
| | - Poornachand Anne
- Department of Anesthesiology and Pain Management, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, Telangana, India
| | - Mohammad Salman Saifuddin
- Department of Anesthesiology and Pain Management, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, Telangana, India
| | - Christopher Asiel
- Department of Anesthesiology and Pain Management, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, Telangana, India
| | - Basanth Kumar Rayani
- Department of Anesthesiology and Pain Management, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, Telangana, India
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24
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Wu C, Guan D, Ren M, Ma Z, Wan C, Cui Y, Zhong P, Zhao W, Li C, Yan F, Xie J, Xue F, Lian Y, Liu H, Wang C, Ji X, Xie N. Aminophylline for treatment of postdural puncture headache: A randomized clinical trial. Neurology 2018; 90:e1523-e1529. [PMID: 29572284 DOI: 10.1212/wnl.0000000000005351] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 01/25/2018] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE To investigate the efficacy and safety of IV aminophylline for patients with postdural puncture headache (PDPH). METHODS We randomly assigned patients to groups receiving either 250 mg IV aminophylline or a placebo within 3 hours of symptom onset once daily for 2 consecutive days. The primary endpoint was headache severity 8 hours after treatment. We assessed this using visual analog scale (VAS) scores taken from patients in a standing position. We also recorded posttreatment VAS score changes, Patient Global Impression of Change (PGIC) scores, and adverse events. We performed an intention-to-treat analysis. RESULTS We enrolled 126 patients with PDPH at 5 centers in China (62 assigned to the aminophylline group and 64 to the placebo group). The median age was 37 years, and 96 (76.2%) patients were women. Compared to the placebo-treated patients, the aminophylline-treated patients had significantly lower mean VAS scores 8 hours after treatment (5.34 vs 2.98, p < 0.001) and were significantly more likely to report improvements on the PGIC (39.1% vs 72.6%, p < 0.01). This therapeutic effect was already evident at the 30-minute time point and persisted for 2 days. There was no significant difference in the incidence of adverse events (4.8% vs 1.6%, p = 0.589). CONCLUSIONS IV aminophylline is an effective and safe early-stage treatment for patients with PDPH. CLINICALTRIALSGOV IDENTIFIER NCT02522013. CLASSIFICATION OF EVIDENCE This study provides Class I evidence that for people with PDPH, IV aminophylline reduces headache severity.
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Affiliation(s)
- Chuanjie Wu
- From the Department of Neurology (C. Wu, Y.L., H.L., C. Wang, N.X.), First Affiliated Hospital of Zhengzhou University; Department of Neurology (D.G., Y.C.), Second Affiliated Hospital of Henan University of Traditional Chinese Medicine; Department of Neurosurgery (M.R., W.Z., C.L., F.Y., X.J.), Xuanwu Hospital Capital Medical University, Beijing; Department of Neurology (Z.M., P.Z.), Suzhou Municipal Hospital, Anhui; Department of Neurology (C. Wan, J.X.), Jinzhou Central Hospital, Liaoning; and Department of Neurology (F.X.), Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Dongsheng Guan
- From the Department of Neurology (C. Wu, Y.L., H.L., C. Wang, N.X.), First Affiliated Hospital of Zhengzhou University; Department of Neurology (D.G., Y.C.), Second Affiliated Hospital of Henan University of Traditional Chinese Medicine; Department of Neurosurgery (M.R., W.Z., C.L., F.Y., X.J.), Xuanwu Hospital Capital Medical University, Beijing; Department of Neurology (Z.M., P.Z.), Suzhou Municipal Hospital, Anhui; Department of Neurology (C. Wan, J.X.), Jinzhou Central Hospital, Liaoning; and Department of Neurology (F.X.), Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Ming Ren
- From the Department of Neurology (C. Wu, Y.L., H.L., C. Wang, N.X.), First Affiliated Hospital of Zhengzhou University; Department of Neurology (D.G., Y.C.), Second Affiliated Hospital of Henan University of Traditional Chinese Medicine; Department of Neurosurgery (M.R., W.Z., C.L., F.Y., X.J.), Xuanwu Hospital Capital Medical University, Beijing; Department of Neurology (Z.M., P.Z.), Suzhou Municipal Hospital, Anhui; Department of Neurology (C. Wan, J.X.), Jinzhou Central Hospital, Liaoning; and Department of Neurology (F.X.), Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Zhengfei Ma
- From the Department of Neurology (C. Wu, Y.L., H.L., C. Wang, N.X.), First Affiliated Hospital of Zhengzhou University; Department of Neurology (D.G., Y.C.), Second Affiliated Hospital of Henan University of Traditional Chinese Medicine; Department of Neurosurgery (M.R., W.Z., C.L., F.Y., X.J.), Xuanwu Hospital Capital Medical University, Beijing; Department of Neurology (Z.M., P.Z.), Suzhou Municipal Hospital, Anhui; Department of Neurology (C. Wan, J.X.), Jinzhou Central Hospital, Liaoning; and Department of Neurology (F.X.), Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Changming Wan
- From the Department of Neurology (C. Wu, Y.L., H.L., C. Wang, N.X.), First Affiliated Hospital of Zhengzhou University; Department of Neurology (D.G., Y.C.), Second Affiliated Hospital of Henan University of Traditional Chinese Medicine; Department of Neurosurgery (M.R., W.Z., C.L., F.Y., X.J.), Xuanwu Hospital Capital Medical University, Beijing; Department of Neurology (Z.M., P.Z.), Suzhou Municipal Hospital, Anhui; Department of Neurology (C. Wan, J.X.), Jinzhou Central Hospital, Liaoning; and Department of Neurology (F.X.), Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yinglin Cui
- From the Department of Neurology (C. Wu, Y.L., H.L., C. Wang, N.X.), First Affiliated Hospital of Zhengzhou University; Department of Neurology (D.G., Y.C.), Second Affiliated Hospital of Henan University of Traditional Chinese Medicine; Department of Neurosurgery (M.R., W.Z., C.L., F.Y., X.J.), Xuanwu Hospital Capital Medical University, Beijing; Department of Neurology (Z.M., P.Z.), Suzhou Municipal Hospital, Anhui; Department of Neurology (C. Wan, J.X.), Jinzhou Central Hospital, Liaoning; and Department of Neurology (F.X.), Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Ping Zhong
- From the Department of Neurology (C. Wu, Y.L., H.L., C. Wang, N.X.), First Affiliated Hospital of Zhengzhou University; Department of Neurology (D.G., Y.C.), Second Affiliated Hospital of Henan University of Traditional Chinese Medicine; Department of Neurosurgery (M.R., W.Z., C.L., F.Y., X.J.), Xuanwu Hospital Capital Medical University, Beijing; Department of Neurology (Z.M., P.Z.), Suzhou Municipal Hospital, Anhui; Department of Neurology (C. Wan, J.X.), Jinzhou Central Hospital, Liaoning; and Department of Neurology (F.X.), Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Wenbo Zhao
- From the Department of Neurology (C. Wu, Y.L., H.L., C. Wang, N.X.), First Affiliated Hospital of Zhengzhou University; Department of Neurology (D.G., Y.C.), Second Affiliated Hospital of Henan University of Traditional Chinese Medicine; Department of Neurosurgery (M.R., W.Z., C.L., F.Y., X.J.), Xuanwu Hospital Capital Medical University, Beijing; Department of Neurology (Z.M., P.Z.), Suzhou Municipal Hospital, Anhui; Department of Neurology (C. Wan, J.X.), Jinzhou Central Hospital, Liaoning; and Department of Neurology (F.X.), Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Chuanhui Li
