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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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Xue X, Song J, Liang Q, Qin J. Bacterial Infection in Deep Paraspinal Muscles in a Parturient Following Epidural Analgesia: A Case Report and Literature Review: A CARE-Compliant Article. Medicine (Baltimore) 2015; 94:e2149. [PMID: 26683923 PMCID: PMC5058895 DOI: 10.1097/md.0000000000002149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Bacterial infection related to epidural catheterizations could occur. In general, the incidence of postoperative infection at the insertion site is very low. Paucity literatures are reported for paraspinal muscle infection after epidural analgesia in parturient. We report a case of paraspinal muscle infection shortly after epidural analgesia in a parturient, who was subjected to because of threatened preterm labor. Epidural morphine was administered for 2 days for childbirth pain control. She began to have constant low-back pain and fever on postpartum Day 2. Magnetic resonance image revealed a broad area of subcutaneous edema with a continuum along the catheter trajectory deep to the paraspinal muscles. A catheter-related bacterial infection was suspected. The surgical debridement and drainage was required combined with intravenous antibiotics on postpartum Day 3. She was soon cured uncomplicatedly. Epidural analgesia is effective to control labor pain and, in general, it is safe. However, the sequelae of complicated infection may be underestimated. A literature search yielded 7 other cases of catheter-related epidural abscess or soft tissue infection. Vigilance for these infections, especially in postpartum patients with backache, is needed. Moreover, early detection and proper treatment of infectious signs at postanesthetic visit are very important.
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Affiliation(s)
- Xuhong Xue
- From the Department of Orthopedics, The Second Hospital, Shanxi Medical University (XXH); Department of Orthopedics, Shanxi Provincial People's Hospital, Shanxi Medical University (SJF); Department of Orthopedics, Shanxi Provincial People's Hospital, Shanxi Medical University (LQY); and Department of Orthopedics, Shanxi Provincial People's Hospital, Shanxi Medical University, Taiyuan, Shanxi, P.R. China (QJB)
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Abstract
Infection is the commonest cause of serious neurologic sequelae of neuraxial anesthesia. The incidence depends on operator skill and patient population. Meningitis, a complication of dural puncture, is usually caused by viridans streptococci. The risk factors are dural puncture during labor, no mask and poor aseptic technique, vaginal infection and bacteremia. Epidural abscess is a complication of epidural catheterization, route of entry the catheter track and the organism usually the staphylococcus. Principal risk factors are prolonged catheterization, poor aseptic technique and traumatic insertion. Prevention includes wearing a mask, using a full sterile technique, avoiding prolonged catheterization and prescribing antibiotics in a high-risk situation.
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Cummings KC, Dolak JA. Case report: Epidural abscess in a parturient with pruritic urticarial papules and plaques of pregnancy (PUPPP). Can J Anaesth 2006; 53:1010-4. [PMID: 16987856 DOI: 10.1007/bf03022530] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
PURPOSE To describe the risk factors for epidural abscess (EA) formation following epidural analgesia in a parturient with pruritic urticarial papules and plaques of pregnancy (PUPPP). CLINICAL FEATURES A 33 yr-old gravida 2 nulliparous patient at 36 weeks gestation presented with severe pre-eclampsia, and PUPPP (treated with prednisone). Magnesium prophylaxis was started and labour was induced. An epidural catheter was placed at the L(3-4) level using standard aseptic technique. Bupivacaine was incrementally injected to achieve a T10 sensory level, and analgesia was maintained using a continuous infusion of 0.0625% bupivacaine with fentanyl. Nine days post-delivery, the patient developed back pain radiating to her right leg, but she was otherwise asymptomatic. She was afebrile; with a slightly tender, non-erythematous, non-draining, 1 cm nodule at the epidural catheter site. Motor and sensory examinations were normal at that time. However, the patient returned 24 hr later and further investigations revealed: WBC 17,800.mm(-3), platelets 486,000.mm(-3), erythrocyte sedimentation rate 50 mm.hr(-1), and C-reactive protein 8.8 mg.dL(-1). The magnetic resonance imaging demonstrated an EA at the L(3-4) level causing minimal cord compression. The patient underwent an emergency decompressive laminectomy. Cultures revealed methicillin-sensitive Staphylococcus aureus. Her pain improved, and she was discharged on the third postoperative day with a six-week course of iv ceftriaxone. CONCLUSION Causative organisms for EAs include coagulase-negative Staphylococci, S. aureus, and Gram-negative bacilli. Infection can occur either hematogenously or by direct contamination during catheter placement. Risk factors include immunocompromised states and PUPPP, as with the case of this patient.
