Complications with 25-gauge and 27-gauge Whitacre needles during combined spinal-epidural analgesia in labor

Evidence-based clinical practice guidelines on postdural puncture headache: a consensus report from a multisociety international working group

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.

Do Spinal Needle Sizes Affect the Development of Traumatic CSF in Neonatal LP Procedures?

Lumbar puncture (LP) is widely employed to evaluate infectious, neurological and metabolic diseases in the newborn. Neonatal LP is a difficult procedure with 45–54% success rates. Although there are studies examining traumatic LP failure, studies on the effects of needle sizes are limited. This study was intended to investigate the effect of needle sizes on LP traumatization. Term and premature babies who underwent LP in the neonatal intensive care unit between 30 November 2017 and 30 July 2019 were included in the study by retrospective file scanning. LP was performed by a pediatric or neonatal specialist using a 22 Gauge pen (G) or 25 G pen spinal needle in all cases, with all patients being placed in the lateral decubitus position. The primary outcome was to evaluate the effect of needle sizes used in LP on traumatization. The secondary outcome was to evaluate traumatization rates and complications. A statistically significant difference was determined in the rate of traumatized LP and desaturation development between needle sizes and CSF microscopic findings (p = 0.031, p = 0.005, and p = 0.006, respectively). The study data show that 25 G pen-tip spinal needles cause less traumatic LP in neonates than 22 G pen-tip spinal needles.

Postdural Puncture Headache-Risks and Current Treatment

PURPOSE OF REVIEW

This manuscript aims to review the risks and the current treatments for postdural puncture headache (PDPH).

RECENT FINDINGS

PDPH is a relatively frequent complication after neuraxial blocks. It is typically orthostatic in nature, presenting as a positional and dull aching or throbbing headache, with added dysregulation of auditory and/or visual signals. Certain characteristics, such as female sex and young age, may predispose patients to the development of PDPH, as may factors such as previous PDPH, bearing down during the second stage of labor, and the neuraxial technique itself. Long-term complications including chronic headache for years following dural puncture have brought into question of the historical classification of PDPH as a self-limiting headache. So far, the underlying mechanism governing PDPH remains under investigation, while a wide variety of prophylactic and therapeutic measures have been explored with various degree of success. In case of mild PDPH, conservative management involving bed rest and pharmacological management should be used as first-line treatment. Nerve blocks are highly efficient alternatives for PDPH patients who do not respond well to conservative treatment. In case of moderate-to-severe PDPH, epidural blood patch remains the therapy of choice. An interdisciplinary approach to care for patients with PDPH is recommended to achieve optimal outcomes.

Spinal needle size and traumatic neonatal lumbar puncture: an observational study (neo-LP)

The incidence of 'traumatic' lumbar puncture (LP; CSF red cells > 500/mm) has been reported to be 35-46% in the neonatal period. A traumatic LP incurs challenges in diagnosis and management of the underlying condition and increases the risk of complications. We aimed to assess the benefits of a smaller outer diameter, larger gauge 25G needle in reducing the incidence of traumatic LPs compared with the standard 22G LP needle. This prospective observational study compared data from two consecutive epochs. Epoch 1 (Control, April 2016-October 2016), 22G needle for LP as standard practice. Epoch 2 (Intervention, November 2016-October 2017) 25G needle used for LP. Primary outcome was the incidence of traumatic LP. Multiple logistic regression analyses were conducted adjusting for corrected gestational age (CGA) at LP, proceduralist experience and need for ventilation as an indicator of illness. There were 240 LPs during the study period involving 361 attempts (22G, n = 228; 25G, n = 133). Median gestation at birth (P = 0.617) and CGA at LP (P = 0.163) were comparable. Multivariate analysis revealed lower incidence of traumatic LP using 25G needle (P < 0.001). Incidence of obtaining a successful CSF sample was similar between groups (P = 0.944). Proceduralist experience (P = 0.189) and neonatal illness (P = 0.801) were not significant factors.Conclusion: Our results showed that traumatic LPs were ~ 50% less common with 25G vs 22G needles while retaining a comparable success rate. Dry taps were more likely among the 25G group.What is Known:• The incidence of neonatal 'traumatic' lumbar puncture (CSF red cells > 500/mm) has been reported to be 35-46%.• A traumatic lumbar puncture incurs challenges in diagnosis and management of the underlying condition and increases the risk of complications.What is New:• Multivariate analysis revealed lower incidence of traumatic lumbar puncture using 25G needle (vs 22G).• Incidence of obtaining a successful CSF sample was similar between groups.

