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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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Thon JN, Weigand MA, Kranke P, Siegler BH. Efficacy of therapies for post dural puncture headache. Curr Opin Anaesthesiol 2024; 37:219-226. [PMID: 38372283 PMCID: PMC11062605 DOI: 10.1097/aco.0000000000001361] [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] [Indexed: 02/20/2024]
Abstract
PURPOSE OF REVIEW Clinical management of postdural puncture headache (PDPH) remains an interdisciplinary challenge with significant impact on both morbidity and quality of life. This review aims to give an overview of the most recent literature on prophylactic and therapeutic measures and to discuss novel findings with regard to currently published consensus practice guideline recommendations. RECENT FINDINGS Although current evidence does not support a recommendation of any specific prophylactic measure, new data is available on the use of intrathecal catheters to prevent PDPH and/or to avoid invasive procedures. In case of disabling or refractory symptoms despite conservative treatments, the epidural blood patch (EBP) remains the therapeutic gold standard and its use should not be delayed in the absence of contraindications. However, recent clinical studies and meta-analyses provide additional findings on the therapeutic use of local anesthetics as potential noninvasive alternatives for early symptom control. SUMMARY There is continuing research focusing on both prophylactic and therapeutic measures offering promising data on potential alternatives to invasive procedures, although there is currently no treatment option that comes close to the effectiveness of an EBP. A better understanding of PDPH pathophysiology is not only necessary to identify new therapeutic targets, but also to recognize patients who benefit most from current treatments, as this might enhance their therapeutic efficacy.
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Affiliation(s)
- Jan N. Thon
- Heidelberg University, Medical Faculty Heidelberg, Department of Anesthesiology, Im Neuenheimer Feld 420, Heidelberg, Germany
| | - Markus A. Weigand
- Heidelberg University, Medical Faculty Heidelberg, Department of Anesthesiology, Im Neuenheimer Feld 420, Heidelberg, Germany
| | - Peter Kranke
- Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital, Würzburg University Hospital, Würzburg, Bavaria, Germany
| | - Benedikt H. Siegler
- Heidelberg University, Medical Faculty Heidelberg, Department of Anesthesiology, Im Neuenheimer Feld 420, Heidelberg, Germany
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Moaveni D, Toledo P. Programmed Intermittent Intrathecal Bolus for Maintenance of Labor Analgesia in an Obstetric Patient: A Case Report. A A Pract 2023; 17:e01739. [PMID: 38088757 DOI: 10.1213/xaa.0000000000001739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Maintenance of labor analgesia with programmed intermittent epidural boluses (PIEBs) has demonstrated benefits over the use of continuous infusions. While programmed intermittent boluses have been used for the maintenance of epidural analgesia, it has not been reported for the maintenance of intrathecal analgesia. Approximately 25% of intrathecal catheters (ITC) ultimately fail, often due to inadequate analgesic coverage. We describe the use of programmed intermittent intrathecal boluses for a laboring parturient who received an ITC. She reported excellent pain relief without significant motor block, high anesthetic block, hypotension, or respiratory distress. This delivery modality may increase the rate of ITC after unintentional dural puncture (UDP).
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Affiliation(s)
- Daria Moaveni
- From the Department of Anesthesiology, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, Florida
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Sugita M, Shimizu K, Hirata N. Continuous Spinal Anesthesia for Labor Analgesia and Cesarean Delivery in a Parturient With Familial Dilated Cardiomyopathy: A Case Report. Cureus 2023; 15:e48877. [PMID: 38111452 PMCID: PMC10726073 DOI: 10.7759/cureus.48877] [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: 11/16/2023] [Indexed: 12/20/2023] Open
Abstract
We report a case of successful continuous spinal anesthesia (CSA) for labor analgesia and cesarean delivery in a patient with familial dilated cardiomyopathy (DCM). A 33-year-old pregnant woman diagnosed with DCM was scheduled for a vaginal delivery under labor analgesia. An accidental intrathecal catheter was placed, and labor analgesia was provided by CSA. The vaginal delivery was converted to a cesarean delivery, and an intrathecal catheter was used for transition, which avoided hemodynamic changes and allowed the patient to safely undergo cesarean delivery. CSA is a reliable and rapidly titratable technique that provides excellent analgesia without hemodynamic changes in patients with DCM undergoing labor analgesia and subsequent cesarean delivery.