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Affiliation(s)
- Kenneth C Cummings
- Department of Regional Practice Anesthesiology, Hillcrest Hospital, 6780 Mayfield Road, Mayfield Heights, Ohio 44124, USA.
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Jo DH, Hong JH, Kim MH. An Analysis of Infection-Related Complications after Epidural Block. Korean J Pain 2006. [DOI: 10.3344/kjp.2006.19.2.164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Dae Hyun Jo
- Pain Clinic, Bundang CHA Medical Center, College of Medicine, Pochon Jung Moon University, Seongnam, Korea
| | - Ji Hee Hong
- Pain Clinic, Bundang CHA Medical Center, College of Medicine, Pochon Jung Moon University, Seongnam, Korea
| | - Myuong Hee Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, Pochon Jung Moon University, Seongnam, Korea
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Chiang HL, Chia YY, Chen YS, Hung CC, Liu K, Lo Y. Epidural abscess in an obstetric patient with patient-controlled epidural analgesia – a case report. Int J Obstet Anesth 2005; 14:242-5. [PMID: 15993774 DOI: 10.1016/j.ijoa.2004.11.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2004] [Revised: 11/01/2004] [Accepted: 11/01/2004] [Indexed: 11/28/2022]
Abstract
We present the case of a 37-year-old pregnant woman who underwent a cesarean section due to previous cesarean delivery. Spinal anesthesia was performed at the L2-3 intervertebral space with an epidural catheter inserted at L1-2 for postoperative patient-controlled epidural analgesia. When the epidural catheter was removed on day three, an area of redness round the entry point was noted and the patient complained of low back pain, but was discharged from hospital. Later the same day, she felt backache so severe that she was unable to stand up or bend her body. She called for help and was sent to our emergency room. Physicians noted a small amount of discharge from the insertion site, and the body temperature was elevated to 38 degrees C. An anesthesiologist and an infectious disease specialist were consulted, and an epidural abscess was suspected. Urgent magnetic resonance imaging revealed an epidural abscess at L1-2. After five days of unsuccessful treatment with oxacillin, a 28-day course of vancomycin, followed by two months of oral fusidic acid, resulted in complete remission of the epidural abscess. The patient has remained free of neurologic deficit.
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Affiliation(s)
- H L Chiang
- Department of Anesthesiology, Kaohsiung Veterans General Hospital and School of Medicine, National Yang-Ming University, Taiwan
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Tsen LC. What’s new and novel in obstetric anesthesia? Contributions from the 2003 scientific literature. Int J Obstet Anesth 2005; 14:126-46. [PMID: 15795148 DOI: 10.1016/j.ijoa.2004.12.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2004] [Accepted: 12/24/2004] [Indexed: 10/25/2022]
Abstract
THE PREGNANT PATIENT: Age; maternal disease; prophylactic antibiotics; gastroesophageal reflux; obesity; starvation; genotyping; coagulopathy; infection; substance abuse; altered drug responses in pregnancy; physiological changes of pregnancy. THE FETUS: Fetal monitoring; intrauterine surgery. THE NEWBORN: Breastfeeding; maternal infection, fever, and neonatal sepsis evaluation. OBSTETRIC COMPLICATIONS: Embolic phenomena; hemorrhage; preeclampsia; preterm delivery. OBSTETRIC MANAGEMENT: External cephalic version and cervical cerclage; elective cesarean delivery; fetal malpresentation; vaginal birth after cesarean delivery; termination of pregnancy. OBSTETRIC ANESTHESIA: Analgesia for labor and delivery; anesthesia for cesarean delivery; anesthesia for short obstetric operations; complications of anesthesia. MISCELLANEOUS: Consent; ethics; history; labor support; websites/books/leaflets/journal announcements.
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Affiliation(s)
- L C Tsen
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston MA 02115, USA.
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