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Griffiths SK, Russell R, Broom MA, Devroe S, Van de Velde M, Lucas DN. Intrathecal catheter placement after inadvertent dural puncture in the obstetric population: management for labour and operative delivery. Guidelines from the Obstetric Anaesthetists' Association. Anaesthesia 2024; 79:1348-1368. [PMID: 39327940 DOI: 10.1111/anae.16434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2024] [Indexed: 09/28/2024]
Abstract
BACKGROUND Anaesthetists of all grades who work on a labour ward are likely to be involved in the insertion or management of an intrathecal catheter after inadvertent dural puncture at some point in their careers. Although the use of intrathecal catheters after inadvertent dural puncture in labour has increased in popularity over recent decades, robust evidence on best practice has been lacking. METHODS The Obstetric Anaesthetists' Association set up an expert working party to review the literature. A modified Delphi approach was used to produce statements and recommendations on insertion and management of intrathecal catheters for labour and operative delivery following inadvertent dural puncture during attempted labour epidural insertion. Statements and recommendations were graded according to the US Preventive Services Task Force grading methodology. RESULTS A total of 296 articles were identified in the initial literature search. Further screening identified 111 full text papers of relevance. A structured narrative review was produced which covered insertion of an intrathecal catheter; initial dosing; maintenance of labour analgesia; topping-up for operative delivery; safety features; complications; and recommended follow-up. The working party agreed on 17 statements and 26 recommendations. These were generally assigned a low or moderate level of certainty. The safety of mother and baby were a key priority in producing these guidelines. CONCLUSIONS With careful management, intrathecal catheters can provide excellent labour analgesia and may also be topped-up to provide anaesthesia for caesarean or operative vaginal delivery. The use of intrathecal catheters, however, also carries the risk of significant drug errors which may result in high- or total-spinal anaesthesia, or even cardiorespiratory arrest. It is vital that all labour wards have clear guidelines on the use of these catheters, and that staff are educated as to their potential complications.
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MESH Headings
- Humans
- Pregnancy
- Female
- Anesthesia, Obstetrical/adverse effects
- Anesthesia, Obstetrical/methods
- Analgesia, Obstetrical/adverse effects
- Analgesia, Obstetrical/methods
- Delivery, Obstetric/adverse effects
- Spinal Puncture/adverse effects
- Spinal Puncture/methods
- Dura Mater/injuries
- Labor, Obstetric
- Anesthesia, Spinal/adverse effects
- Catheterization/adverse effects
- Catheterization/methods
- Injections, Spinal/adverse effects
- Analgesia, Epidural/adverse effects
- Analgesia, Epidural/instrumentation
- Analgesia, Epidural/methods
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Affiliation(s)
- Sarah K Griffiths
- Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Robin Russell
- Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Malcolm A Broom
- Department of Anaesthesia, Glasgow Royal Infirmary and Princess Royal Maternity Hospital, Glasgow, UK
| | - Sarah Devroe
- Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium
- Department of Anaesthesiology, University Hospital Gasthuisberg, Leuven, Belgium
| | - Marc Van de Velde
- Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium
- Department of Anaesthesiology, University Hospital Gasthuisberg, Leuven, Belgium
| | - D N Lucas
- Department of Anaesthesia, London North West University Healthcare NHS Trust, London, UK
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Orbach-Zinger S, Jadon A, Lucas DN, Sia AT, Tsen LC, Van de Velde M, Heesen M. Intrathecal catheter use after accidental dural puncture in obstetric patients: literature review and clinical management recommendations. Anaesthesia 2021; 76:1111-1121. [PMID: 33476424 DOI: 10.1111/anae.15390] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2020] [Indexed: 01/20/2023]
Abstract
If an accidental dural puncture occurs, one option is to insert a catheter and use it as an intrathecal catheter. This avoids the need for a further injection and can rapidly provide labour analgesia and anaesthesia for caesarean section. However, there are no recommendations for managing intrathecal catheters and, therefore, significant variation in clinical practice exists. Mismanagement of the intrathecal catheter can lead to increased motor block, high spinal anaesthesia, drug error, hypotension and fetal bradycardia. Care must be taken with an intrathecal catheter to adhere to strict aseptic technique, meticulous labelling, cautious administration of medications and good communication with the patient and other staff. Every institution considering the use of intrathecal catheters should establish a protocol. For labour analgesia, we recommend the use of dilute local anaesthetic agents and opioids. For caesarean section anaesthesia, gradual titration to the level of the fourth thoracic dermatome, with full monitoring, in a facility equipped to manage complications, should be performed using local anaesthetics combined with lipophilic opioids and morphine or diamorphine. Although evidence of the presence and duration of intrathecal catheters on the development of post-dural puncture headache and need for epidural blood patch is limited, we suggest considering leaving the intrathecal catheter in for 24 hours to reduce the chance of developing a post-dural puncture headache while maintaining precautions to avoid drug error and cerebrospinal fluid leakage. Injection of sterile normal saline into the intrathecal catheter may reduce post-dural puncture headache. The level of evidence for these recommendations was low.
