Prolonged intrathecal catheterisation after inadvertent dural taps in labour

Lower incidence of post-dural puncture headache with spinal catheterization after accidental dural puncture in obstetric patients

BACKGROUND

Accidental dural puncture (ADP) and post-dural puncture headache (PDPH) are important complications of obstetric regional anesthesia. Inserting the catheter intrathecally after ADP to prevent PDPH has gained popularity. Nonetheless, data on the effect of an intrathecal catheter on PDPH and epidural blood patch (EBP) rates are mixed. Our primary objective was to examine if spinal catheterization reduces the incidence of PDPH after ADP in obstetric patients.

METHODS

Anesthetic records of 29,749 regional blocks performed between January 1997 and July 2013 were analyzed retrospectively. In all blocks containing an epidural component, 18-gauge epidural needles were used. All patients who experienced a witnessed ADP or PDPH without ADP were identified. Data from patients with or without a prolonged spinal catheter were compared.

RESULTS

There were 128 events of witnessed ADP (0.43%). Following known ADP, 39 women had an epidural catheter placed at a different level and 89 had an intrathecal catheter (20-gauge) for at least 24 h. Sixty-one patients developed PDPH after observed ADP (48%). Prolonged intrathecal catheter placement significantly reduced the incidence of PDPH after ADP to 42% compared with 62% in those who have the catheter re-sited epidurally [odds ratio = 2.3 (95% confidence interval 1.04-4.86); P = 0.04].

CONCLUSIONS

The incidence of ADP, PDPH and blood patching is similar with previously published studies. After witnessed ADP, inserting the epidural catheter intrathecally significantly reduced the incidence of PDPH.

Anesthesia complications in the birthplace: is the neuraxial block always to blame?

This article highlights the common and some of the very serious complications that may occur following neuraxial analgesia for labor and delivery, including headache, backache, infection, hypotension, and hematoma. Total spinal and failed block also are discussed, as are complications unique to epidural anesthesia, such as the intravascular injection of large volumes of local anesthetic (causing seizure or cardiac arrest) and accidental dural puncture.

Immediate management of inadvertent dural puncture during insertion of a labour epidural: a survey of Australian obstetric anaesthetists

Immediate management of inadvertent dural puncture during insertion of an epidural needle during labour is controversial and evidence to guide clinical practice is limited. We surveyed Australian obstetric anaesthetists by anonymous postal questionnaire. Of the 671 surveys sent, 417 (62%) were returned. Following dural puncture, 265 respondents (64%) indicated that they "would usually remove the Tuohy needle and resite". The most common reason for this decision was concern regarding the safety of intrathecal catheters (ITC) (n = 236, 89%), in particular, the risk of misuse (n = 182, 70%). The most frequently reported reason for "usually inserting an ITC" was that this reduced the incidence (n = 120, 84%) and severity (n = 110, 77%) of post dural puncture headache. Increased frequency of ITC insertion was reported by respondents who practised more frequent sessions of obstetric anaesthesia, had fewer years of experience as a consultant anaesthetist and worked in a public hospital. The more widespread use of ITCs seems to be limited by safety concerns.

Postpartum headaches: summary report of the National Obstetric Anaesthetic Database (NOAD) 1999

The National Obstetric Anaesthetic Database was established in 1998 to support collection of national data on obstetric analgesia and anaesthesia. The first year's project aimed to determine the incidence, characteristics, contributing factors and management of postpartum headaches with anaesthetic interventions. A total of 65348 women were reported to have had anaesthetic interventions. There were individual records of 404 women in whom postdural puncture headache (PDPH) was diagnosed (47 mild, 134 moderate, 202 severe and 21 unspecified) and 571 in whom headache was not related to dural puncture (315 mild, 176 moderate, 44 severe and 36 unspecified). Recognised dural puncture occurred in 165 women (41%), 130 (79%) during labour. Placement of spinal catheters on dural puncture in 51 women did not influence headache severity. Abdominal compression used to test the diagnosis of PDPH was only positive in 56/186 parturients (30%). Epidural blood patch was performed in 240 women with PDPH, of whom 101 women (42%) received their first blood patch within two days of delivery. The incidence of headache ranged from 1.1% to 1.9% between all anaesthetic techniques but increased to 11% for women receiving multiple regional anaesthetics. The predominant characteristics of PDPH were limitation of daily activity (n=305, 75%), severity (moderate/severe) and a postural element (n = 325, 80%), all significantly different from headache from other causes (P = 0.001). Shoulder/neck stiffness (n=172, 43%) was the commonest symptom associated with PDPH.