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Poma S, Bonomo MC, Gazzaniga G, Pizzulli M, De Silvestri A, Baldi C, Broglia F, Ciceri M, Fuardo M, Morgante F, Pellicori S, Roldi EM, Delmonte MP, Mojoli F, Locatelli A. Complications of unintentional dural puncture during labour epidural analgesia: a 10-year retrospective observational study. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2023; 3:42. [PMID: 37880725 PMCID: PMC10601237 DOI: 10.1186/s44158-023-00127-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 10/14/2023] [Indexed: 10/27/2023]
Abstract
INTRODUCTION Unintentional dural puncture (UDP) occurs in 0.5-1.5% of labour epidural analgesia cases. To date, little is known about evidence of UDP-related complications. This work aimed to assess the incidence of intrapartum and postpartum complications in parturients who experienced UDP. METHODS This is a 10-year retrospective observational study on parturients admitted to our centre who presented UDP. Data collection gathered UDP-related complications during labour and postpartum. All women who displayed UDP received medical therapy and bed rest. An epidural blood patch (EBP) was not used in this population. Once asymptomatic, patients were discharged from the hospital. RESULTS Out of 7718 neuraxial analgesia cases, 97 cases of UDP occurred (1.25%). During labour, complications appeared in a small percentage of analgesia procedures performed, including total spinal anaesthesia (1.0%), extended motor block (3%), hypotension (4.1%), abnormal foetal heart rate (2%), inadequate analgesia (14.4%), and general anaesthesia following neuraxial anaesthesia failure (33.3% of emergency caesarean sections). During the postpartum period, 53.6% of parturients exhibited a postdural puncture headache, 13.4% showed neurological symptoms, and 14.4% required neurological consultation and neuroimaging. No patient developed subdural hematoma or cerebral venous sinus thrombosis; one woman presented posterior reversible encephalopathy syndrome associated with eclampsia. Overall, 82.5% of women experienced an extension of hospital stay. CONCLUSION Major complications occurred in a small percentage of patients during labour. However, since they represent high-risk maternal and neonatal health events, a dedicated anaesthesiologist and a trained obstetric team are essential. No major neurological complications were registered postpartum, and EBP was not performed. Nevertheless, all patients with UDP were carefully monitored and treated until complete recovery before discharge, leading to an extension of their hospitalization.
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Affiliation(s)
- S Poma
- Anaesthesia and Postoperative Intensive Care, Department of Anaesthesia and Intensive Care 3, I.R.C.C.S. Policlinic San Matteo Hospital Foundation, Pavia, 27100, Italy.
| | - M C Bonomo
- Department of Anaesthesia and Intensive Care, ASST Bergamo EST, Seriate Hospital, Seriate, Italy
| | - G Gazzaniga
- Department of Anaesthesia and Intensive Care 1, I.R.C.C.S. Policlinic San Matteo Hospital Foundation, Pavia, Italy
| | - M Pizzulli
- Anaesthesia and Postoperative Intensive Care, Department of Anaesthesia and Intensive Care 3, I.R.C.C.S. Policlinic San Matteo Hospital Foundation, Pavia, 27100, Italy
| | - A De Silvestri
- Clinical Epidemiology and Biostatistics, Scientific Direction, I.R.C.C.S. Policlinic San Matteo Hospital Foundation, Pavia, Italy
| | - C Baldi
- Anaesthesia and Postoperative Intensive Care, Department of Anaesthesia and Intensive Care 3, I.R.C.C.S. Policlinic San Matteo Hospital Foundation, Pavia, 27100, Italy
| | - F Broglia
- Anaesthesia and Postoperative Intensive Care, Department of Anaesthesia and Intensive Care 3, I.R.C.C.S. Policlinic San Matteo Hospital Foundation, Pavia, 27100, Italy
| | - M Ciceri
- Anaesthesia and Postoperative Intensive Care, Department of Anaesthesia and Intensive Care 3, I.R.C.C.S. Policlinic San Matteo Hospital Foundation, Pavia, 27100, Italy
| | - M Fuardo
- Anaesthesia and Postoperative Intensive Care, Department of Anaesthesia and Intensive Care 3, I.R.C.C.S. Policlinic San Matteo Hospital Foundation, Pavia, 27100, Italy
| | - F Morgante
- Anaesthesia and Postoperative Intensive Care, Department of Anaesthesia and Intensive Care 3, I.R.C.C.S. Policlinic San Matteo Hospital Foundation, Pavia, 27100, Italy
| | - S Pellicori
- Anaesthesia and Postoperative Intensive Care, Department of Anaesthesia and Intensive Care 3, I.R.C.C.S. Policlinic San Matteo Hospital Foundation, Pavia, 27100, Italy
| | - E M Roldi
- Anaesthesia and Postoperative Intensive Care, Department of Anaesthesia and Intensive Care 3, I.R.C.C.S. Policlinic San Matteo Hospital Foundation, Pavia, 27100, Italy
| | - M P Delmonte
- Anaesthesia and Postoperative Intensive Care, Department of Anaesthesia and Intensive Care 3, I.R.C.C.S. Policlinic San Matteo Hospital Foundation, Pavia, 27100, Italy
| | - F Mojoli
- Department of Anaesthesia and Intensive Care 1, I.R.C.C.S. Policlinic San Matteo Hospital Foundation, Pavia, Italy
| | - A Locatelli
- Anaesthesia and Postoperative Intensive Care, Department of Anaesthesia and Intensive Care 3, I.R.C.C.S. Policlinic San Matteo Hospital Foundation, Pavia, 27100, Italy