- From the Department of Neurology (C. Wu, Y.L., H.L., C. Wang, N.X.), First Affiliated Hospital of Zhengzhou University; Department of Neurology (D.G., Y.C.), Second Affiliated Hospital of Henan University of Traditional Chinese Medicine; Department of Neurosurgery (M.R., W.Z., C.L., F.Y., X.J.), Xuanwu Hospital Capital Medical University, Beijing; Department of Neurology (Z.M., P.Z.), Suzhou Municipal Hospital, Anhui; Department of Neurology (C. Wan, J.X.), Jinzhou Central Hospital, Liaoning; and Department of Neurology (F.X.), Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Feng Yan
- From the Department of Neurology (C. Wu, Y.L., H.L., C. Wang, N.X.), First Affiliated Hospital of Zhengzhou University; Department of Neurology (D.G., Y.C.), Second Affiliated Hospital of Henan University of Traditional Chinese Medicine; Department of Neurosurgery (M.R., W.Z., C.L., F.Y., X.J.), Xuanwu Hospital Capital Medical University, Beijing; Department of Neurology (Z.M., P.Z.), Suzhou Municipal Hospital, Anhui; Department of Neurology (C. Wan, J.X.), Jinzhou Central Hospital, Liaoning; and Department of Neurology (F.X.), Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Jinqiu Xie
- From the Department of Neurology (C. Wu, Y.L., H.L., C. Wang, N.X.), First Affiliated Hospital of Zhengzhou University; Department of Neurology (D.G., Y.C.), Second Affiliated Hospital of Henan University of Traditional Chinese Medicine; Department of Neurosurgery (M.R., W.Z., C.L., F.Y., X.J.), Xuanwu Hospital Capital Medical University, Beijing; Department of Neurology (Z.M., P.Z.), Suzhou Municipal Hospital, Anhui; Department of Neurology (C. Wan, J.X.), Jinzhou Central Hospital, Liaoning; and Department of Neurology (F.X.), Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Fang Xue
- From the Department of Neurology (C. Wu, Y.L., H.L., C. Wang, N.X.), First Affiliated Hospital of Zhengzhou University; Department of Neurology (D.G., Y.C.), Second Affiliated Hospital of Henan University of Traditional Chinese Medicine; Department of Neurosurgery (M.R., W.Z., C.L., F.Y., X.J.), Xuanwu Hospital Capital Medical University, Beijing; Department of Neurology (Z.M., P.Z.), Suzhou Municipal Hospital, Anhui; Department of Neurology (C. Wan, J.X.), Jinzhou Central Hospital, Liaoning; and Department of Neurology (F.X.), Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yajun Lian
- From the Department of Neurology (C. Wu, Y.L., H.L., C. Wang, N.X.), First Affiliated Hospital of Zhengzhou University; Department of Neurology (D.G., Y.C.), Second Affiliated Hospital of Henan University of Traditional Chinese Medicine; Department of Neurosurgery (M.R., W.Z., C.L., F.Y., X.J.), Xuanwu Hospital Capital Medical University, Beijing; Department of Neurology (Z.M., P.Z.), Suzhou Municipal Hospital, Anhui; Department of Neurology (C. Wan, J.X.), Jinzhou Central Hospital, Liaoning; and Department of Neurology (F.X.), Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Hongbo Liu
- From the Department of Neurology (C. Wu, Y.L., H.L., C. Wang, N.X.), First Affiliated Hospital of Zhengzhou University; Department of Neurology (D.G., Y.C.), Second Affiliated Hospital of Henan University of Traditional Chinese Medicine; Department of Neurosurgery (M.R., W.Z., C.L., F.Y., X.J.), Xuanwu Hospital Capital Medical University, Beijing; Department of Neurology (Z.M., P.Z.), Suzhou Municipal Hospital, Anhui; Department of Neurology (C. Wan, J.X.), Jinzhou Central Hospital, Liaoning; and Department of Neurology (F.X.), Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Cui Wang
- From the Department of Neurology (C. Wu, Y.L., H.L., C. Wang, N.X.), First Affiliated Hospital of Zhengzhou University; Department of Neurology (D.G., Y.C.), Second Affiliated Hospital of Henan University of Traditional Chinese Medicine; Department of Neurosurgery (M.R., W.Z., C.L., F.Y., X.J.), Xuanwu Hospital Capital Medical University, Beijing; Department of Neurology (Z.M., P.Z.), Suzhou Municipal Hospital, Anhui; Department of Neurology (C. Wan, J.X.), Jinzhou Central Hospital, Liaoning; and Department of Neurology (F.X.), Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xunming Ji
- From the Department of Neurology (C. Wu, Y.L., H.L., C. Wang, N.X.), First Affiliated Hospital of Zhengzhou University; Department of Neurology (D.G., Y.C.), Second Affiliated Hospital of Henan University of Traditional Chinese Medicine; Department of Neurosurgery (M.R., W.Z., C.L., F.Y., X.J.), Xuanwu Hospital Capital Medical University, Beijing; Department of Neurology (Z.M., P.Z.), Suzhou Municipal Hospital, Anhui; Department of Neurology (C. Wan, J.X.), Jinzhou Central Hospital, Liaoning; and Department of Neurology (F.X.), Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Nanchang Xie
- From the Department of Neurology (C. Wu, Y.L., H.L., C. Wang, N.X.), First Affiliated Hospital of Zhengzhou University; Department of Neurology (D.G., Y.C.), Second Affiliated Hospital of Henan University of Traditional Chinese Medicine; Department of Neurosurgery (M.R., W.Z., C.L., F.Y., X.J.), Xuanwu Hospital Capital Medical University, Beijing; Department of Neurology (Z.M., P.Z.), Suzhou Municipal Hospital, Anhui; Department of Neurology (C. Wan, J.X.), Jinzhou Central Hospital, Liaoning; and Department of Neurology (F.X.), Second Hospital of Hebei Medical University, Shijiazhuang, China.
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25
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Engelborghs S, Niemantsverdriet E, Struyfs H, Blennow K, Brouns R, Comabella M, Dujmovic I, van der Flier W, Frölich L, Galimberti D, Gnanapavan S, Hemmer B, Hoff E, Hort J, Iacobaeus E, Ingelsson M, Jan de Jong F, Jonsson M, Khalil M, Kuhle J, Lleó A, de Mendonça A, Molinuevo JL, Nagels G, Paquet C, Parnetti L, Roks G, Rosa-Neto P, Scheltens P, Skårsgard C, Stomrud E, Tumani H, Visser PJ, Wallin A, Winblad B, Zetterberg H, Duits F, Teunissen CE. Consensus guidelines for lumbar puncture in patients with neurological diseases. ALZHEIMER'S & DEMENTIA: DIAGNOSIS, ASSESSMENT & DISEASE MONITORING 2017; 8:111-126. [PMID: 28603768 PMCID: PMC5454085 DOI: 10.1016/j.dadm.2017.04.007] [Citation(s) in RCA: 165] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Introduction Cerebrospinal fluid collection by lumbar puncture (LP) is performed in the diagnostic workup of several neurological brain diseases. Reluctance to perform the procedure is among others due to a lack of standards and guidelines to minimize the risk of complications, such as post-LP headache or back pain. Methods We provide consensus guidelines for the LP procedure to minimize the risk of complications. The recommendations are based on (1) data from a large multicenter LP feasibility study (evidence level II-2), (2) systematic literature review on LP needle characteristics and post-LP complications (evidence level II-2), (3) discussion of best practice within the Joint Programme Neurodegenerative Disease Research Biomarkers for Alzheimer's disease and Parkinson's Disease and Biomarkers for Multiple Sclerosis consortia (evidence level III). Results Our consensus guidelines address contraindications, as well as patient-related and procedure-related risk factors that can influence the development of post-LP complications. Discussion When an LP is performed correctly, the procedure is well tolerated and accepted with a low complication rate.