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Affiliation(s)
- Michiko Sugita
- Department of Anesthesiology, Kumamoto University Hospital, Kumamoto, JPN
| | - Kazuko Shimizu
- Department of Anesthesiology, Kumamoto University Hospital, Kumamoto, JPN
| | - Naoyuki Hirata
- Department of Anesthesiology, Kumamoto University Hospital, Kumamoto, JPN
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Taraskiewicz D, Sheeran J, De Marco P, Tiouririne M, Elkassabany N. Etiology, management, and sequela of postdural puncture headache. Curr Opin Anaesthesiol 2023; 36:565-571. [PMID: 37552012 DOI: 10.1097/aco.0000000000001286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
PURPOSE The purpose of this article is to provide readers with a concise overview of the cause, incidence, treatment of, and sequalae of postdural puncture headaches (PDPH). Over the past 2 years, much data has been published on modifiable risk factors for PDPH, treatments for PDPH, and sequalae of PDPH particularly long-term. RECENT FINDINGS There is emerging data about how modifiable risk factors for PDPH are not as absolute as once believed. There have been several new meta-analysis and clinical trials published, providing more data about effective therapies for PDPH. Significantly, much recent data has come out about the sequalae, particularly long-term of dural puncture. SUMMARY Emerging evidence demonstrates that in patients who are at low risk of PDPH, needle type and gauge may be of no consequence in a patient developing a PDPH. Although epidural blood patch (EBP) remains the gold-standard of therapy, several other interventions, both medical and procedural, show promise and may obviate the need for EBP in patients with mild-moderate PDPH. Patients who endure dural puncture, especially accidental dural puncture (ADP) are at low but significant risk of developing short term issues as well as chronic pain symptoms.
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Affiliation(s)
- Daniel Taraskiewicz
- Department of Anesthesiology, University of Virginia, School of Medicine, Hospital of the University of Virginia, Virginia, USA
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Binyamin Y, Azem K, Heesen M, Gruzman I, Frenkel A, Fein S, Eidelman LA, Garren A, Frank D, Orbach-Zinger S. The effect of placement and management of intrathecal catheters following accidental dural puncture on the incidence of postdural puncture headache and severity: a retrospective real-world study. Anaesthesia 2023; 78:1256-1261. [PMID: 37439056 DOI: 10.1111/anae.16088] [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: 05/29/2023] [Indexed: 07/14/2023]
Abstract
Accidental dural puncture during an attempt to establish labour epidural analgesia can result in postdural puncture headache and long-term debilitating conditions. Epidural blood patch, the gold standard treatment for this headache, is invasive and not always successful. Inserting an intrathecal catheter after accidental dural puncture may prevent postdural puncture headache. We evaluated the effect of intrathecal catheter insertion on the incidence of postdural puncture headache and the need for epidural blood patch and whether duration of intrathecal catheterisation or injection of intrathecal saline affected outcome. Our retrospective study was conducted at two tertiary, university-affiliated medical centres between 2017 and 2022 and included 92,651 epidurals and 550 cases of accidental dural puncture (0.59%); 219 parturients (39.8%) received an intrathecal catheter and 331 (60.2%) a resited epidural. Use of an intrathecal catheter versus resiting the epidural did not decrease the odds of postdural puncture headache, adjusted odds ratio (aOR) (95%CI) 0.91 (0.81-1.01), but was associated with a lower need for epidural blood patch (aOR (95%CI) 0.82 (0.73-0.91), p < 0.001). We found no benefit in leaving in the intrathecal catheter for 24 h postpartum (postdural puncture headache, aOR (95%CI) 1.01 (1.00-1.02), p = 0.015; epidural blood patch, aOR (95%CI) 1.00 (0.99-1.01), p = 0.40). We found an added benefit of injecting intrathecal saline as it decreased the incidence of postdural puncture headache (aOR (95%CI) 0.85 (0.73-0.99), p = 0.04) and the need for epidural blood patch (aOR (95%CI) 0.75 (0.64-0.87), p < 0.001). Our study confirms the benefits of intrathecal catheterisation and provides guidance on how to best manage an intrathecal catheter.