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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: 1] [Impact Index Per Article: 1.0] [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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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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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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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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6
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Izquierdo M, Wang XF, Wagner Iii K, Prada C, Torres A, Bolden N. Preliminary findings and outcomes associated with the use of a continuous spinal protocol for labor pain relief following accidental dural puncture. Reg Anesth Pain Med 2019:rapm-2019-100544. [PMID: 31541011 DOI: 10.1136/rapm-2019-100544] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 07/22/2019] [Accepted: 08/26/2019] [Indexed: 01/21/2023]
Abstract
BACKGROUND Various interventions have shown promise in reducing complications following accidental dural puncture. However, these have yet to be studied as a single, comprehensive protocol. The aim of this study is to compare outcomes associated with the use of a continuous spinal protocol for labor pain relief versus resiting the epidural catheter following accidental dural puncture. METHODS We reviewed the charts of patients managed via our continuous spinal protocol and compared this group with patients for whom the epidural was resited following accidental dural puncture during the 5-year period prior to implementing our protocol. We assessed incidence of postdural puncture headache, epidural blood patch, frequency of catheter replacement, use of pressors, verbal pain scores at 0, 1, 2, 3, 4 hours following catheter placement, infection rates (meningitis/epidural abscess) and mode of delivery. RESULTS There were 129 women in the continuous spinal protocol group and 52 in the resited epidural group. The incidence of postdural puncture headache was lower in the continuous spinal group versus the resited epidural group (21.7% vs 67.3%, p<0.001), and the incidence of epidural blood patch was lower in the continuous spinal group versus the resited epidural group (12.4% vs 50.0%, p<0.001). Verbal pain scores were consistently lower in the continuous spinal group compared with the resited epidural group at all time intervals studied. CONCLUSION Patients managed via this continuous spinal protocol had significantly lower incidence of postdural puncture headache and epidural blood patch with more effective labor analgesia following accidental dural puncture.
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Affiliation(s)
- Marcos Izquierdo
- Department of Anesthesiology, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Xiao-Feng Wang
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Karl Wagner Iii
- Department of Anesthesiology, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Cristian Prada
- Department of Anesthesiology, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Augusto Torres
- Department of Anesthesiology, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Norman Bolden
- Department of Anesthesiology, MetroHealth Medical Center, Cleveland, Ohio, USA
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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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8
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ElSheikh S, Gamal G. Sequential higher epidural catheter re-insertion after accidental dural puncture ameliorates the frequency and severity of post-dural puncture headache. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2010.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Somaya ElSheikh
- Department of Anesthesia ICU and Pain Relief National Cancer Institute Cairo University Egypt
| | - Ghada Gamal
- Department of Anesthesia ICU and Pain Relief National Cancer Institute Cairo University Egypt
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Russell R, Laxton C, Lucas DN, Niewiarowski J, Scrutton M, Stocks G. Treatment of obstetric post-dural puncture headache. Part 2: epidural blood patch. Int J Obstet Anesth 2019; 38:104-118. [PMID: 30711239 DOI: 10.1016/j.ijoa.2018.12.005] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 11/12/2018] [Accepted: 12/16/2018] [Indexed: 12/31/2022]
Abstract
The 2009-12 MBRRACE-UK report highlighted the deaths of two women in whom dural puncture had occurred during insertion of a labour epidural catheter. Despite suffering long-term headaches, neither woman was adequately followed-up after discharge from hospital. Death resulted from a cerebral vein thrombosis in one case and a subdural haematoma in the other. Due to significant variation in the treatment of obstetric post-dural puncture headache, an Obstetric Anaesthetists' Association working group was set up to produce evidence-based guidelines to guide clinicians. These guidelines have been condensed into two review articles. In this second review, the role of an epidural blood patch is discussed using a question and answer format.