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Affiliation(s)
- Sebastiaan Engelborghs
- Reference Center for Biological Markers of Dementia (BIODEM), Department of Biomedical Sciences, Institute Born-Bunge, University of Antwerp, Antwerp, Belgium.,Department of Neurology and Memory Clinic, Hospital Network Antwerp (ZNA) Middelheim and Hoge Beuken, Antwerp, Belgium
| | - Ellis Niemantsverdriet
- Reference Center for Biological Markers of Dementia (BIODEM), Department of Biomedical Sciences, Institute Born-Bunge, University of Antwerp, Antwerp, Belgium
| | - Hanne Struyfs
- Reference Center for Biological Markers of Dementia (BIODEM), Department of Biomedical Sciences, Institute Born-Bunge, University of Antwerp, Antwerp, Belgium
| | - Kaj Blennow
- Clinical Neurochemistry Laboratory, Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Mölndal, Sweden
| | - Raf Brouns
- Department of Neurology, Universitair Ziekenhuis Brussel (UZ Brussel), Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Manuel Comabella
- Servei de Neurologia-Neuroimmunologia, Centre d'Esclerosi Múltiple de Catalunya (Cemcat), Institut de Receca Vall d'Hebron (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Irena Dujmovic
- Clinic of Neurology, Clinical Centre of Serbia, Department of Neurology, Faculty of Medicine, University of Belgrade School of Medicine, Belgrade, Serbia
| | - Wiesje van der Flier
- Alzheimer center and Department of Neurology, Neuroscience Campus Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
| | - Lutz Frölich
- Department of Geriatric Psychiatry, Central Institute of Mental Health, Medical Faculty, Mannheim/Heidelberg University, Mannheim, Germany
| | - Daniela Galimberti
- Neurology Unit, Department of Pathophysiology and Transplantation, University of Milan, Fondazione Ca' Granda, IRCCS Ospedale Policlinico, Milan, Italy
| | - Sharmilee Gnanapavan
- Department of Neuroscience and Trauma, Blizard Institute, Queen Mary University of London, London, United Kingdom
| | - Bernhard Hemmer
- Department of Neurology, Technische Universität München, Munich, Germany.,Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Erik Hoff
- Department of Neurology, Atrium Medisch Centrum Parkstad, Heerlen, The Netherlands
| | - Jakub Hort
- Memory Disorders Clinic, Department of Neurology, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic.,International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czech Republic
| | - Ellen Iacobaeus
- Department of Clinical Neuroscience, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - Martin Ingelsson
- Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
| | - Frank Jan de Jong
- Department of Neurology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Michael Jonsson
- Memory Clinic, Department of Neuropsychiatry, Sahlgrenska University Hospital, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Mölndal, Sweden
| | - Michael Khalil
- Department of Neurology, Medical University Graz, Graz, Austria
| | - Jens Kuhle
- Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Alberto Lleó
- Memory Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.,Centro de Investigación Biomédica en Red en enfermedades Neurodegenerativas, CIBERNED, Madrid, Spain
| | - Alexandre de Mendonça
- Laboratory of Neurosciences, Department of Molecular Medicine and Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | - José Luis Molinuevo
- Alzheimer's disease and other cognitive disorders unit, Neurology Service, Hospital Clinic i Universitari, IDIBAPS, Barcelona, Spain
| | - Guy Nagels
- Department of Neurology, Universitair Ziekenhuis Brussel (UZ Brussel), Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Brussels, Belgium.,Faculté de Psychologie et des sciences de l'éducation, UMons, Mons, Belgium.,National MS Center Melsbroek, Brussels, Belgium
| | - Claire Paquet
- Research Memory Center Lariboisière Hospital University Paris Diderot INSERMU942, Paris, France
| | - Lucilla Parnetti
- Section of Neurology, Centre for Memory Disturbances, Department of Medicine, University of Perugia, Perugia, Italy
| | - Gerwin Roks
- Department of Neurology, St Elisabeth Ziekenhuis, Tilburg, The Netherlands
| | - Pedro Rosa-Neto
- Departments of Neurology & Neurosurgery and Psychiatry, McGill Centre for Studies in Aging, Douglas Hospital Research Center, McGill University, Montreal, Canada.,Departments of Psychiatry, McGill Centre for Studies in Aging, Douglas Hospital Research Center, McGill University, Montreal, Canada
| | - Philip Scheltens
- Alzheimer center and Department of Neurology, Neuroscience Campus Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
| | | | - Erik Stomrud
- Clinical Memory Research Unit, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Hayrettin Tumani
- CSF Laboratory and Multiple Sclerosis Outpatient Unit, Department of Neurology, University of Ulm, Ulm, Germany
| | - Pieter Jelle Visser
- Neurochemistry Laboratory and Biobank, Department of Clinical Chemistry, Neuroscience Campus Amsterdam, VU University Medical Center, Amsterdam, The Netherlands.,Alzheimer Centre Limburg, School for Mental Health and Neuroscience, Department of Psychiatry and Neuropsychology, Maastricht University, Maastricht, The Netherlands
| | - Anders Wallin
- Memory Clinic, Department of Neuropsychiatry, Sahlgrenska University Hospital, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Mölndal, Sweden
| | - Bengt Winblad
- Karolinska Institutet, Department of Neurobiology, Care Sciences and Society (NVS), Center for Alzheimer Research, Division for Neurogeriatrics, Huddinge, Sweden
| | - Henrik Zetterberg
- Clinical Neurochemistry Laboratory, Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Mölndal, Sweden.,UCL Institute of Neurology, Department of Molecular Neuroscience, London, United Kingdom
| | - Flora Duits
- Alzheimer center and Department of Neurology, Neuroscience Campus Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
| | - Charlotte E Teunissen
- Neurochemistry Laboratory and Biobank, Department of Clinical Chemistry, Neuroscience Campus Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
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26
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Arevalo‐Rodriguez I, Muñoz L, Godoy‐Casasbuenas N, Ciapponi A, Arevalo JJ, Boogaard S, Roqué i Figuls M. Needle gauge and tip designs for preventing post-dural puncture headache (PDPH). Cochrane Database Syst Rev 2017; 4:CD010807. [PMID: 28388808 PMCID: PMC6478120 DOI: 10.1002/14651858.cd010807.pub2] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Ingrid Arevalo‐Rodriguez
- Universidad Tecnológica EquinoccialCochrane Ecuador. Centro de Investigación en Salud Pública y Epidemiología Clínica (CISPEC). Facultad de Ciencias de la Salud Eugenio EspejoAv. Mariscal Sucre s/n y Av. Mariana de JesúsQuitoEcuador
- Fundacion Universitaria de Ciencias de la Salud ‐ Hospital de San Jose/Hospital Infantil de San JoseDivision of ResearchBogotá D.C.Colombia
| | - Luis Muñoz
- Hospital de San José, Fundación Universitaria de Ciencias de la SaludDepartment of Anaesthesia10th Street No 18‐75Bogotá D.C.Colombia
| | - Natalia Godoy‐Casasbuenas
- Fundación Universitaria de Ciencias de la Salud ‐ Hospital de San José/Hospital Infantil de San JoséDivision of ResearchBogotáColombia
| | - Agustín Ciapponi
- Institute for Clinical Effectiveness and Health Policy (IECS‐CONICET)Argentine Cochrane CentreDr. Emilio Ravignani 2024Buenos AiresCapital FederalArgentinaC1414CPV
| | - Jimmy J Arevalo
- Hospital de San José, Fundación Universitaria de Ciencias de la SaludDepartment of Anaesthesia10th Street No 18‐75Bogotá D.C.Colombia
- VU University Medical CenterDepartment of AnesthesiologyAmsterdamNetherlands
| | - Sabine Boogaard
- VU University Medical CenterDepartment of AnesthesiologyAmsterdamNetherlands
| | - Marta Roqué i Figuls
- CIBER Epidemiología y Salud Pública (CIBERESP)Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau)Sant Antoni Maria Claret 171Edifici Casa de ConvalescènciaBarcelonaCatalunyaSpain08041
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27
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Riveros-Pérez E. ¿Es necesario seguir curando con una punción lo que se ocasionó con otra? COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2017. [DOI: 10.1016/j.rca.2017.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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28
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Nair AS, Rayani BK. Sphenopalatine ganglion block for relieving postdural puncture headache: technique and mechanism of action of block with a narrative review of efficacy. Korean J Pain 2017; 30:93-97. [PMID: 28416992 PMCID: PMC5392662 DOI: 10.3344/kjp.2017.30.2.93] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 02/11/2017] [Accepted: 02/13/2017] [Indexed: 11/08/2022] Open
Abstract
The sphenopalatine ganglion (SPG) is a parasympathetic ganglion, located in the pterygopalatine fossa. The SPG block has been used for a long time for treating headaches of varying etiologies. For anesthesiologists, treating postdural puncture headaches (PDPH) has always been challenging. The epidural block patch (EBP) was the only option until researchers explored the role of the SPG block as a relatively simple and effective way to treat PDPH. Also, since the existing evidence proving the efficacy of the SPG block in PDPH is scarce, the block cannot be offered to all patients. EBP can be still considered if an SPG block is not able to alleviate pain due to PDPH.