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Affiliation(s)
- Y Binyamin
- Department of Anaesthesia, Soroka University Medical Center and the Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Karam Azem
- Department of Anaesthesia, Beilinson Hospital, Rabin Medical Center Associated with Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
| | - M Heesen
- Department of Anaesthesia, Kantonsspital Baden, Baden, Switzerland
| | - I Gruzman
- Department of Anaesthesia, Soroka University Medical Center and the Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - A Frenkel
- Department of Anaesthesia, Soroka University Medical Center and the Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - S Fein
- Department of Anaesthesia, Beilinson Hospital, Rabin Medical Center Associated with Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
| | - L A Eidelman
- Department of Anaesthesia, Assuta Medical Center, Ashdod, Israel
| | - A Garren
- Columbia University, New York, NY, USA
| | - D Frank
- Department of Anaesthesia, Soroka University Medical Center and the Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - S Orbach-Zinger
- Department of Anaesthesia, Beilinson Hospital, Rabin Medical Center Associated with Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
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Broom MA. Intrathecal catheterisation after accidental dural puncture: real-world data, real-world benefits and real-world barriers. Anaesthesia 2023; 78:1195-1198. [PMID: 37553790 DOI: 10.1111/anae.16116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2023] [Indexed: 08/10/2023]
Affiliation(s)
- M A Broom
- Department of Anaesthesia, Glasgow Royal Infirmary and Princess Royal Maternity Hospital, Glasgow, UK
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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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Creazzola F, Aversano M, Prencipe F, Barelli R, Pasqualetti P, Simonelli I, Frigo MG. Effective prevention of post-dural puncture headache with insertion of an intrathecal catheter in parturients: a retrospective study and meta-analysis. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE (ONLINE) 2023; 3:22. [PMID: 37475027 DOI: 10.1186/s44158-023-00107-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 07/05/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND Accidental dural puncture is a common complication of labour analgesia. It can trigger post-dural puncture headache, with associated morbidity and increased costs. Intrathecal catheter placement is a prophylactic procedure which can reduce incidence and severity of post-dural puncture headache. METHODS We conducted a retrospective single-centred study to define incidence and risk factors of accidental dural puncture and post-dural puncture headache in an obstetric population. We also evaluated effectiveness of intrathecal catheter placement compared to epidural catheter replacement in reducing incidence of post-dural puncture headache. We then conducted a systematic review and meta-analysis which included all studies comparing intrathecal catheter placement to epidural catheter replacement in obstetric patients with accidental dural puncture assessing the outcome of reduced incidence of post-dural puncture headache as a dichotomous variable. RESULTS Accidental dural puncture had an incidence of 0.25% (60 cases). Of these, 66% developed post-dural puncture headache. A total of 77% (47/60) of patients with accidental dural puncture were treated with an intrathecal catheter placement, while 23% (13/60) had an epidural catheter replacement. Incidence of post-dural puncture headache was lower in the intrathecal catheter group (spinal 26/47, 60.5% epidural 11/13, 84.6%), although not reaching statistical significance (RR 0.71, CI 95%: 0.51-1.00; p = 0.049). The meta-analysis revealed that intrathecal catheter placement significantly reduced incidence of post-dural puncture headache compared to epidural catheter replacement (pooled RR 0.81, 95% CI 0.72-0.91, p < 0.001). CONCLUSIONS Intrathecal catheter placement is a promising measure to prevent post-dural puncture headache, especially if followed by a pain management protocol and a continuous saline infusion.
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Affiliation(s)
- F Creazzola
- Obstetric Anaesthesia, San Camillo Forlanini Hospital, Circonvallazione Gianicolense 87, 00152, Rome, RM, Italy
| | - M Aversano
- Obstetric Anaesthesia and Intensive Care Departmental Unit, Fatebenefratelli Gemelli Isola - Isola Tiberina Hospital, Via Di Ponte Quattro Capi 39, Rome, RM, 00186, Italy.