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Affiliation(s)
- S Orbach-Zinger
- Department of Anaesthesia, Rabin Medical Centre, Beilinson Hospital, Petach Tikvah, Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
| | - A Jadon
- Tata Motors Hospital, Jamshedpur, Jharkhand, India.,Anaesthesia, Pain Relief Service, Department of Anaesthesia and Pain Relief Service, Jata Motors Hospital, Jamshedpur, Jharkhand, India
| | - D N Lucas
- LNWH NHS Trust, Harrow, UK.,Department of Anaesthesia, London North West University Healthcare NHS Trust, London, UK
| | - A T Sia
- Department of Women's Anaesthesia, KK Women and Children Hospital, Singapore, Anaesthesiology Program, Duke-NUS Graduate Medical School, Singapore
| | - L C Tsen
- Harvard Medical School, Department of Anesthesiology, Peri-operative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - M Van de Velde
- Department of Cardiovascular Sciences, KU Leuven, Belgium.,Department of Anesthesiology, UZ Leuven, Leuven, Belgium
| | - M Heesen
- Department of Anaesthesia, Kantonsspital Baden, Baden, Switzerland
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Heesen M, Hilber N, Rijs K, van der Marel C, Rossaint R, Schäffer L, Klimek M. Intrathecal catheterisation after observed accidental dural puncture in labouring women: update of a meta-analysis and a trial-sequential analysis. Int J Obstet Anesth 2019; 41:71-82. [PMID: 31522933 DOI: 10.1016/j.ijoa.2019.08.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 07/11/2019] [Accepted: 08/05/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Our meta-analysis from 2013 showed that inserting a catheter intrathecally after an observed accidental dural puncture can reduce the need for epidural blood patch in labouring women requesting epidural analgesia. We updated our conventional meta-analysis and added a trial-sequential analysis (TSA). METHODS A systematic literature search was conducted to identify studies that compared inserting the catheter intrathecally with an epidural catheter re-site or with no intervention. The extracted data were pooled and the risk ratio (RR) and 95% confidence interval (95%CI) for the incidence of post-dural puncture headache (PDPH) was calculated, using the random effects model. A contour-enhanced funnel plot was constructed. A TSA was performed and the cumulative Z score, monitoring and futility boundaries were constructed. RESULTS Our search identified 13 studies, reporting on 1653 patients, with a low risk of bias. The RR for the incidence of PDPH was 0.82 (95%CI 0.71 to 0.95) and the RR for the need for epidural blood patch was 0.62 (95%CI 0.49 to 0.79); heterogeneity of both analyses was high. The TSA showed that the monitoring or futility boundaries were not crossed, indicating insufficient data to exclude a type I error of statistical analysis. Contour-enhanced funnel plots were symmetric, suggesting no publication bias. CONCLUSIONS Conventional meta-analyses showed for the first time that intrathecal catheterisation can reduce the incidence of PDPH. However, TSA did not corroborate this finding. Despite increasing use in clinical practice there is no firm evidence on which to base a definite conclusion.
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Affiliation(s)
- M Heesen
- Department of Anaesthesia, Kantonsspital Baden, Baden, Switzerland.
| | - N Hilber
- Department of Anaesthesia, Kantonsspital Baden, Baden, Switzerland
| | - K Rijs
- Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - C van der Marel
- Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - R Rossaint
- Department of Anaesthesiology, University Hospital RWTH Aachen, Aachen, Germany
| | - L Schäffer
- Department of Obstetrics, Kantonsspital Baden, Baden, Switzerland
| | - M Klimek
- Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
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