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Affiliation(s)
- Abhijit S Nair
- Department of Anaesthesia and Pain Medicine, Basavatarakam Indo-American Cancer Hospital and Research Centre, Hyderabad, India
| | - Basanth Kumar Rayani
- Department of Anaesthesia and Pain Medicine, Basavatarakam Indo-American Cancer Hospital and Research Centre, Hyderabad, India
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29
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30
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Bordlee JW, Beakley BD, Mody R, McConville AP, Weed JT, McClure BP, Foldes PJ, Ma JG, Kaye AD, Eskander JP. A case of paradoxical presentation of a postural postdural puncture headache after combined spinal-epidural anesthesia. J Clin Anesth 2017; 38:156-157. [PMID: 28372658 DOI: 10.1016/j.jclinane.2016.08.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Accepted: 08/09/2016] [Indexed: 10/20/2022]
Abstract
We report a case of paradoxical presentation of a postural postdural puncture headache secondary to dural puncture with a 25-gauge Whitacre needle for combined spinal-epidural anesthesia. This 27-year-old female patient presented to the emergency department with elevated blood pressure and a global headache 9 days after administration of epidural anesthesia for a spontaneous vaginal delivery after an uncomplicated pregnancy. The patient reported that the headache was more intense when lying down and immediately improved when she sat or stood up from a recumbent position. The patient was discharged from emergency department after an improvement following treatment with labetalol, ondansetron, ketorolac, and fluid resuscitation.
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Affiliation(s)
- John W Bordlee
- Department of Anesthesiology, Tulane School of Medicine, New Orleans, LA.
| | - Burton D Beakley
- Department of Anesthesiology, Tulane School of Medicine, New Orleans, LA
| | - Rayomond Mody
- Department of Anesthesiology, Tulane School of Medicine, New Orleans, LA
| | - Anne P McConville
- Department of Anesthesiology, Tulane School of Medicine, New Orleans, LA
| | - Jonathan T Weed
- Department of Anesthesiology, Tulane School of Medicine, New Orleans, LA
| | - Brian P McClure
- Department of Anesthesiology, Tulane School of Medicine, New Orleans, LA
| | - Peter J Foldes
- Department of Anesthesiology, Tulane School of Medicine, New Orleans, LA
| | - Jonathan G Ma
- Department of Anesthesiology, Tulane School of Medicine, New Orleans, LA
| | - Alan D Kaye
- Department of Anesthesiology, Tulane School of Medicine, New Orleans, LA
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Uyar Türkyilmaz E, Eryilmaz NC, Güzey NA, Moraloğlu Ö. Bloqueio bilateral do nervo occipital maior para tratamento de cefaleia pós‐punção dural após cesarianas. Braz J Anesthesiol 2016; 66:445-50. [DOI: 10.1016/j.bjan.2015.12.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Accepted: 03/23/2015] [Indexed: 10/21/2022] Open
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Haché M, Swoboda KJ, Sethna N, Farrow-Gillespie A, Khandji A, Xia S, Bishop KM. Intrathecal Injections in Children With Spinal Muscular Atrophy: Nusinersen Clinical Trial Experience. J Child Neurol 2016; 31:899-906. [PMID: 26823478 PMCID: PMC4871174 DOI: 10.1177/0883073815627882] [Citation(s) in RCA: 151] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 12/20/2015] [Indexed: 12/22/2022]
Abstract
Nusinersen (ISIS-SMNRx or ISIS 396443) is an antisense oligonucleotide drug administered intrathecally to treat spinal muscular atrophy. We summarize lumbar puncture experience in children with spinal muscular atrophy during a phase 1 open-label study of nusinersen and its extension. During the studies, 73 lumbar punctures were performed in 28 patients 2 to 14 years of age with type 2/3 spinal muscular atrophy. No complications occurred in 50 (68%) lumbar punctures; in 23 (32%) procedures, adverse events were attributed to lumbar puncture. Most common adverse events were headache (n = 9), back pain (n = 9), and post-lumbar puncture syndrome (n = 8). In a subgroup analysis, adverse events were more frequent in older children, children with type 3 spinal muscular atrophy, and with a 21- or 22-gauge needle compared to a 24-gauge needle or smaller. Lumbar punctures were successfully performed in children with spinal muscular atrophy; lumbar puncture-related adverse event frequency was similar to that previously reported in children.
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Affiliation(s)
- Manon Haché
- Division of Pediatric Anesthesia, Columbia University Medical Center, New York, NY, USA
| | - Kathryn J Swoboda
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Navil Sethna
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Alan Farrow-Gillespie
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical School, Dallas, TX, USA
| | | | - Shuting Xia
- Ionis Pharmaceuticals, Inc., Carlsbad, CA, USA
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Che X, Zhang W, Xu M. Continuous epidural pumping of saline contributes to prevent and treat postdural puncture headache. J Clin Anesth 2016; 34:154-8. [PMID: 27687364 DOI: 10.1016/j.jclinane.2016.03.066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 03/16/2016] [Indexed: 12/16/2022]
Abstract
STUDY OBJECTIVE Postdural puncture headache (PDPH) is the most common symptom of accidental dural puncture, a frequent complication of intraspinal anesthesia. We developed a postoperative intervention technique to prevent and treat PDPH in accidental dural puncture patients, including epidural pumping of saline. This retrospective study aimed to retrospectively evaluate this new technique for PDPH prevention and treatment. DESIGN Retrospective study. SETTING Beijing Obstetrics and Gynecology Hospital affiliated to the Capital Medical University, between January 2006 and December 2012. PATIENTS Eighty-seven cases undergoing intraspinal anesthesia were assessed. INTERVENTIONS Of these patients, 68 cases had successful repuncture and were assigned to group A (epidural filling group, n=68), receiving continuous epidural pumping of 0.9% NS (150mL) at a rate of 6mL/h; the remaining cases were assigned to group B (conservative therapy group, n=19). MEASUREMENTS Age, height, and body weight were collected, and postoperative headache was assessed using a visual analog scale. MAIN RESULTS Of 68 patients in group A, 49 (72.1%) developed PDPH, whereas all in group B developed PDPH (P=.009). In addition, all patients showed PDPH within 3days after surgery regardless of treatment group. However, a statistically significant difference was obtained for PDPH duration between groups A and B (P<.001). Multivariate logistic regression analysis showed that frequency of epidural puncture and continuous epidural pumping of saline were significant risk factors for PDPH. CONCLUSIONS Our data indicated that application of 6mL/h saline effectively contributes to PDPH management, and its clinical application should be broadened.