| | - F Prencipe
- Obstetric Anaesthesia and Intensive Care Departmental Unit, Fatebenefratelli Gemelli Isola - Isola Tiberina Hospital, Via Di Ponte Quattro Capi 39, Rome, RM, 00186, Italy
| | - R Barelli
- Anaesthesia and Intensive Care Unit, Sant'Eugenio Hospital, Piazzale Dell'Umanesimo 10, 00144, Rome, RM, Italy
| | - P Pasqualetti
- Service of Medical Statistics and Information Technology, Fatebenefratelli Foundation for Health Research and Education, Via Di Ponte Quattro Capi 39, 00186, Rome, RM, Italy
| | - I Simonelli
- Service of Medical Statistics and Information Technology, Fatebenefratelli Foundation for Health Research and Education, Via Di Ponte Quattro Capi 39, 00186, Rome, RM, Italy
| | - M G Frigo
- Obstetric Anaesthesia and Intensive Care Departmental Unit, Fatebenefratelli Gemelli Isola - Isola Tiberina Hospital, Via Di Ponte Quattro Capi 39, Rome, RM, 00186, Italy
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10
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Yan M, Wang Q, Zhang Y, Sun Y, Sun J. Post-dural puncture headache accompanied by obvious nasal congestion: A case report. Medicine (Baltimore) 2023; 102:e34078. [PMID: 37327260 PMCID: PMC10270513 DOI: 10.1097/md.0000000000034078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 06/02/2023] [Indexed: 06/18/2023] Open
Abstract
INTRODUCTION Post-dural puncture headache (PDPH) is the most common complication of intraspinal nerve block in gravida. PDPH may be accompanied by neck stiffness, tinnitus, hearing loss, photophobia or nausea. PATIENT CONCERNS A 33-year-old woman whose dura was accidentally punctured during labor analgesia complained of severe headache, dizziness, and nasal congestion; these symptoms aggravated when she looked up, and her sense of smell was normal 8 hours after catheter removal. DIAGNOSES Based on the patient's complaints and clinical appearance, diagnosis of PDPH was considered. INTERVENTIONS Nasal congestion disappeared with headache and dizziness after epidural injections of saline. The puerpera received saline injections 4 times; after treatment, she was discharged from the hospital when the symptoms did not limit her daily movement. OUTCOMES The symptoms disappeared completely on the seventh day of telephone follow-up visit. The mechanism of her nasal obstruction is not very clear. CONCLUSION We believe it is caused by the pulling of the intracranial nerve as the brain tissue sinks and shifts due to the decrease in intracranial pressure.
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Affiliation(s)
- Ming Yan
- Department of Anesthesiology, The Huai’an Maternity and Child Clinical College of Xuzhou Medical University (Huai’ an maternal and child health care center), Huaian, China
| | - Qiao Wang
- Department of Anesthesiology, The Huai’an Maternity and Child Clinical College of Xuzhou Medical University (Huai’ an maternal and child health care center), Huaian, China
| | - Yufeng Zhang
- Department of Anesthesiology, The Huai’an Maternity and Child Clinical College of Xuzhou Medical University (Huai’ an maternal and child health care center), Huaian, China
| | - Yue Sun
- Department of Anesthesiology, The Huai’an Maternity and Child Clinical College of Xuzhou Medical University (Huai’ an maternal and child health care center), Huaian, China
| | - Jian Sun
- Department of Anesthesiology, The Huai’an Maternity and Child Clinical College of Xuzhou Medical University (Huai’ an maternal and child health care center), Huaian, China
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11
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Schyns-van den Berg AM, Gupta A. Postdural puncture headache - revisited. Best Pract Res Clin Anaesthesiol 2023. [DOI: 10.1016/j.bpa.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