Dural puncture epidural analgesia for labor: a randomized comparison between 25-gauge and 27-gauge pencil point spinal needles

BACKGROUND

This double-blind, randomized trial compared dural puncture epidural analgesia (DPEA) for labor using 25-gauge and 27-gauge pencil point spinal needles. We hypothesized that both needle sizes would result in similar onset time (equivalence margin=2.5 min) and therefore designed the study as an equivalence trial.

METHODS

One hundred and forty patients undergoing labor were randomized to DPEA with 25-gauge (n=70) or 27-gauge (n=70) pencil point spinal needles. After the placement of the epidural catheter, a bolus of 20 mL of bupivacaine 0.125% and fentanyl 2 µg/mL was administered to all subjects. Thereafter, patients received boluses of 12 mL of bupivacaine 0.125% every 2 hours as needed.A blinded investigator recorded the onset time (defined as the temporal interval required to achieve a pain score ≤1 on a 0-10 scale), S2 block, sensory block height (30 min after the initial bolus of local anesthetic), presence of motor block (30 min after the initial bolus of local anesthetic), number of top-up doses required during labor and incidence of postural headache.

RESULTS

Out of the 140 recruited patients, 135 were retained for analysis. Compared with their 27-gauge counterparts, 25-gauge pencil point spinal needles provided a 1.6 min shorter DPEA onset (95% CI of the difference of the means: -3.2 to -0.1 min). However, there were no intergroup differences in terms of S2 block, sensory block height, motor block, number of top-up doses and incidence of postural headache.

CONCLUSION

Dural puncture epidural analgesia with 25-gauge pencil point spinal needles provides a 1.6 min shorter onset time than DPEA with 27-gauge spinal needles. Although statistically significant, such a difference may not be clinically relevant. Further investigation is required to compare 25-gauge and 27-gauge spinal needles for DPEA in the setting of different local anesthetic infusion strategies.

TRIAL REGISTRATION NUMBER

NCT03389945.

Needle gauge and tip designs for preventing post-dural puncture headache (PDPH)

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.

Subdural Hematoma Associated With Labor Epidural Analgesia: A Case Series

OBJECTIVE

This report aimed to describe the characteristics and impact of subdural hematoma (SDH) after labor epidural analgesia.

CASE REPORTS

Eleven obstetric patients had SDHs associated with the use of labor epidural analgesia over 7 years at a tertiary care hospital. Ten of 11 patients had signs consistent with postdural puncture headache before the diagnosis of SDH. Five patients (45%) had a recognized unintentional dural puncture, 1 (9%) had a combined spinal-epidural with a 24-gauge needle, and 5 (45%) had no recognized dural puncture. For 10 of the 11 cases, SDH was diagnosed at a mean of 4.1 days (range, 1-7 days) after performance of labor epidural analgesia; one case was diagnosed at 25 days. Ten (91%) of 11 cases had a second hospital stay for a mean of 2.8 days (range, 2-4 days) for observation, without further requirement for neurosurgical intervention. One case (9%) had decompressive hemicraniectomy after becoming unresponsive. The observed rate of labor epidural analgesia-associated SDH was 0.026% (11 in 42,969, approximately 1:3900), and the rate of SDH was 1.1% (5 in 437, approximately 1:87) if a recognized dural puncture occurred during epidural catheter placement.