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Affiliation(s)
- Xiangming Che
- Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing 100006, China.
| | - Wenyu Zhang
- Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing 100006, China
| | - Mingjun Xu
- Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing 100006, China
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Arevalo-Rodriguez I, Ciapponi A, Roqué i Figuls M, Muñoz L, Bonfill Cosp X. Posture and fluids for preventing post-dural puncture headache. Cochrane Database Syst Rev 2016; 3:CD009199. [PMID: 26950232 PMCID: PMC6682345 DOI: 10.1002/14651858.cd009199.pub3] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Post-dural puncture headache (PDPH) is a common complication of lumbar punctures. Several theories have identified the leakage of cerebrospinal fluid (CSF) through the hole in the dura as a cause of this side effect. It is therefore necessary to take preventive measures to avoid this complication. Prolonged bed rest has been used to treat PDPH once it has started, but it is unknown whether prolonged bed rest can also be used to prevent it. Similarly, the value of administering fluids additional to those of normal dietary intake to restore the loss of CSF produced by the puncture is unknown. This review is an update of a previously published review in the Cochrane Database of Systematic Reviews (Issue 7, 2013) on "Posture and fluids for preventing post-dural puncture headache". OBJECTIVES To assess whether prolonged bed rest combined with different body and head positions, as well as administration of supplementary fluids after lumbar puncture, prevent the onset of PDPH in people undergoing lumbar puncture for diagnostic or therapeutic purposes. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and LILACS, as well as trial registries up to February 2015. SELECTION CRITERIA We identified randomized controlled trials that compared the effects of bed rest versus immediate mobilization, head-down tilt versus horizontal position, prone versus supine positions during bed rest, and administration of supplementary fluids versus no/less supplementation, as prevention measures for PDPH in people who have undergone lumbar puncture. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the studies for eligibility through the web-based software EROS (Early Review Organizing Software). Two different review authors independently assessed risk of bias using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions. We resolved any disagreements by consensus. We extracted data on cases of PDPH, severe PDPH, and any headache after lumbar puncture and performed intention-to-treat analyses and sensitivity analyses by risk of bias. We assessed the evidence using GRADE (Grading of Recommendations Assessment, Development and Evaluation) and created a 'Summary of findings' table. MAIN RESULTS We included 24 trials with 2996 participants in this updated review. The number of participants in each trial varied from 39 to 382. Most of the included studies compared bed rest versus immediate mobilization, and only two assessed the effects of supplementary fluids versus no supplementation. We judged the overall risk of bias of the included studies as low to unclear. The overall quality of evidence was low to moderate, downgraded because of the risk of bias assessment in most cases. The primary outcome in our review was the presence of PDPH.There was low quality evidence for an absence of benefits associated with bed rest compared with immediate mobilization on the incidence of severe PDPH (risk ratio (RR) 0.98; 95% confidence interval (CI) 0.68 to 1.41; participants = 1568; studies = 9) and moderate quality evidence on the incidence of any headache after lumbar puncture (RR 1.16; 95% CI 1.02 to 1.32; participants = 2477; studies = 18). Furthermore, bed rest probably increased PDPH (RR 1.24; 95% CI 1.04 to 1.48; participants = 1519; studies = 12) compared with immediate mobilization. An analysis restricted to the most methodologically rigorous trials (i.e. those with low risk of bias in allocation method, missing data and blinding of outcome assessment) gave similar results. There was low quality evidence for an absence of benefits associated with fluid supplementation on the incidence of severe PDPH (RR 0.67; 95% CI 0.26 to 1.73; participants = 100; studies = 1) and PDPH (RR 1; 95% CI 0.59 to 1.69; participants = 100; studies = 1), and moderate quality evidence on the incidence of any headache after lumbar puncture (RR 0.94; 95% CI 0.66 to 1.34; participants = 200; studies = 2). We did not expect other adverse events and did not assess them in this review. AUTHORS' CONCLUSIONS Since the previous version of this review, we found one new study for inclusion, but the conclusion remains unchanged. We considered the quality of the evidence for most of the outcomes assessed in this review to be low to moderate. As identified studies had shortcomings on aspects related to randomization and blinding of outcome assessment, we therefore downgraded the quality of the evidence. In general, there was no evidence suggesting that routine bed rest after dural puncture is beneficial for the prevention of PDPH onset. The role of fluid supplementation in the prevention of PDPH remains unclear.
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Affiliation(s)
- Ingrid Arevalo-Rodriguez
- Division of Research, Fundación Universitaria de Ciencias de la Salud - Hospital de San José/Hospital Infantil de San José, Carrera 19 Nº 8a - 32, Bogotá D.C., Colombia, 11001
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Uyar Türkyilmaz E, Camgöz Eryilmaz N, Aydin Güzey N, Moraloğlu Ö. Bilateral greater occipital nerve block for treatment of post-dural puncture headache after caesarean operations. Braz J Anesthesiol 2016; 66:445-50. [PMID: 27591456 DOI: 10.1016/j.bjane.2015.03.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Revised: 03/12/2015] [Accepted: 03/23/2015] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND Post-dural puncture headache (PDPH) is an important complication of neuroaxial anesthesia and more frequently noted in pregnant women. The pain is described as severe, disturbing and its location is usually fronto-occipital. The conservative treatment of PDPH consists of bed rest, fluid theraphy, analgesics and caffeine. Epidural blood patch is gold standard theraphy but it is an invasive method. The greater occipital nerve (GON) is formed of sensory fibers that originate in the C2 and C3 segments of the spinal cord and it is the main sensory nerve of the occipital region. GON blockage has been used for the treatment of many kinds of headache. The aim of this retrospective study is to present the results of PDPH treated with GON block over 1 year period in our institute. METHODS 16 patients who had been diagnosed to have PDPH, and performed GON block after caesarean operations were included in the study. GON blocks were performed as the first treatment directly after diagnose of the PDPH with levobupivacaine and dexamethasone. RESULTS The mean VAS score of the patients was 8.75 (±0.93) before the block; 3.87 (±1.78) 10min after the block; 1.18 (±2.04) 2h after the block and 2.13 (±1.64) 24h after the block. No adverse effects were observed. CONCLUSIONS Treatment of PDPH with GON block seems to be a minimal invasive, easy and effective method especially after caesarean operations. A GON block may be considered before the application of a blood patch.
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Affiliation(s)
- Esra Uyar Türkyilmaz
- Zekai Tahir Burak Womens' Health Training and Research Hospital, Department of Anesthesiology and Reanimation, Ankara, Turkey.