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Hu F, Zou L, Chang H, Tian L, Liu F, Lan Y, Zhang F, Liu X. Comparison of effectiveness, cost and safety between moderate sedation and deep sedation under esophagogastroduodenoscopy in Chinese population: a quasi-experimental study. Scand J Gastroenterol 2022; 57:1105-1111. [PMID: 35403537 DOI: 10.1080/00365521.2022.2060050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Most endoscopists routinely perform moderate or deep sedation for esophagogastroduodenoscopy (EGD). Considering that there is no consensus on the optimal sedation depth and it varies from country to country, our study aims to compare the effectiveness, cost and safety of these two sedation methods in the Chinese population. METHODS This quasi-experimental study included a total of 556 eligible patients from July 2020 to June 2021, and they entered the moderate sedation group or deep sedation group based on their choices. Baseline information, scores of Patient Satisfaction with Sedation Instrument (PSSI) and Clinician Satisfaction with Sedation Instrument (CSSI), examination time, sedation time, recovery time, expenses before medicare reimbursement, hypoxaemia and hypotension were compared between the two groups. Propensity Score Matching (PSM) analysis was conducted to balance the confounding factors. RESULTS After PSM, 470 patients were involved in the analysis, with 235 for each group. The moderate sedation was clearly superior to the deep sedation group in terms of PSSI score (98.00 ± 0.94 vs. 97.29 ± 1.26), CSSI score (98.00 ± 0.78 vs. 97.67 ± 1.30), sedation time (11.90 ± 2.04 min vs. 13.21 ± 2.75 min), recovery time (25.40 ± 3.77 min vs. 28.0 ± 4.85 min), expenses (433.04 ± 0.00 Yuan vs. 789.85 ± 0.21 Yuan), with all p < .001. Examination time was not significantly different between the two groups (p = .124). In addition, the moderate sedation group had a lower occurrence rate of hypoxaemia (0.36% vs. 3.27%, p = .010) and hypotension (17.44% vs. 44.00%, p < .001) compared to the deep sedation group. CONCLUSIONS Moderate sedation presented better effectiveness and safety and lower cost, and thereby it should be recommended as a widely used sedation method in clinical practice in China. Trial registration: This trial was registered on http://www.chictr.org.cn/index.aspx (ChiCTR2000038050).
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Affiliation(s)
- Feng Hu
- Department of Gastroenterology, Shangluo Central Hospital, Shangluo, P. R. China
| | - Long Zou
- Department of Gastroenterology, Shangluo Central Hospital, Shangluo, P. R. China
| | - Hongxia Chang
- Department of Anesthesiology, Shangluo Central Hospital, Shangluo, P. R. China
| | - Lin Tian
- Department of Gastroenterology, Shangluo Central Hospital, Shangluo, P. R. China
| | - Fanrong Liu
- Endoscopy Department of Gastroenterology, Shangluo Central Hospital, Shangluo, P. R. China
| | - Ya Lan
- Department of Gastroenterology, Shangluo Central Hospital, Shangluo, P. R. China
| | - Fangxin Zhang
- Department of Gastroenterology, Xi'an International Medical Center Hospital, Xi'an, P. R. China
| | - Xiao Liu
- Department of Gastroenterology, Xi'an International Medical Center Hospital, Xi'an, P. R. China
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13
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Siegler BH, Oehler B, Kranke P, Weigand MA. [Postdural puncture headache in obstetrics : Pathogenesis, diagnostics and treatment]. DIE ANAESTHESIOLOGIE 2022; 71:646-660. [PMID: 35925200 DOI: 10.1007/s00101-022-01171-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/22/2022] [Indexed: 06/15/2023]
Abstract
Postdural puncture headache (PDPH) is one of the most important complications of peripartum neuraxial analgesia. Loss of cerebrospinal fluid volume and pressure as well as compensatory intracranial vasodilation are assumed to be responsible. Potentially severe long-term sequelae necessitate the correct diagnosis of PDPH, exclusion of relevant differential diagnoses (with atypical symptoms and when indicated via imaging techniques) and rapid initiation of effective treatment. Nonopioid analgesics, caffeine and occasionally theophylline, gabapentin and hydrocortisone are the cornerstones of pharmacological treatment, while the timely placement of an autologous epidural blood patch (EBP) represents the gold standard procedure when symptoms persist despite the use of analgesics. Procedures using neural treatment are promising alternatives, especially when an EBP is not desired by the patient or is contraindicated. Interdisciplinary and interprofessional consensus standard procedures can contribute to optimization of the clinical management of this relevant complication.