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Affiliation(s)
- R Russell
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
| | - C Laxton
- Department of Anaesthetics, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - D N Lucas
- Department of Anaesthetics, Northwick Park Hospital, London North West University Healthcare NHS Trust, Harrow, UK
| | - J Niewiarowski
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - M Scrutton
- Department of Anaesthetics, St Michael's Hospital, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - G Stocks
- Department of Anaesthetics, Queen Charlotte's and Chelsea Hospital, Imperial College Healthcare NHS Trust, London, UK
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Bansal T, Jaiswal R, Bala M, Seelwal D. Continuous spinal anaesthesia for caesarean section in a patient with peripartum cardiomyopathy. Indian J Anaesth 2019; 63:317-319. [PMID: 31000900 PMCID: PMC6460981 DOI: 10.4103/ija.ija_769_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Teena Bansal
- Department of Anaesthesiology and Critical Care, Pt. B.D. Sharma University of Health Sciences, Rohtak, Haryana, Punjab, India
| | - Rajmala Jaiswal
- Department of Anaesthesiology and Critical Care, Pt. B.D. Sharma University of Health Sciences, Rohtak, Haryana, Punjab, India
| | - Manju Bala
- Department of Anaesthesiology and Critical Care, Pt. B.D. Sharma University of Health Sciences, Rohtak, Haryana, Punjab, India
| | - Deepika Seelwal
- Department of Anaesthesiology and Critical Care, Pt. B.D. Sharma University of Health Sciences, Rohtak, Haryana, Punjab, India
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12
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Rana K, Jenkins S, Rana M. Insertion of an intrathecal catheter following a recognised accidental dural puncture reduces the need for an epidural blood patch in parturients: an Australian retrospective study. Int J Obstet Anesth 2018; 36:11-16. [PMID: 30245259 DOI: 10.1016/j.ijoa.2018.08.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 08/04/2018] [Accepted: 08/08/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND There is no clear consensus about how best to prevent post-dural puncture headache (PDPH) following an accidental dural puncture in parturients. Our primary objective was to investigate whether the insertion of an intrathecal catheter following accidental dural puncture reduces the incidence of PDPH and therapeutic epidural blood patch. METHODS Anaesthetic records from January 2009 to December 2015 were reviewed retrospectively and parturients who had an accidental dural puncture and/or PDPH were identified. Data from those with a recognised dural puncture in whom an intrathecal catheter was inserted at the time of accidental dural puncture (ITC group) were compared to those without an intrathecal catheter (non-ITC group), as were outcomes of patients with an intrathecal catheter for ≥24 hours compared to <24 hours. RESULTS Of 94 recognised accidental dural punctures, 66 were in the ITC group (37 for ≥24 h) and 28 in the non-ITC group. In the ITC group, 22 (33.3%) required an epidural blood patch in comparison to 19 (67.9%) in the non-ITC group (P <0.01, 95% CI 12.5 to 52.0). In the ITC group, 62 (93.9%) developed PDPH in comparison to 28 (100%) in the non-ITC group (P=0.186, 95% CI -6.55 to 14.57). Intrathecal catheter insertion for ≥24 h obviated the need for an epidural blood patch in 28 (75.7%) parturients, compared to 13 (59.1%) if <24 h (P=0.184, 95% CI -7.08 to 39.72). CONCLUSION Inserting an intrathecal catheter after a recognised accidental dural puncture significantly reduced the need for an epidural blood patch.
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Affiliation(s)
- K Rana
- Medical School, The University of Adelaide, Australia.
| | - S Jenkins
- Department of Anaesthesia, Lyell McEwin Hospital, Haydown Rd, Elizabeth Vale, South Australia, Australia
| | - M Rana
- Medical School, The University of Adelaide, Australia; Department of Anaesthesia, Lyell McEwin Hospital, Haydown Rd, Elizabeth Vale, South Australia, Australia
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13
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Deng J, Wang L, Zhang Y, Chang X, Ma X. Insertion of an intrathecal catheter in parturients reduces the risk of post-dural puncture headache: A retrospective study and meta-analysis. PLoS One 2017; 12:e0180504. [PMID: 28678882 PMCID: PMC5498039 DOI: 10.1371/journal.pone.0180504] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 06/18/2017] [Indexed: 12/24/2022] Open
Abstract
This study aimed to determine whether insertion of an intrathecal catheter following accidental dural puncture (ADP) in obstetric patients can reduce the incidence of post-dural puncture headache (PDPH) and the requirement of a therapeutic epidural blood patch (TEBP). This was also compared with relocating the epidural catheter at a different vertebral interspace. A retrospective study was performed, as well as a meta-analysis of the literature to further validate our findings. We reviewed the records of 86 obstetric patients who suffered from ADP during epidural anesthesia or combined spinal-epidural anesthesia from October 2015 to November 2016 at our institution. Although, there was no significant decrease in the incidence of PDPH (P = 0.08), the requirement for a TEBP (P = 0.025) was significantly reduced in the intrathecal catheter group compared with the relocated group. In the meta-analysis, 13 eligible studies including 1044 obstetric patients were finally identified. To estimate the pooled risk ratios (RRs), fixed or random effect models were used depending on the heterogeneity. We initially found that an intrathecal catheter significantly reduced the incidence of PDPH (pooled RR = 0.823; 95% CI = 0.700–0.967; P = 0.018) and the requirement of a TEBP (pooled RR = 0.616; 95% CI = 0.443–0.855; P = 0.004). Our study shows that insertion of an intrathecal catheter following ADP might be an effective and dependable method for reducing the risk of a PDPH and requirement for a TEBP in obstetric patients.
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Affiliation(s)
- Jiali Deng
- Department of Anesthesia, Jiaxing Maternity and Child Health Hospital, School of Medicine, Jiaxing University, Jiaxing, Zhejiang, China
| | - Lizhong Wang
- Department of Anesthesia, Jiaxing Maternity and Child Health Hospital, School of Medicine, Jiaxing University, Jiaxing, Zhejiang, China
| | - Yinfa Zhang
- Department of Anesthesia, Jiaxing Maternity and Child Health Hospital, School of Medicine, Jiaxing University, Jiaxing, Zhejiang, China
| | - Xiangyang Chang
- Department of Anesthesia, Jiaxing Maternity and Child Health Hospital, School of Medicine, Jiaxing University, Jiaxing, Zhejiang, China
| | - Xingjie Ma
- Department of Cardiothoracic Surgery, First Hospital of Jiaxing, School of Medicine, Jiaxing University, Jiaxing, Zhejiang, China
- * E-mail:
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Lenart MJ, Carness JM. Cerebrospinal Fluid-Cutaneous Fistula After Continuous Spinal Catheter in an Obstetric Patient. ACTA ACUST UNITED AC 2017; 7:103-7. [PMID: 27580408 DOI: 10.1213/xaa.0000000000000356] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 23-year-old woman at 41 weeks and 6 days estimated gestational age underwent continuous spinal analgesia for labor after a recognized, unintended dural puncture. Excellent analgesia was maintained throughout labor and vaginal delivery, the intrathecal catheter was left in situ for 24 hours postpartum, and the catheter was subsequently removed without apparent complication. On physical examination during her anesthesia postoperative visit, clear fluid was noted to be slowly draining from the catheter insertion site. Although she denied all symptoms associated with a dural puncture, including headache, a cerebrospinal fluid-cutaneous fistula was diagnosed. An epidural blood patch was placed, which terminated the cerebrospinal fluid leak. No long-term complications were evident. Subsequent literature review revealed a rare incidence of this type of complication and varied recommendations for intervention and optimal management. We review the literature with regard to this complication and offer discussion regarding the various suggested means of diagnosis and therapy.