| | - Nuray Camgöz Eryilmaz
- Zekai Tahir Burak Womens' Health Training and Research Hospital, Department of Anesthesiology and Reanimation, Ankara, Turkey
| | - Nihan Aydin Güzey
- Zekai Tahir Burak Womens' Health Training and Research Hospital, Department of Anesthesiology and Reanimation, Ankara, Turkey
| | - Özlem Moraloğlu
- Zekai Tahir Burak Womens' Health Training and Research Hospital, Department of Obstetrics and Gynecology, Ankara, Turkey
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Sjövall S, Kokki M, Turunen E, Laisalmi M, Alahuhta S, Kokki H. Postdural puncture headache and epidural blood patch use in elderly patients. J Clin Anesth 2015; 27:574-8. [DOI: 10.1016/j.jclinane.2015.07.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Revised: 04/28/2015] [Accepted: 07/14/2015] [Indexed: 10/23/2022]
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Abstract
BACKGROUND This is an updated version of the original Cochrane review published in Issue 8, 2011, on 'Drug therapy for treating post-dural puncture headache'.Post-dural puncture headache (PDPH) is the most common complication of lumbar puncture, an invasive procedure frequently performed in the emergency room. Numerous pharmaceutical drugs have been proposed to treat PDPH but there are still some uncertainties about their clinical effectiveness. OBJECTIVES To assess the effectiveness and safety of drugs for treating PDPH in adults and children. SEARCH METHODS The searches included the Cochrane Central Register of Controlled Trials (CENTRAL 2014, Issue 6), MEDLINE and MEDLINE in Process (from 1950 to 29 July 2014), EMBASE (from 1980 to 29 July 2014) and CINAHL (from 1982 to July 2014). There were no language restrictions. SELECTION CRITERIA We considered randomised controlled trials (RCTs) assessing the effectiveness of any pharmacological drug used for treating PDPH. Outcome measures considered for this review were: PDPH persistence of any severity at follow-up (primary outcome), daily activity limited by headache, conservative supplementary therapeutic option offered, epidural blood patch performed, change in pain severity scores, improvements in pain severity scores, number of days participants stay in hospital, any possible adverse events and missing data. DATA COLLECTION AND ANALYSIS Review authors independently selected studies, assessed risk of bias and extracted data. We estimated risk ratios (RR) for dichotomous data and mean differences (MD) for continuous outcomes. We calculated a 95% confidence interval (CI) for each RR and MD. We did not undertake meta-analysis because the included studies assessed different sorts of drugs or different outcomes. We performed an intention-to-treat (ITT) analysis. MAIN RESULTS We included 13 small RCTs (479 participants) in this review (at least 274 participants were women, with 118 parturients after a lumbar puncture for regional anaesthesia). In the original version of this Cochrane review, only seven small RCTs (200 participants) were included. Pharmacological drugs assessed were oral and intravenous caffeine, subcutaneous sumatriptan, oral gabapentin, oral pregabalin, oral theophylline, intravenous hydrocortisone, intravenous cosyntropin and intramuscular adrenocorticotropic hormone (ACTH).Two RCTs reported data for PDPH persistence of any severity at follow-up (primary outcome). Caffeine reduced the number of participants with PDPH at one to two hours when compared to placebo. Treatment with caffeine also decreased the need for a conservative supplementary therapeutic option.Treatment with gabapentin resulted in better visual analogue scale (VAS) scores after one, two, three and four days when compared with placebo and also when compared with ergotamine plus caffeine at two, three and four days. Treatment with hydrocortisone plus conventional treatment showed better VAS scores at six, 24 and 48 hours when compared with conventional treatment alone and also when compared with placebo. Treatment with theophylline showed better VAS scores compared with acetaminophen at two, six and 12 hours and also compared with conservative treatment at eight, 16 and 24 hours. Theophylline also showed a lower mean "sum of pain" when compared with placebo. Sumatriptan and ACTH did not show any relevant effect for this outcome.Theophylline resulted in a higher proportion of participants reporting an improvement in pain scores when compared with conservative treatment.There were no clinically significant drug adverse events.The rest of the outcomes were not reported by the included RCTs or did not show any relevant effect. AUTHORS' CONCLUSIONS None of the new included studies have provided additional information to change the conclusions of the last published version of the original Cochrane review. Caffeine has shown effectiveness for treating PDPH, decreasing the proportion of participants with PDPH persistence and those requiring supplementary interventions, when compared with placebo. Gabapentin, hydrocortisone and theophylline have been shown to decrease pain severity scores. Theophylline has also been shown to increase the proportion of participants that report an improvement in pain scores when compared with conventional treatment.There is a lack of conclusive evidence for the other drugs assessed (sumatriptan, adrenocorticotropic hormone, pregabalin and cosyntropin).These conclusions should be interpreted with caution, due to the lack of information to allow correct appraisal of risk of bias, the small sample sizes of the studies and also their limited generalisability, as nearly half of the participants were postpartum women in their 30s.
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Affiliation(s)
- Xavier Basurto Ona
- Emergency Department, Hospital de Figueres, Fundació Salut Empordà, Rda Rector Aroles s/n, Figueres, Girona-Catalunya, Spain, 17600
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38
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Kapoor SG, Ahmed S. Cervical epidural blood patch--A literature review. PAIN MEDICINE 2015; 16:1897-904. [PMID: 26122010 DOI: 10.1111/pme.12793] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Epidural blood patches (EBP) are rarely performed at the cervical levels, primarily due to fear of neurological complications such as spinal cord compression. We reviewed the literature to provide an evidence-based review of performance of cervical EBPs, with a specific focus on indication, technique, safety, and efficacy. DESIGN A comprehensive electronic literature search was done to include studies that reported on performance of cervical EBPs in patients with CSF leak at the cervical level. Data regarding indication, level of CSF leak, level of cervical EBP, volume of blood used, efficacy, and complications were collected. RESULTS A total of 15 studies, reporting on 19 patients were included. All patients presented with a headache that increased in the standing position, and improved in the supine position. All patients were identified to have a CSF leak at the cervical level. Eight patients first underwent a lumbar EBP, without complete, long-term relief. All these patients, along with 11 patients who did not undergo a lumbar EPB prior to cervical EBP, reported complete, long-term pain relief. EBPs were mostly done in the prone position, using imaging guidance. An average of 5-8 mL of autologous blood was injected in the epidural space. No major neurological complications were reported in any patient. CONCLUSION The review suggests that cervical EBP can be performed for cervical CSF leaks associated with positional headache without a significant risk of serious adverse events. CLASSIFICATION OF EVIDENCE Our review provides Class II level of evidence that cervical EBPs are safe and effective in reliving positional headache due to CSF leak.
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Affiliation(s)
- Shruti G Kapoor
- Department of Anesthesiology, Stony Brook University, Stony Brook, New York, USA
| | - Shihab Ahmed
- Department of anethesia, critical care and pain medicine, Harvard Medical School, Boston, Massachusetts, USA
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Omole OB, Ogunbanjo GA. Postdural puncture headache: evidence-based review for primary care. S Afr Fam Pract (2004) 2015. [DOI: 10.1080/20786190.2015.1014154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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40
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Chronic headache and backache are long-term sequelae of unintentional dural puncture in the obstetric population. J Clin Anesth 2015; 27:201-6. [DOI: 10.1016/j.jclinane.2014.07.008] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 07/07/2014] [Accepted: 07/10/2014] [Indexed: 11/17/2022]
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Abstract
In this review article the clinical manifestations, imaging findings, diagnostic and therapeutic approaches for intracranial hypotension are described. The typical manifestation, orthostatic headache, may sometimes be masked by atypical manifestations including coma, frontotemporal dementia and symptoms associated with leptomeningeal hemosiderosis. Spinal and cranial magnetic resonance imaging (MRI) findings are not always unequivocal and the diagnostic and therapeutic approaches are controversially discussed: Searching for the underlying spinal leak(s) of cerebral spinal fluid (CSF) is considered to be unnecessary or done with different modalities, such as computed tomography (CT) myelography, gadolinium-enhanced myelography and digital subtraction myelography. Various treatment approaches including conservative therapy, blind, fluoroscopy-guided and CT-guided epidural blood patches, CT-guided fibrin injection and surgery exist.
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Affiliation(s)
- H Urbach
- Klinik für Neuroradiologie, Universitätsklinikum Freiburg, Breisacher Str. 64, 79106, Freiburg, Deutschland,
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Pratt SD, Kaczka DW, Hess PE. Observational study of changes in epidural pressure and elastance during epidural blood patch in obstetric patients. Int J Obstet Anesth 2014; 23:144-50. [PMID: 24631062 DOI: 10.1016/j.ijoa.2014.01.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2013] [Revised: 12/16/2013] [Accepted: 01/17/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND During an epidural blood patch, we inject blood until the patient describes mild back pressure, often leading to injection of more than 20 mL of blood. We undertook this study to measure the epidural pressures generated during an epidural blood patch and to identify the impact of volume on epidural elastance in obstetric patients. METHODS This study was performed in postpartum patients who presented for an epidural blood patch with symptoms consistent with a postdural puncture headache. After identification of the epidural space using loss of resistance to air or saline, we measured static epidural pressure after each 5-mL injection of blood. Models were then fitted to the data and the epidural elastance and compliance calculated. RESULTS Eighteen blood patches were performed on 17 patients. The mean final volume injected was 18.9±7.8 mL [range 6-38 mL]. The mean final pressure generated was 13.1±13.4 mmHg [range 2-56 mmHg]. A curvilinear relationship existed between volume injected and pressure, which was described by two models: (1) pressure=0.0254×(mL injected)(2)+0.0297 mL, or (2) pressure=0.0679×mL(1.742). The value for r2 was approximately 0.57 for both models. We found no correlation between the final pressure generated and the success of the epidural blood patch. CONCLUSIONS We found a curvilinear relationship between the volume of blood injected during an epidural blood patch and the pressure generated in the epidural space. However, there was a large variation in both the volume of blood and the epidural pressure generated. The clinical importance of this finding is not known. A larger study would be required to demonstrate whether pressure is a predictor of success.