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Affiliation(s)
- Benedikt Hermann Siegler
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Deutschland.
| | - Beatrice Oehler
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Deutschland
| | - Peter Kranke
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Deutschland
| | - Markus Alexander Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Deutschland
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14
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Chau A, Tsen L. Neuraxial labor analgesia: Initiation techniques. Best Pract Res Clin Anaesthesiol 2022; 36:3-15. [PMID: 35659957 DOI: 10.1016/j.bpa.2022.04.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 04/06/2022] [Accepted: 04/12/2022] [Indexed: 11/16/2022]
Abstract
The ideal technique for labor analgesia would have a quick onset, predictable quality, and adjustable depth and duration. Moreover, it would be easy to perform and have minimal maternal and fetal side effects. A catheter-based neuraxial approach encompasses these desirable characteristics and includes the epidural, combined spinal epidural, dural puncture epidural, and intrathecal catheter techniques. In this review, we outline the unique technical considerations, analgesic characteristics, and side effect profiles for each technique that can ultimately impact the maternal-fetal dyad. The selection of neuraxial analgesia techniques should consider the patient and team's goals and expectations, the clinical context, and the institutional culture. Labor analgesic techniques that initiate with an intentional dural puncture component have a faster onset, greater bilateral and sacral spread, and lower rates of epidural catheter failure. Further elucidation of the mechanisms, benefits, and risks of each neuraxial initiation technique will continue to benefit patients and care providers.
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Affiliation(s)
- Anthony Chau
- BC Women's Hospital, Department of Anesthesia, Vancouver, BC, Canada; Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Lawrence Tsen
- Brigham and Women's Hospital, Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Boston, MA, USA.
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15
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Recognized and unrecognized dural punctures in 12,981 labor epidurals: an audit of management. J Anesth 2022; 36:399-404. [PMID: 35474399 PMCID: PMC9156467 DOI: 10.1007/s00540-022-03062-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Accepted: 04/01/2022] [Indexed: 10/31/2022]
Abstract
PURPOSE Unintentional dural puncture (DP) and post-dural puncture headache (PDPH) continue to cause discomfort and disability in a small proportion of post-partum women. We report an audit of the management of recognized and unrecognized DP over 10 years. METHODS Clinical data were prospectively collected for women who experienced a recognized DP or developed symptoms following a neuraxial procedure. Details were documented regarding patient characteristics, the neuraxial procedure, symptoms reported, and epidural blood patches. We reported rates of recognized DP, unrecognized DP, PDPH, and blood patches performed. Data were presented as number (percent) and proportions of interest compared using Chi square analysis. RESULTS Between January 2009 and December 2018, 12,981 women utilized labor epidural analgesia. A recognized DP occurred in 131 (1.0%) and an unrecognized DP in 60 (0.5%), with unrecognized DPs comprising 31% of the total. Of 131 recognized punctures, 86 (66%) developed a PDPH. A total of 146 (1.1%) women experienced a PDPH. Of those, a blood patch was performed in 93 (64%). Intrathecal catheters were inserted for > 24 h in 43 (33%) women with a recognized DP. Of those, 33 (77%) developed a PDPH, compared to 53 (60%) of those without an intrathecal catheter in situ for > 24 h (P = 0.06). CONCLUSIONS Rates of DP were consistent with those reported by others. Unrecognized DP comprised a third of all DP, and systematic post-neuraxial follow-up is essential to identify these women. Epidural blood patch was performed in most women experiencing symptoms of PDPH.
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16
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Niraj G, Mushambi M, Gauthama P, Patil A, Kelkar A, Hart E, Nurmikko T. Persistent headache and low back pain after accidental dural puncture in the obstetric population: a prospective, observational, multicentre cohort study. Anaesthesia 2021; 76:1068-1076. [PMID: 33891312 DOI: 10.1111/anae.15491] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2021] [Indexed: 11/30/2022]
Abstract
Accidental dural puncture following epidural insertion can cause a post-dural headache that is defined by the International Headache Society as self-limiting. We aimed to confirm if accidental dural puncture could be associated with persistent headache and back pain when compared with matched control parturients. We performed a prospective multicentre cohort study evaluating the incidence of persistent headache following accidental dural puncture at nine UK obstetric units. Parturients who sustained an accidental dural puncture were matched with controls who had undergone an uneventful epidural insertion. Participants were followed-up at six-monthly intervals for 18 months. Primary outcome was the incidence of persistent headache at 18 months. Ninety parturients who had an accidental dural puncture were matched with 180 controls. The complete dataset for primary analysis was available for 256 (95%) participants. Incidence of persistent headache at 18 months was 58.4% (52/89) in the accidental puncture group and 17.4% (29/167) in the control group, odds ratio (95%CI) 18.4 (6.0-56.7), p < 0.001, after adjustment for past history of headache, Hospital Anxiety and Depression Scale (depression) and Hospital Anxiety and Depression Scale (anxiety) scores. Incidence of low back pain at 18 months was 48.3% (43/89) in the accidental puncture group and 17.4% (29/167) in the control group, odds ratio (95%CI) 4.14 (2.11-8.13), with adjustment. We have demonstrated that accidental dural puncture is associated with long-term morbidity including persistent headache in parturients. This challenges the current definition of post-dural puncture headache as a self-limiting condition and raises possible clinical, financial and medicolegal consequences.