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Affiliation(s)
- Mark J Lenart
- From the Department of Anesthesiology, Naval Medical Center Portsmouth, Portsmouth, Virginia
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Accidental Dural Puncture Management: 10-Year Experience at an Academic Tertiary Care Center. Reg Anesth Pain Med 2016; 41:169-74. [PMID: 26735153 DOI: 10.1097/aap.0000000000000339] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND AND OBJECTIVES The use of spinal catheters for extended periods after accidental dural puncture (ADP) and administration of intrathecal saline via spinal catheters have been advocated to decrease the incidence of postdural puncture headache and the subsequent need for epidural blood patch (EBP), with mixed results observed. METHODS We reviewed the medical records of 218 patients with ADP who either had the epidural resited or had a spinal catheter (with or without the administration of intrathecal saline). We compared the incidence of headache and the need for blood patch between these groups. We also assessed complications when a standard lidocaine epidural test dose was administered intrathecally and compared this with complications when a solution normally used for labor combined spinal epidurals was administered. RESULTS There was no difference in the incidence of postdural puncture headache between the resited epidural group and the spinal catheter group, 68.0% versus 55.9% (odds ratio [OR], 1.7; 95% confidence interval [95% CI], 1.0-2.9; P = 0.07). Resiting the epidural catheter was associated with a significant increase in the number of EBPs when compared with using a spinal catheter, 52.0% versus 20.3% (OR, 4.2; 95% CI, 2.4-7.6; P < 0.001) and when compared with spinal catheters with intrathecal saline, 52.0% versus 8.1% (OR, 12.3; 95% CI, 4.3-35.4; P < 0.001). There was a significant difference in the number of blood patches between normal body mass index patients and morbidly obese patients, 55.2% versus 25.0% (OR, 3.7; 95% CI, 1.2-11.2; P = 0.02). Complications (hypotension prompting pressors, high spinal, and emergency cesarean delivery because of nonreassuring fetal status) occurred more frequently when a lidocaine test dose was immediately administered after ADP versus administering a labor combined spinal epidural solution. CONCLUSIONS Insertion of spinal catheters after ADP and administration of intrathecal normal saline via spinal catheters reduce the need for EBP compared with resiting the epidural. Administration of the standard epidural test dose intrathecally is associated with frequent and significant complications.
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Orbach-Zinger S, Ashwal E, Hazan L, Bracco D, Ioscovich A, Hiersch L, Khinchuck A, Aviram A, Eidelman LA. Risk Factors for Unintended Dural Puncture in Obstetric Patients: A Retrospective Cohort Study. Anesth Analg 2016; 123:972-6. [PMID: 27537928 DOI: 10.1213/ane.0000000000001510] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Unintended dural puncture (UDP) is one of the main risks of epidural analgesia, with a reported incidence of approximately 1.5% among the obstetric population. UDP is associated with maternal adverse outcomes, with the most frequent adverse outcome being postdural puncture headache (PDPH). Our retrospective cohort study objective was to identify demographic and obstetric risk factors that increase the risk of unintentional dural puncture as well as describing the obstetric outcome once a dural puncture has occurred. METHODS We retrospectively reviewed all cases of UDPs during attempted vaginal delivery between the years 2004 and 2013 in a single Israeli hospital. Each UDP case was matched with the 2 parturients who received epidural analgesia before and 2 parturients after performed by the same anesthesiologist (control group). Demographic, anesthetic, and obstetric variables were compared between the UDP and control groups. RESULTS Out of 46,668 epidural procedures, 177 cases of UDPs were documented (0.4%). One hundred seven women (60.5%) developed PDPH, and 38 (35.5%) required an epidural blood patch. In multivariate logistic regression, the degree of cervical dilation in centimeters at the time of epidural insertion was associated with an increased rate of UDP (P < .001). Multiparity was associated with PDPH after UDP (P = .004). Women with UDP had longer length of hospital stay than those without UDP (P < .001). CONCLUSIONS UDP, an uncommon complication, is associated with obstetric factors. Nevertheless, it does not seem to be associated with adverse obstetric outcomes except for prolonged duration of hospital stay.