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Affiliation(s)
- S D Pratt
- Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA.
| | - D W Kaczka
- Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - P E Hess
- Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA
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Arevalo-Rodriguez I, Muñoz L, Arevalo JJ, Ciapponi A, Roqué i Figuls M. Needle gauge and tip designs for preventing post-dural puncture headache (PDPH). Cochrane Database Syst Rev 2013. [DOI: 10.1002/14651858.cd010807] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Arevalo-Rodriguez I, Ciapponi A, Munoz L, Roqué i Figuls M, Bonfill Cosp X. Posture and fluids for preventing post-dural puncture headache. Cochrane Database Syst Rev 2013:CD009199. [PMID: 23846960 DOI: 10.1002/14651858.cd009199.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Post-dural puncture headache (PDPH) is a common complication of lumbar punctures. Several theories have identified the leakage of cerebrospinal fluid (CSF) through the hole in the dura as a cause of this side effect. Therefore, it is necessary to take preventive measures to avoid this complication. Prolonged bed rest has been used as a therapeutic measure once PDPH has started, but it is unknown if it can be also be used to prevent it. Similarly, the value of administering fluids additional to those of normal dietary intake to restore the loss of CSF produced by the puncture is unknown. OBJECTIVES To assess whether prolonged bed rest combined with different body and head positions, as well as administration of supplementary fluids after lumbar puncture, prevent the onset of PDPH in people undergoing lumbar puncture for diagnostic or therapeutic purposes. SEARCH METHODS We searched the Cochrane Controlled Trials Register, MEDLINE, EMBASE, and LILACS up to June 2013. SELECTION CRITERIA We identified randomized controlled trials (RCTs) that compared the effects of bed rest versus early/immediate mobilization, head-down tilt versus horizontal position, prone versus supine positions during bed rest, and administration of supplementary fluids versus no/less supplementation, as prevention measures for PDPH in people who have undergone lumbar puncture. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the studies for eligibility through the web-based software EROS (Early Review Organizing Software). Two different review authors independently assessed risk of bias using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions. We solved any disagreements by consensus. We extracted data on cases of PDPH, severe PDPH, and any headache after lumbar puncture and performed intention-to-treat analyses and sensitivity analyses by risk of bias. MAIN RESULTS We included 23 trials (2477 participants) in this review. There was no beneficial effect associated with bed rest compared with immediate mobilization on the incidence of PDPH (risk for bed rest 26.4%; risk for mobilization 20.5%; risk ratio (RR) 1.30; 95% confidence interval (CI) 1.09 to 1.55), severe PDPH (risk for bed rest 10.6%; risk for mobilization 10.7%; RR 1.00; 95% CI 0.75 to 1.32), and presence of any headache after lumbar puncture (risk for bed rest 33.6%; risk for mobilization 28.6%; RR 1.18; 95% CI 1.05 to 1.32). Analyses restricted to the most methodologically rigorous trials gave similar results. Likewise, the two trials that assessed fluid supplementation did not find this preventive measure to be useful in the prevention of PDPH. AUTHORS' CONCLUSIONS There is no evidence from RCTs that suggests that routine bed rest after dural puncture is beneficial for the prevention of PDPH onset. The role of fluid supplementation in the prevention of PDPH remains unclear.
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Affiliation(s)
- Ingrid Arevalo-Rodriguez
- Division of Research, Fundación Universitaria de Ciencias de la Salud, Hospital de San José/ Hospital Infantil de San José, BogotáD.C., Colombia.
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BRADBURY CL, SINGH SI, BADDER SR, WAKELY LJ, JONES PM. Prevention of post-dural puncture headache in parturients: a systematic review and meta-analysis. Acta Anaesthesiol Scand 2013; 57:417-30. [PMID: 23278515 DOI: 10.1111/aas.12047] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2012] [Indexed: 02/01/2023]
Abstract
Post-dural puncture headaches (PDPHs) present an important clinical problem. We assessed methods to decrease accidental dural punctures (ADPs) and interventions to reduce PDPH following ADP. Multiple electronic databases were searched for randomised clinical trials (RCTs) of parturients having labour epidurals, in which the studied intervention could plausibly affect ADP or PDPH, and the incidence of at least one of these was recorded. Forty RCTs (n = 11,536 epidural insertions) were included, studying combined spinal-epidurals (CSEs), loss of resistance medium, prophylactic epidural blood patches, needle bevel orientation, ultrasound-guided insertion, epidural morphine, Special Sprotte needles, acoustic-guided insertion, administration of cosyntropin, and continuous spinal analgesia. The RCTs for CSE, loss of resistance medium, and prophylactic epidural blood patches were meta-analysed. Five methods reduced PDPH: prophylactic epidural blood patch {four trials, median quality score = 2, risk difference = -0.48 [95% confidence interval (CI): -0.88 to -0.086]}, lateral positioning of the epidural needle bevel upon insertion (one trial, quality score = 1), Special Sprotte needles [one trial, quality score = 5, risk difference = -0.44 (95% CI: -0.67 to -0.21)], epidural morphine [one trial, quality score = 4, risk difference = -0.36 (95% CI -0.59 to -0.13)], and cosyntropin [one trial, quality score = 5, risk difference = -0.36 (95% CI -0.55 to -0.16)]. Several methods potentially reduce PDPH. Special Sprotte needles, epidural morphine, and cosyntropin are thus far each supported by a single, albeit good quality trial. Prophylactic blood patches are supported by three trials, but these had flawed methodology. Mostly, trials were of limited quality, and further well-conducted, large studies are needed.