CONCLUSIONS

Subdural hematoma after labor epidural anesthesia is rare but potentially more common than historically estimated. Cases of postdural puncture headache after labor epidural anesthesia should be monitored closely for severe neurologic signs and symptoms that could herald SDH.

Influence of needle diameter on spinal anaesthesia puncture failures for caesarean section: A prospective, randomised, experimental study

OBJECTIVES

Spinal anaesthesia represents the technique of choice for elective caesarean section. The purpose of this study was to compare the puncture failure rates with 25, 26 or 27 gauge (G) pencil-point, Whitacre type (with introducer) needles during spinal anaesthesia for caesarean section.

STUDY DESIGN

Prospective, randomised, experimental study in healthy subjects.

PATIENTS AND METHODS

We recruited 330 adults, consecutively scheduled parturients, randomised into three groups. The subarachnoid puncture procedure was standardised. The flexibility of the three needle types was assessed in vitro, and a force was applied using a dynamometer. The occurrence of postdural puncture headache was also evaluated.

RESULTS

The number of spinal puncture failures was significantly higher in the 27G group, than in the 25G (P=0.006) group and the 26G (P<0.001) group, but did not differ between the 25G and 26G groups (P=0.606). Ten postdural puncture headaches were observed without significant differences among the groups.

CONCLUSIONS

This prospective study showed that puncture failures occur less frequently with the use of 25G or 26G pencil-point needles as compared to 27G needles, probably due to the higher flexibility of the latter. This characteristic was demonstrated in vitro, in a reproducible model. This experiment suggests that a 26G pencil-point needle is the optimal gauge for performing spinal anaesthesia for scheduled caesarean sections.

Responses to dural puncture during institution of combined spinal-epidural analgesia: a comparison of 27 gauge pencil-point and 27 gauge cutting-edge needles

Pencil-point spinal needles are popular for combined spinal-epidural analgesia because they cause less dural puncture headache than cutting-edge spinal needles. However many parturients move, grimace, vocalise or experience paraesthesia or dysaesthesia during dural puncture when performing 'needle through needle' combined spinal-epidural analgesia. We compared dural puncture responses induced by pencil-point and cutting-edge needles (both 27 gauge). With institutional approval, 115 parturients presenting for elective caesarean section or labour analgesia were audited. After lignocaine infiltration, a Tuohy-type needle was inserted to loss of resistance to saline at a mid-lumbar interspace, and either a 27 gauge cutting-edge or 27 gauge pencil-point needle was inserted 'needle through needle' through the dura. During dural penetration, the occurrence of patient movement, grimacing or vocalisation was noted by a blinded observer, as was the patient's response to the question "Did you feel that?" asked by the anaesthetist. The audit comprised two similar groups of patients (caesarean section, n=30; labour analgesia, n=85). In both groups, grimacing and movement during thecal penetration occurred more frequently with pencil-point needles (P < 0.05 and P < 0.025, respectively). Pooled data analysis revealed that pencil-point and cutting-edge needles induced grimacing and movement in 17 (22%) and 2 (5%), spontaneous vocalisation in 4 (5%) and 1 (3%) and was perceived by 13 (17%) and 3 (8%) parturients (P < 0.025, P=NS, P=NS), respectively. Overall, 34 and 6 objective and subjective patient responses (P < 0.005) occurred when inserting these needles, respectively. Dural puncture by a 27 gauge pencil-point needle inserted 'needle through needle' when instituting combined spinal-epidural analgesia induces more iatrogenic responses than a 27 gauge cutting-edge needle.

Needle-induced paresthesiae during single-shot spinal anesthesia: a comparison of sitting versus lateral decubitus position

BACKGROUND AND OBJECTIVES

Paresthesiae occasionally occur during spinal puncture or injection of local anesthetic for spinal anesthesia. No information is currently available regarding the effects of the patient's position on the incidence of needle-induced paresthesiae. The purpose of this prospective, observational study was to compare the occurrence of needle-induced paresthesiae in patients who received single-shot spinal anesthesia in the sitting position or in the lateral decubitus position.