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Affiliation(s)
- Sharon Orbach-Zinger
- From the Departments of *Anesthesia and †Obstetrics and Gynecology, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel; and ‡Department of Anesthesia, Shaare Zedek Medical Center, Jerusalem, Israel
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Che X, Zhang W, Xu M. Continuous epidural pumping of saline contributes to prevent and treat postdural puncture headache. J Clin Anesth 2016; 34:154-8. [PMID: 27687364 DOI: 10.1016/j.jclinane.2016.03.066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 03/16/2016] [Indexed: 12/16/2022]
Abstract
STUDY OBJECTIVE Postdural puncture headache (PDPH) is the most common symptom of accidental dural puncture, a frequent complication of intraspinal anesthesia. We developed a postoperative intervention technique to prevent and treat PDPH in accidental dural puncture patients, including epidural pumping of saline. This retrospective study aimed to retrospectively evaluate this new technique for PDPH prevention and treatment. DESIGN Retrospective study. SETTING Beijing Obstetrics and Gynecology Hospital affiliated to the Capital Medical University, between January 2006 and December 2012. PATIENTS Eighty-seven cases undergoing intraspinal anesthesia were assessed. INTERVENTIONS Of these patients, 68 cases had successful repuncture and were assigned to group A (epidural filling group, n=68), receiving continuous epidural pumping of 0.9% NS (150mL) at a rate of 6mL/h; the remaining cases were assigned to group B (conservative therapy group, n=19). MEASUREMENTS Age, height, and body weight were collected, and postoperative headache was assessed using a visual analog scale. MAIN RESULTS Of 68 patients in group A, 49 (72.1%) developed PDPH, whereas all in group B developed PDPH (P=.009). In addition, all patients showed PDPH within 3days after surgery regardless of treatment group. However, a statistically significant difference was obtained for PDPH duration between groups A and B (P<.001). Multivariate logistic regression analysis showed that frequency of epidural puncture and continuous epidural pumping of saline were significant risk factors for PDPH. CONCLUSIONS Our data indicated that application of 6mL/h saline effectively contributes to PDPH management, and its clinical application should be broadened.
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Affiliation(s)
- Xiangming Che
- Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing 100006, China.
| | - Wenyu Zhang
- Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing 100006, China
| | - Mingjun Xu
- Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing 100006, China
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Tien M, Peacher DF, Franz AM, Jia SY, Habib AS. Failure rate and complications associated with the use of spinal catheters for the management of inadvertent dural puncture in the parturient: a retrospective comparison with re-sited epidural catheters. Curr Med Res Opin 2016; 32:841-6. [PMID: 26818623 DOI: 10.1185/03007995.2016.1146665] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Objective To report on the failure rate of spinal catheters placed following inadvertent dural puncture (IDP) compared with re-sited epidural catheters in the obstetric population. Research design and methods Patients who experienced IDP during epidural or combined spinal epidural placement with 17 or 18 gauge Tuohy needles for labor analgesia between 2003 and 2014 were identified using our post-dural puncture headache (PDPH) database. Patients were categorized into two groups: those who had spinal catheters inserted and those who had epidural catheters re-sited. Main outcome measure Failure rate associated with spinal or re-sited epidural catheters (defined as need for repeat block or alternative analgesic modality). Secondary outcomes were incidence of PDPH, need for epidural blood patch (EBP), and adverse events. Results A total of 109 patients were included in the final analysis; 79 ultimately had spinal catheters and 30 ultimately had re-sited epidural catheters. There were no differences between spinal catheters and re-sited epidural catheters in failure rate (22% vs. 13%, P = 0.33), incidence of PDPH (73% vs. 60%, P = 0.24), need for EBP (42% vs. 30%, P = 0.28), number of headache days, or maximum headache scores. There was also no difference in the rate of adverse events including high block levels, hypotension, and fetal bradycardia (9% vs. 7%, P = 1.0) between the two groups. Conclusions There were no differences in failure rates, PDPH outcomes, or adverse events between spinal catheters and re-sited epidural catheters following IDP in parturients receiving labor analgesia. Limitations of the study include its single-center retrospective non-randomized design, and the uneven number of patients in the two groups with a relatively small number in the re-sited epidural catheter group.
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Affiliation(s)
- Michael Tien
- a Mayo Medical School, Mayo Clinic College of Medicine , Rochester , MN , USA
| | - Dionne F Peacher
- b Department of Anesthesiology and Critical Care , The University of Pennsylvania Health System , Philadelphia , PA , USA
| | - Amber M Franz
- c Department of Anesthesiology , Duke University Medical Center , Durham , NC , USA
| | - Shawn Y Jia
- c Department of Anesthesiology , Duke University Medical Center , Durham , NC , USA
| | - Ashraf S Habib
- c Department of Anesthesiology , Duke University Medical Center , Durham , NC , USA
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Jagannathan D, Arriaga A, Elterman K, Kodali B, Robinson J, Tsen L, Palanisamy A. Effect of neuraxial technique after inadvertent dural puncture on obstetric outcomes and anesthetic complications. Int J Obstet Anesth 2016; 25:23-9. [DOI: 10.1016/j.ijoa.2015.09.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Revised: 08/27/2015] [Accepted: 09/12/2015] [Indexed: 11/30/2022]
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Cohn J, Moaveni D, Sznol J, Ranasinghe J. Complications of 761 short-term intrathecal macrocatheters in obstetric patients: a retrospective review of cases over a 12-year period. Int J Obstet Anesth 2015; 25:30-6. [PMID: 26421698 DOI: 10.1016/j.ijoa.2015.08.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 08/03/2015] [Accepted: 08/10/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND A continuous spinal catheter is a reliable alternative to standard neuraxial techniques in obstetric anesthesia. Despite the potential advantages of intrathecal catheters, they remain underutilized due to fear of infection, nerve damage or post-dural puncture headache. In our tertiary care center, intrathecal catheters are either placed intentionally in high-risk obstetric patients or following inadvertent dural puncture using a 19-gauge macrocatheter passed through a 17-gauge epidural needle. METHODS A retrospective review of 761 intrathecal catheters placed from 2001 to 2012 was conducted. An institutional obstetric anesthesia database was used to identify patients with intrathecal catheters. Medical records were reviewed for procedural details and complications. RESULTS There were no serious complications, including meningitis, epidural or spinal abscess, hematoma, arachnoiditis, or cauda equina syndrome, associated with intrathecal catheters. The failure rates were 2.8% (3/108) for intentional placements and 6.1% (40/653) for placements following accidental dural puncture. The incidence of post-dural puncture headache was 41% (312/761) and the epidural blood patch rate was 31% (97/312). CONCLUSIONS This review demonstrates that intrathecal catheters are dependable and an option for labor analgesia and surgical anesthesia for cesarean delivery. Serious long-lasting complications are rare.