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Affiliation(s)
- C. L. BRADBURY
- Department of Anesthesia & Perioperative Medicine; Schulich School of Medicine & Dentistry; St Joseph's Health Care London; London; ON; Canada
| | - S. I. SINGH
- Department of Anesthesia & Perioperative Medicine; Schulich School of Medicine & Dentistry; St Joseph's Health Care London; London; ON; Canada
| | - S. R. BADDER
- Department of Anesthesia & Perioperative Medicine; Schulich School of Medicine & Dentistry; St Joseph's Health Care London; London; ON; Canada
| | - L. J. WAKELY
- Department of Anesthesia & Perioperative Medicine; Schulich School of Medicine & Dentistry; St Joseph's Health Care London; London; ON; Canada
| | - P. M. JONES
- Department of Anesthesia & Perioperative Medicine; Schulich School of Medicine & Dentistry; St Joseph's Health Care London; London; ON; Canada
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Basurto Ona X, Uriona Tuma SM, Martínez García L, Solà I, Bonfill Cosp X. Drug therapy for preventing post-dural puncture headache. Cochrane Database Syst Rev 2013; 2013:CD001792. [PMID: 23450533 PMCID: PMC8406520 DOI: 10.1002/14651858.cd001792.pub3] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Post-dural (post-lumbar or post-spinal) puncture headache (PDPH) is one of the most common complications of diagnostic, therapeutic or inadvertent lumbar punctures. Many drug options have been used to prevent headache in clinical practice and have also been tested in some clinical studies, but there are still some uncertainties about their clinical effectiveness. OBJECTIVES To assess the effectiveness and safety of drugs for preventing PDPH in adults and children. SEARCH METHODS The search strategy included the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library 2012, Issue 5), MEDLINE (from 1950 to May 2012), EMBASE (from 1980 to May 2012) and CINAHL (from 1982 to June 2012). There was no language restriction. SELECTION CRITERIA We considered randomised controlled trials (RCTs) that assessed the effectiveness of any drug used for preventing PDPH. DATA COLLECTION AND ANALYSIS Review authors independently selected studies, assessed risks of bias and extracted data. We estimated risk ratios (RR) for dichotomous data and mean differences (MD) for continuous outcomes. We calculated a 95% confidence interval (CI) for each RR and MD. We did not undertake meta-analysis because participants' characteristics or assessed doses of drugs were too different in the included studies. We performed an intention-to-treat (ITT) analysis. MAIN RESULTS We included 10 RCTs (1611 participants) in this review with a majority of women (72%), mostly parturients (women in labour) (913), after a lumbar puncture for regional anaesthesia. Drugs assessed were epidural and spinal morphine, spinal fentanyl, oral caffeine, rectal indomethacin, intravenous cosyntropin, intravenous aminophylline and intravenous dexamethasone.All the included RCTs reported data on the primary outcome, i.e. the number of participants affected by PDPH of any severity after a lumbar puncture. Epidural morphine and intravenous cosyntropin reduced the number of participants affected by PDPH of any severity after a lumbar puncture when compared to placebo. Also, intravenous aminophylline reduced the number of participants affected by PDPH of any severity after a lumbar puncture when compared to no intervention, while intravenous dexamethasone increased it. Spinal morphine increased the number of participants affected by pruritus when compared to placebo, and epidural morphine increased the number of participants affected by nausea and vomiting when compared to placebo. Oral caffeine increased the number of participants affected by insomnia when compared to placebo.The remainder of the interventions analysed did not show any relevant effect for any of the outcomes.None of the included RCTs reported the number of days that patients stayed in hospital. AUTHORS' CONCLUSIONS Morphine and cosyntropin have shown effectiveness for reducing the number of participants affected by PDPH of any severity after a lumbar puncture, when compared to placebo, especially in patients with high risk of PDPH, such as obstetric patients who have had an inadvertent dural puncture. Aminophylline also reduced the number of participants affected by PDPH of any severity after a lumbar puncture when compared to no intervention in patients undergoing elective caesarean section. Dexamethasone increased the risk of PDPH, after spinal anaesthesia for caesarean section, when compared to placebo. Morphine also increased the number of participants affected by adverse events (pruritus and nausea and vomiting)There is a lack of conclusive evidence for the other drugs assessed (fentanyl, caffeine, indomethacin and dexamethasone).These conclusions should be interpreted with caution, owing to the lack of information, to allow correct appraisal of risk of bias and the small sample sizes of studies.
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Affiliation(s)
- Xavier Basurto Ona
- Emergency Department, Hospital de Figueres, Fundació Salut Empordà, Figueres, Spain.
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Simmons SW, Taghizadeh N, Dennis AT, Hughes D, Cyna AM. Combined spinal-epidural versus epidural analgesia in labour. Cochrane Database Syst Rev 2012; 10:CD003401. [PMID: 23076897 PMCID: PMC7154384 DOI: 10.1002/14651858.cd003401.pub3] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Traditional epidural techniques have been associated with prolonged labour, use of oxytocin augmentation and increased incidence of instrumental vaginal delivery. The combined spinal-epidural (CSE) technique has been introduced in an attempt to reduce these adverse effects. CSE is believed to improve maternal mobility during labour and provide more rapid onset of analgesia than epidural analgesia, which could contribute to increased maternal satisfaction. OBJECTIVES To assess the relative effects of CSE versus epidural analgesia during labour. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (28 September 2011) and reference lists of retrieved studies. We updated the search on 30 June 2012 and added the results to the awaiting classification section. SELECTION CRITERIA All published randomised controlled trials (RCTs) involving a comparison of CSE with epidural analgesia initiated for women in the first stage of labour. Cluster-randomised trials were considered for inclusion. Quasi RCTs and cross-over trials were not considered for inclusion in this review. DATA COLLECTION AND ANALYSIS Three review authors independently assessed the trials identified from the searches for inclusion, assessed trial quality and extracted the data. Data were checked for accuracy. MAIN RESULTS Twenty-seven trials involving 3274 women met our inclusion criteria. Twenty-six outcomes in two sets of comparisons involving CSE versus traditional epidurals and CSE versus low-dose epidural techniques were analysed.Of the CSE versus traditional epidural analyses five outcomes showed a significant difference. CSE was more favourable in relation to speed of onset of analgesia from time of injection (mean difference (MD) -2.87 minutes; 95% confidence interval (CI) -5.07 to -0.67; two trials, 129 women); the need for rescue analgesia (risk ratio (RR) 0.31; 95% CI 0.14 to 0.70; one trial, 42 women); urinary retention (RR 0.86; 95% CI 0.79 to 0.95; one trial, 704 women); and rate of instrumental delivery (RR 0.81; 95% CI 0.67 to 0.97; six trials, 1015 women). Traditional epidural was more favourable in relation to umbilical venous pH (MD -0.03; 95% CI -0.06 to -0.00; one trial, 55 women). There were no data on maternal satisfaction, blood patch for post dural puncture headache, respiratory depression, umbilical cord pH, rare neurological complications, analgesia for caesarean section after analgesic intervention or any economic/use of resources outcomes for this comparison. No differences between CSE and traditional epidural were identified for mobilisation in labour, the need for labour augmentation, the rate of caesarean birth, incidence of post dural puncture headache, maternal hypotension, neonatal Apgar scores or umbilical arterial pH.For CSE versus low-dose epidurals, three outcomes were statistically significant. Two of these reflected a faster onset of effective analgesia from time of injection with CSE and the third was of more pruritus with CSE compared to low-dose epidural (average RR 1.80; 95% CI 1.22 to 2.65; 11 trials, 959 women; random-effects, T² = 0.26, I² = 84%). There was no significant difference in maternal satisfaction (average RR 1.01; 95% CI 0.98 to 1.05; seven trials, 520 women; random-effects, T² = 0.00, I² = 45%). There were no data on respiratory depression, maternal sedation or the need for labour augmentation. No differences between CSE and low-dose epidural were identified for need for rescue analgesia, mobilisation in labour, incidence of post dural puncture headache, known dural tap, blood patch for post dural headache, urinary retention, nausea/vomiting, hypotension, headache, the need for labour augmentation, mode of delivery, umbilical pH, Apgar score or admissions to the neonatal unit. AUTHORS' CONCLUSIONS There appears to be little basis for offering CSE over epidurals in labour, with no difference in overall maternal satisfaction despite a slightly faster onset with CSE and conversely less pruritus with low-dose epidurals. There was no difference in ability to mobilise, maternal hypotension, rate of caesarean birth or neonatal outcome. However, the significantly higher incidence of urinary retention, rescue interventions and instrumental deliveries with traditional techniques would favour the use of low-dose epidurals. It is not possible to draw any meaningful conclusions regarding rare complications such as nerve injury and meningitis.
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Affiliation(s)
- Scott W Simmons
- Department of Anaesthesia,MercyHospital forWomen,Heidelberg, Australia.
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Affiliation(s)
- Saowarat Snidvongs
- Pain Fellow and Specialist Registrar in Anaesthesia, Boyle's Department of Anaesthesia, St Bartholomew's Hospital , London EC1A 7BE , UK
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Fiala A, Baumgartner E, Paal P. Reply from the authors. Br J Anaesth 2012. [DOI: 10.1093/bja/aes246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Marr R, Kapoor A, Redfern N. Epidural blood patch is the gold standard treatment for dural puncture headache. Br J Anaesth 2012; 109:288-9; author reply 289. [DOI: 10.1093/bja/aes240] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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