METHODS

A total of 620 patients operated on under spinal anesthesia were included. Spinal anesthesia was performed in the sitting position in 142 patients and in the lateral decubitus position in 478 patients. All blocks were performed with a 25-gauge, 90-mm, Sprotte needle, at the L3-L4 or L4-L5 level. Patients' demographics, patients' position (lateral decubitus or sitting), number of skin punctures, incidence of paresthesiae, and success of the anesthesia were recorded.

RESULTS

The overall incidence of paresthesiae was higher in the lateral decubitus position (16.95%) compared with the sitting position (9.15%) (P = 0.0230). The number of punctures and the success rate were similar in both positions. Studying the incidence of paresthesiae for each position, when performing 1 or more punctures, there was no position-related difference noted if a single-needle puncture was sufficient to perform the block (8.0% in the lateral decubitus group versus 5.1% in the sitting group) (P = 0.3305). This difference between positions was significant when more than a single-needle puncture was required (34.1% in the lateral decubitus group versus 18.6% in the sitting group) (P = 0.0497).

CONCLUSIONS

Patient's position may influence the occurrence of needle-induced paresthesiae during spinal anesthesia. Lateral decubitus position resulted in a higher incidence of paresthesiae than the sitting position. However, there is no position-related difference noted if a single-needle puncture is sufficient to perform the block.

[Continuous subarachnoid analgesia and anesthesia for labor and cesarean section in a patient who had previously undergone surgery for ependymoma]

We report the case of a 38-year-old primipara who had undergone surgery 2 years earlier for an intradural ependymoma at L2-L3 and who was currently asymptomatic. A combined epidural-subarachnoid block was performed for analgesia during labor but this technique was only effective for the first 2 hours. When analgesia via epidural cannula was no longer adequate, it was decided to perform a continuous subarachnoid block. Later, the fetus's head was seen to be too large to fit through the pelvis; for cesarean section, the mother was administered fractionated doses of local anesthetic via the subarachnoid cannula until analgesia reached T4. The patient did not develop postdural puncture headache. Continuous subarachnoid anesthesia may be considered the technique of choice where the patient has a history of spinal surgery.

Management of persistent post-dural puncture headache after repeated epidural blood patch

We report a case of persistent post-dural puncture headache (PDPH) in a patient despite two epidural blood patches (EBPs). Successful resolution of headache was achieved with a third EBP performed under computed tomography (CT) guidance. A 38-year-old female had a total abdominal hysterectomy under combined spinal-epidural anesthesia with no complications. After surgery, she developed a postural headache consistent with PDPH. The first EBP was performed by injecting autologous blood through the epidural catheter that was in situ. The second EBP was performed under fluoroscopy. The patient continued to have a persistent headache. A computed tomography (CT) myelogram demonstrated cerebrospinal fluid (CSF) leak at L3-4 level. A "directed" CT-guided blood patch was then performed successfully with resolution of the headache.

Postpartum neurologic symptoms following single-shot spinal block for labour analgesia

BACKGROUND

As part of a quality assurance program, we investigated the incidence of postpartum neurologic symptoms in multiparous parturients receiving spinal block for labour analgesia, now in routine use in our labour ward.

METHODS

Two hundred and twenty-nine consecutive multiparous parturients presenting for vaginal delivery and requesting spinal analgesia were asked to participate in this prospective study. All parturients received our standard intrathecal analgesia (ITA): 2.5 mg bupivacaine (1 ml) + 25 microg fentanyl (0.5 ml) using a 27-gauge Quincke-type needle. The patients filled in a questionnaire on the first day after delivery and again upon discharge. Complaints typical of neurologic sequelae were noted and a neurologic examination was performed, if necessary. All patients with postdural puncture headache (PDPH) and transient neurologic symptoms (TNSs) were interviewed by telephone 2 weeks after discharge to determine the course of the symptoms.