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Affiliation(s)
- J Cohn
- University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, USA.
| | - D Moaveni
- University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, USA
| | - J Sznol
- University of Miami Public Health Sciences, Miami, FL, USA
| | - J Ranasinghe
- University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, USA
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Verstraete S, Walters MA, Devroe S, Roofthooft E, Van de Velde M. Lower incidence of post-dural puncture headache with spinal catheterization after accidental dural puncture in obstetric patients. Acta Anaesthesiol Scand 2014; 58:1233-9. [PMID: 25307708 DOI: 10.1111/aas.12394] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2014] [Indexed: 01/30/2023]
Abstract
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.
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Affiliation(s)
- S Verstraete
- Department of Anesthesiology, University Hospitals Gasthuisberg, Leuven, Belgium
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The influence of timing on the effectiveness of epidural blood patches in parturients. Int J Obstet Anesth 2013; 22:303-9. [DOI: 10.1016/j.ijoa.2013.04.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Revised: 04/19/2013] [Accepted: 04/30/2013] [Indexed: 11/20/2022]
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Heesen M, Klöhr S, Rossaint R, Walters M, Straube S, van de Velde M. Insertion of an intrathecal catheter following accidental dural puncture: a meta-analysis. Int J Obstet Anesth 2012; 22:26-30. [PMID: 23219220 DOI: 10.1016/j.ijoa.2012.10.004] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2011] [Revised: 10/04/2012] [Accepted: 10/08/2012] [Indexed: 11/28/2022]
Abstract
BACKGROUND Inserting an intrathecal catheter after accidental dural puncture in parturients to prevent postdural puncture headache is becoming increasingly popular. We aimed to identify relevant published articles investigating this intervention and subject data to a meta-analysis. METHODS A systematic literature search was performed, paralleled by a hand search of abstract publications. Studies that reported the dichotomous outcome parameters postdural puncture headache or need for an epidural blood patch were considered eligible. Risk ratios with 95% confidence intervals were calculated. RESULTS We identified nine reports investigating placement of intrathecal catheters after accidental dural puncture. The risk ratio for an epidural blood patch after intrathecal catheter insertion was 0.64 (95% CI 0.49-0.84, P=0.001). The risk ratio for postdural puncture headache was 0.82 (95% CI 0.67-1.01, P=0.06). DISCUSSION Inserting an intrathecal catheter significantly reduced the risk for an epidural blood patch; the incidence of postdural puncture headache was reduced but not significantly. Accidental dural puncture is a rare complication and therefore trials on intervention need to include a large number of patients which is time-consuming and costly. Intrathecal catheterisation is a promising approach for the prevention of postdural puncture headache and should be evaluated further. This intervention has additional benefits including a reduced risk of repeat dural puncture, rapid onset of action and use for anaesthesia.
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Affiliation(s)
- M Heesen
- Department of Anaesthesiology, Klinikum am Bruderwald, Bamberg, Germany.
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Russell IF. A prospective controlled study of continuous spinal analgesia versus repeat epidural analgesia after accidental dural puncture in labour. Int J Obstet Anesth 2011; 21:7-16. [PMID: 22153280 DOI: 10.1016/j.ijoa.2011.10.005] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2010] [Revised: 10/09/2011] [Accepted: 10/20/2011] [Indexed: 01/22/2023]
Abstract
BACKGROUND After accidental dural puncture in labour it is suggested that inserting an intrathecal catheter and converting to spinal analgesia reduces postdural puncture headache and epidural blood patch rates. This treatment has never been tested in a controlled manner. METHODS Thirty-four hospitals were randomised to one of two protocols for managing accidental dural puncture during attempted labour epidural analgesia: repeating the epidural procedure or converting to spinal analgesia by inserting the epidural catheter intrathecally. Hospitals changed protocols at six-month intervals for two years. RESULTS One hundred and fifteen women were recruited but 18 were excluded from initial analysis because of practical complications which had the potential to affect the incidence of headache and blood patch rates. Of the remaining 97 women, 47 were assigned to the repeat epidural group and 50 to the spinal analgesia group. Conversion to spinal analgesia did not reduce the incidence of postdural puncture headache (spinal 72% vs. epidural 62%, P=0.2) or blood patch (spinal 50% vs. epidural 55%, P=0.6). Binary logistic analysis revealed the relative risk of headache increased with 16-gauge vs. 18-gauge epidural needles (RR=2.21, 95% CI 1.4-2.6, P=0.005); anaesthetist inexperience (RR=1.02 per year difference in experience, 95% CI 1.001-1.05, P=0.043), and spontaneous vaginal compared to caesarean delivery (RR=1.58, 95% CI 1.14-1.79, P=0.02). These same factors also increased the risk of a blood patch: 16-gauge vs. 18-gauge needles (RR=2.92, 95% CI 1.37-3.87, P=0.01), anaesthetist inexperience (RR=1.06 per year difference in experience, 95% CI 1.02-1.09, P=0.006), spontaneous vaginal versus caesarean delivery (RR=2.22, 95% CI 1.47-2.63, P=0.002). When all patients were included for analysis of complications, there was a significantly greater requirement for two or more additional attempts to establish neuraxial analgesia associated with repeating the epidural (41% vs. 12%, P=0.0004) and a 9% risk of second dural puncture. CONCLUSIONS Converting to spinal analgesia after accidental dural puncture did not reduce the incidence of headache or blood patch, but was associated with easier establishment of neuraxial analgesia for labour. The most significant factor increasing headache and blood patch rates was the use of a 16-gauge compared to an 18-gauge epidural needle.