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Affiliation(s)
- G Niraj
- Department of Anaesthesia, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - M Mushambi
- Department of Anaesthesia, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - P Gauthama
- Department of Anaesthesia, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - A Patil
- Department of Anaesthesia, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - A Kelkar
- Department of Anaesthesia, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - E Hart
- Department of Anaesthesia, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - T Nurmikko
- The Walton Centre NHS Foundation Trust, Liverpool, UK
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17
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Song LL, Zhou Y, Geng ZY. Epidural analgesia followed by epidural hydroxyethyl starch prevented post-dural puncture headache: Twenty case reports and a review of the literature. World J Clin Cases 2021; 9:1946-1952. [PMID: 33748246 PMCID: PMC7953408 DOI: 10.12998/wjcc.v9.i8.1946] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 11/27/2020] [Accepted: 12/16/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Accidental dural puncture (ADP) and subsequent post-dural puncture headache (PDPH) remain common complications of epidural procedures for obstetric anesthesia and analgesia. No clear consensus exists on the best way to prevent PDPH after ADP.
CASE SUMMARY We report our findings in twenty parturients who underwent an incorporated strategy of epidural analgesia followed by epidural hydroxyethyl starch (HES) to prevent PDPH after ADP with a 16-gauge Tuohy needle during epidural procedures. ADP with a 16-gauge Tuohy needle occurred in nine parturients undergoing a cesarean section (CS) and in eleven parturients receiving labor analgesia. An epidural catheter was re-sited at the same or adjacent intervertebral space in all patients. After CS, the epidural catheter was used for postoperative pain relief over a 48-h period. After delivery in eleven cases, epidural infusion was maintained for 24 h. Thereafter, 15 mL of 6% HES 130/0.4 was administered via the epidural catheter immediately prior to catheter removal. None of the parturients developed PDPH or neurologic deficits over a follow-up period of at least two months to up to one year postpartum.
CONCLUSION An incorporated strategy of epidural analgesia followed by epidural hydroxyethyl starch may have great efficacy in preventing PDPH after ADP.
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Affiliation(s)
- Lin-Lin Song
- Department of Anesthesiology, Peking University First Hospital, Beijing 100034, China
| | - Yin Zhou
- Department of Anesthesiology, Peking University First Hospital, Beijing 100034, China
| | - Zhi-Yu Geng
- Department of Anesthesiology, Peking University First Hospital, Beijing 100034, China
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18
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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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19
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Moaveni D. Management of intrathecal catheters in the obstetric patient. BJA Educ 2021; 20:216-219. [PMID: 33456953 DOI: 10.1016/j.bjae.2020.02.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2020] [Indexed: 11/17/2022] Open
Affiliation(s)
- D Moaveni
- University of Miami/Jackson Memorial Hospital, Miami, FL, USA
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20
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Columb MO, Cochrane NE, Thompson EL. Forest plots and deforestation: time to save the trees! Int J Obstet Anesth 2020; 45:14-16. [PMID: 33358636 DOI: 10.1016/j.ijoa.2020.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 10/20/2020] [Accepted: 11/01/2020] [Indexed: 01/17/2023]
Affiliation(s)
- M O Columb
- Department of Anaesthesia and Intensive Care Medicine Manchester University Foundation NHS Trust Wythenshawe Hospital, Manchester, UK.
| | - N E Cochrane
- Department of Intensive Care Medicine and Anaesthesia, NIHR Academic Clinical Fellow in Intensive Care Medicine, Manchester University Foundation NHS Trust Wythenshawe Hospital, UK
| | - E L Thompson
- Department of Anaesthesia, Manchester University Foundation NHS Trust, Wythenshawe Hospital, Manchester, UK
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