RESULTS

Two hundred and twelve parturients were included in the study. Eighteen (8.5%) parturients complained of PDPH, the severity of which was mild in eight (4%), moderate in seven (3%), and severe in three (1%) patients, respectively. Fifteen (7%) mothers were treated with analgesics or bedrest only. Three (1%) patients were given an epidural blood patch. The paramedian approach was associated with the development of PDPH (P = 0.04). Transient neurologic symptoms were experienced by nine (4.2%) mothers, lasting 1-3 days, mostly presenting as bilateral pain in the buttocks or thighs. One parturient suffered from paraesthesia of the left foot lasting for 3 days. Forty (19%) mothers complained of non-postural headache and 28 (13%) of new-onset back pain. Three mothers (1%) would not want to receive a further spinal block.

CONCLUSION

Transient neurologic symptoms (TNSs) after spinal block occurred infrequently. The incidence of PDPH was higher than in the obstetric population in general and calls for re-evaluation of our spinal block methods. Despite the occurrence of neurologic sequelae, patient acceptability was high.

PDPH is a common complication of neuraxial blockade in parturients: a meta-analysis of obstetrical studies

PURPOSE

Postdural puncture headache (PDPH) is an iatrogenic complication of neuraxial blockade. We systematically reviewed the literature on parturients to determine the frequency, onset, and duration of PDPH.

METHODS

Citations on PDPH in the obstetrical population were identified by computerized searches, citation review, and hand searches of abstracts and conference proceedings. Citations were included if they contained extractable data on frequency, onset, or duration of PDPH. Using meta-analysis, we calculated pooled estimates of the frequency of accidental dural puncture for epidural needles and pooled estimates of the frequencies of PDPH for epidural and spinal needles.

RESULTS

Parturients have approximately a 1.5% [95% confidence interval (CI) 1.5% to 1.5%) risk of accidental dural puncture with epidural insertion. Of these, approximately half (52.1%; 95% CI, 51.4% to 52.8%) will result in PDPH. The risk of PDPH from spinal needles diminishes with small diameter, atraumatic needles, but is still appreciable (Whitacre 27-gauge needle 1.7%; 95% CI, 1.6% to 1.8%). PDPH occurs as early as one day and as late as seven days after dural puncture and lasts 12 hr to seven days.

CONCLUSION

PDPH is a common complication for parturients undergoing neuraxial blockade.

Obstetric epidural analgesia

PURPOSE OF THE REVIEW

There has recently been a growing interest in developing and modulating the techniques of neuraxial analgesia to meet the changing individual needs of parturients for pain relief during the course of labour and delivery.

RECENT FINDINGS

Neuraxial analgesia is now very safe. Modern low-dose spinal-epidural regimens provide efficacious analgesia, stable maternal haemodynamics and few tolerable side effects. Complications are possible, however, due to the invasive nature of the technique, patient characteristics or medical malpractice.

SUMMARY

Labour epidural analgesia still remains the 'gold standard' of obstetric pain management, although spinal analgesia with the single-injection technique is an attractive option due to its simplicity, reliability and efficacy. Up till now, there has been no single new drug to overcome the superiority of neuraxial analgesia in obstetrics.

Combined spinal-epidural analgesia for labor: breakthrough or unjustified invasion?

The combined spina-epidural (CSE) technique has become increasingly popular for labor analgesia. The advantages of the CSE include more rapid onset of analgesia, reduced total drug dosage, minimal or no motor blockade, and increased patient satisfaction. CSE has also been associated with more rapid cervical dilation when compared to epidural analgesia in nulliparous women in early labor. Despite these potential advantages, the indications for CSE versus epidural analgesia remain unclear and controversial. This review should allow better understanding of the benefits and risks of this technique, and bearing in mind that no ultimate neuraxial analgesic exists, it would seem that CSE should be considered a major breakthrough in the management of labor analgesia.