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Affiliation(s)
- I F Russell
- Department of Anaesthesia, Hull Royal Infirmary, Hull, East Yorkshire, UK.
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Baysinger CL, Pope JE, Lockhart EM, Mercaldo ND. The management of accidental dural puncture and postdural puncture headache: a North American survey. J Clin Anesth 2011; 23:349-60. [PMID: 21696932 DOI: 10.1016/j.jclinane.2011.04.003] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2010] [Revised: 03/21/2011] [Accepted: 04/20/2011] [Indexed: 02/01/2023]
Affiliation(s)
- Curtis L Baysinger
- Division of Obstetric Anesthesia, Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, TN 37232, USA.
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López Correa T, Garzón Sánchez J, Sánchez Montero F, Muriel Villoria C. Cefalea postpunción dural en obstetricia. REVISTA ESPAÑOLA DE ANESTESIOLOGÍA Y REANIMACIÓN 2011; 58:563-73. [PMID: 22279876 DOI: 10.1016/s0034-9356(11)70141-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Apfel CC, Saxena A, Cakmakkaya OS, Gaiser R, George E, Radke O. Prevention of postdural puncture headache after accidental dural puncture: a quantitative systematic review. Br J Anaesth 2010; 105:255-63. [PMID: 20682567 DOI: 10.1093/bja/aeq191] [Citation(s) in RCA: 106] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
No clear consensus exists on how to best prevent severe headache from occurring after accidental dural puncture. We conducted a quantitative systematic review to identify all available evidence for the prevention of postdural puncture headache (PDPH) and included 17 studies with 1264 patients investigating prophylactic epidural blood patch (PEBP), epidural morphine, intrathecal catheters, and epidural or intrathecal saline. The relative risk (RR) for headache after PEBP was 0.48 [95% confidence interval (CI): 0.23-0.99] in five non-randomized controlled trials (non-RCTs) and 0.32 (0.10-1.03) in four randomized controlled trials (RCTs). The RR for epidural morphine (based on a single RCT) was 0.25 (0.08-0.78). All other interventions were based on non-RCTs and failed statistical significance, including long-term intrathecal catheters with an RR of 0.21 (0.02-2.65). There are a number of promising options to prevent PDPH, yet heterogeneity between the studies and publication bias towards small non-RCTs with positive results limits the available evidence. Thus, a large multicentre RCT is needed to determine the best preventative practices.
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Affiliation(s)
- C C Apfel
- Perioperative Clinical Research Core, Department of Anesthesia and Perioperative Care, University of California at San Francisco, 1600 Divisadero St., San Francisco, CA, USA.
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Van de Velde M. Modern neuraxial labor analgesia: options for initiation, maintenance and drug selection. ACTA ACUST UNITED AC 2010; 56:546-61. [PMID: 20112546 DOI: 10.1016/s0034-9356(09)70457-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
In the present review we outline the state-of-the-art of neuraxial analgesia. As neuraxial analgesia remains the gold standar of analgesia during labor, we review the most recent literature on this topic. The neuraxial analgesia techniques, types of administration, drugs, adjuvants, and adverse effects are investigated from the references. Most authors would agree that central neuraxial analgesia is the best form to manage labor pain. When neuraxial analgesia is administered to the parturient in labor, different management choices must be made by the anesthetist: how will we initiate analgesia, how will analgesia be maintained, which local anesthetic will we use for neuraxial analgesia and which adjuvant drugs will we combine? The present manuscript tries to review the literature to answer these questions.
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Affiliation(s)
- M Van de Velde
- Department of Anesthesiology, University Hospitals Gasthuisberg, Katholieke Universiteit Leuven, Leuven, Belgium.
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Double-space combined spinal-epidural technique for elective caesarean section: a review of 10 years’ experience in a UK teaching maternity unit. Int J Obstet Anesth 2010; 19:183-7. [DOI: 10.1016/j.ijoa.2009.06.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2009] [Revised: 06/23/2009] [Accepted: 06/24/2009] [Indexed: 11/21/2022]
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Newman MJ, Cyna AM, Middleton P. Epidural catheter replacement and intrathecal catheter techniques for preventing post-dural puncture headache following an inadvertent dural puncture in labour. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2010. [DOI: 10.1002/14651858.cd008266] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Matthew J Newman
- Women's and Children's Hospital; Department of Women's Anaesthesia; 72 King William Road Adelaide South Australia Australia 5006
| | - Allan M Cyna
- Women's and Children's Hospital; Department of Women's Anaesthesia; 72 King William Road Adelaide South Australia Australia 5006
| | - Philippa Middleton
- The University of Adelaide; ARCH: Australian Research Centre for Health of Women and Babies, Discipline of Obstetrics and Gynaecology; Women's and Children's Hospital 72 King William Road Adelaide South Australia Australia 5006
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Intrathecal catheterization after unintentional dural puncture during orthopedic surgery. J Anesth 2010; 24:43-8. [PMID: 20058033 DOI: 10.1007/s00540-009-0858-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2009] [Accepted: 10/10/2009] [Indexed: 10/20/2022]
Abstract
PURPOSE We investigated whether inserting an intrathecal catheter and leaving it in place for 24 h after an unintentional dural puncture in orthopedic patients reduced the incidence of post-dural puncture headache (PDPH). METHODS The study consisted of 427 patients in whom a total of 21 unintentional dural punctures had occurred during orthopedic surgery performed between 2002 and 2006. Seven patients (phase I; evaluated retrospectively) each underwent placement of an epidural catheter at another level after dural puncture during the period January 2002 to February 2004. Fourteen patients (phase II; evaluated prospectively) received an epidural catheter through the dural tear after an unintentional dural puncture during the period February 2004-March 2006 RESULTS In phase I, 5 of the 7 patients experienced PDPH, and one required an epidural blood patch. In phase II, only one of the 14 patients complained of PDPH, which resolved after 48 h of medical therapy. No patient experienced paresthesia, neurologic or hemorrhagic complication, or infection. CONCLUSION Inserting an epidural catheter through the dural tear following an unintentional dural puncture and leaving it in place for 24 h significantly reduces the incidence of PDPH.
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Van de Velde M, Schepers R, Berends N, Vandermeersch E, De Buck F. Ten years of experience with accidental dural puncture and post-dural puncture headache in a tertiary obstetric anaesthesia department. Int J Obstet Anesth 2008; 17:329-35. [PMID: 18691871 DOI: 10.1016/j.ijoa.2007.04.009] [Citation(s) in RCA: 113] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2007] [Accepted: 04/01/2007] [Indexed: 01/22/2023]
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Newman MJ, Cyna AM. Immediate management of inadvertent dural puncture during insertion of a labour epidural: a survey of Australian obstetric anaesthetists. Anaesth Intensive Care 2008; 36:96-101. [PMID: 18326140 DOI: 10.1177/0310057x0803600117] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- M J Newman
- Department of Women's Anaesthesia, Women's and Children's Hospital, Adelaide, South Australia, Australia
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Sleth JC, Saizy C, Servais R, Pluskwa F, Lafforgue E. [Intrathecal catheter after wet tap in labour: headache prevention?]. ACTA ACUST UNITED AC 2006; 25:1083-4. [PMID: 17005360 DOI: 10.1016/j.annfar.2006.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Awsare AN, Patwardhan A, Wagle A. Intrathecal catheters after dural puncture--some unanswered questions. Anaesthesia 2005; 60:1243-4. [PMID: 16288628 DOI: 10.1111/j.1365-2044.2005.04447.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Yentis SM. Enthusing about infusing after dural puncture. Int J Obstet Anesth 2004; 10:332. [PMID: 15321601 DOI: 10.1054/ijoa.2001.0907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Choi PT, Galinski SE, Takeuchi L, Lucas S, Tamayo C, Jadad AR. PDPH is a common complication of neuraxial blockade in parturients: a meta-analysis of obstetrical studies. Can J Anaesth 2003; 50:460-9. [PMID: 12734154 DOI: 10.1007/bf03021057] [Citation(s) in RCA: 211] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Peter T Choi
- Department of Anesthesia, St. Joseph's Healthcare and McMaster University, 1200 Main Street West, Room HSC-2U5, Hamilton, Ontario L8N 3Z5, Canada.
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Chan TML, Ahmed E, Yentis SM, Holdcroft A. Postpartum headaches: summary report of the National Obstetric Anaesthetic Database (NOAD) 1999. Int J Obstet Anesth 2003; 12:107-12. [PMID: 15321498 DOI: 10.1016/s0959-289x(03)00007-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/01/2002] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- T M L Chan
- Department of Anaesthesia, King's College Hospital, London, UK
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Abstract
In maternity units in which central neuraxial techniques are frequently used, newer methods of epidural drug delivery (continuous infusion, patient-controlled) are well established and combined spinal-epidural analgesia is commonly used. Continuous spinal analgesia has reemerged as a useful approach after accidental dural puncture. Lumbar sympathetic block has been revisited and the safety of paracervical nerve block improved. The analgesic properties of systemic opioid in labor are poor, but PCIA at least has psychological benefits and allows rapid drug titration. PCIA is again under investigation because of the potent antinociceptive effects of the short-acting mu-opioid agonist, remifentanil. The premixing of nitrous oxide and a subanesthetic concentration of volatile anesthetic for patient-controlled administration has been tested under control of midwifery staff and without direct medical supervision.
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Affiliation(s)
- Michael Paech
- Department of Medicine and Pharmacology, University of Western Australia, Department of Anaesthesia and Pain Medicine, King Edward Memorial Hospital for Women and Royal Perth Hospitals, Western Australia, Australia.
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Abstract
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.
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Affiliation(s)
- Pirjo O Ranta
- Department of Anaesthesiology and Intensive Care Medicine, Oulu University, Oulu, Finland.
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Total spinal with levobupivacaine: the ‘hole’ story. Int J Obstet Anesth 2002. [DOI: 10.1054/ijoa.2001.0932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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