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Uppal V, Russell R, Sondekoppam RV, Ansari J, Baber Z, Chen Y, DelPizzo K, Dirzu DS, Kalagara H, Kissoon NR, Kranz PG, Leffert L, Lim G, Lobo C, Lucas DN, Moka E, Rodriguez SE, Sehmbi H, Vallejo MC, Volk T, Narouze S. Evidence-based clinical practice guidelines on postdural puncture headache: a consensus report from a multisociety international working group. Reg Anesth Pain Med 2024; 49:471-501. [PMID: 37582578 DOI: 10.1136/rapm-2023-104817] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 07/25/2023] [Indexed: 08/17/2023]
Abstract
INTRODUCTION Postdural puncture headache (PDPH) can follow unintentional dural puncture during epidural techniques or intentional dural puncture during neuraxial procedures such as a lumbar puncture or spinal anesthesia. Evidence-based guidance on the prevention, diagnosis or management of this condition is, however, currently lacking. This multisociety guidance aims to fill this void and provide practitioners with comprehensive information and patient-centric recommendations to prevent, diagnose and manage patients with PDPH. METHODS Based on input from committee members and stakeholders, the committee cochairs developed 10 review questions deemed important for the prevention, diagnosis and management of PDPH. A literature search for each question was performed in MEDLINE (Ovid) on 2 March 2022. The results from each search were imported into separate Covidence projects for deduplication and screening, followed by data extraction. Additional relevant clinical trials, systematic reviews and research studies published through March 2022 were also considered for the development of guidelines and shared with contributors. Each group submitted a structured narrative review along with recommendations graded according to the US Preventative Services Task Force grading of evidence. The interim draft was shared electronically, with each collaborator requested to vote anonymously on each recommendation using two rounds of a modified Delphi approach. RESULTS Based on contemporary evidence and consensus, the multidisciplinary panel generated 50 recommendations to provide guidance regarding risk factors, prevention, diagnosis and management of PDPH, along with their strength and certainty of evidence. After two rounds of voting, we achieved a high level of consensus for all statements and recommendations. Several recommendations had moderate-to-low certainty of evidence. CONCLUSIONS These clinical practice guidelines for PDPH provide a framework to improve identification, evaluation and delivery of evidence-based care by physicians performing neuraxial procedures to improve the quality of care and align with patients' interests. Uncertainty remains regarding best practice for the majority of management approaches for PDPH due to the paucity of evidence. Additionally, opportunities for future research are identified.
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Affiliation(s)
- Vishal Uppal
- Department of Anesthesia, Pain Management & Perioperative Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Robin Russell
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Rakesh V Sondekoppam
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Jessica Ansari
- Anesthesia Department, Stanford Health Care, Stanford, California, USA
| | - Zafeer Baber
- Department of Anesthesiology and Perioperative Medicine, Newton-Wellesley Hospital, Newton, Massachusetts, USA
| | - Yian Chen
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California, USA
| | - Kathryn DelPizzo
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA
| | - Dan Sebastian Dirzu
- Anesthesia and Intensive Care, Emergency County Hospital Cluj-Napoca, Cluj-Napoca, Romania
| | - Hari Kalagara
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic in Florida, Jacksonville, Florida, USA
| | - Narayan R Kissoon
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Peter G Kranz
- Depatement of Radiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Lisa Leffert
- Department of Anesthesiology, Yale New Haven Health System; Yale University School of Medicine, New Haven, Connecticut, USA
| | - Grace Lim
- Department of Anesthesiology & Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Obstetrics & Gynecology, Magee Womens Hospital of UPMC, Pittsburgh, Pennsylvania, USA
| | - Clara Lobo
- Anesthesiology Institute, Interventional Pain Medicine Department, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
| | - Dominique Nuala Lucas
- Department of Anaesthesia, London North West Healthcare NHS Trust, Harrow, London, UK
| | - Eleni Moka
- Department of Anaesthesiology, Creta Interclinic Hospital - Hellenic Healthcare Group (HHG), Heraklion, Crete, Greece
| | - Stephen E Rodriguez
- Department of Anesthesia, Walter Reed Army Medical Center, Bethesda, Maryland, USA
| | - Herman Sehmbi
- Department of Anesthesia, Western University, London, Ontario, Canada
| | - Manuel C Vallejo
- Departments of Medical Education, Anesthesiology, Obstetrics & Gynecology, West Virginia University, Morgantown, West Virginia, USA
| | - Thomas Volk
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Germany
| | - Samer Narouze
- Northeast Ohio Medical University, Rootstown, Ohio, USA
- Center for Pain Medicine, Western Reserve Hospital, Cuyahoga Falls, OH, USA
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Berger A, Jordan J, Li Y, Kowalczyk J, Hess P. Epidural catheter replacement rates with dural puncture epidural labor analgesia compared with epidural analgesia without dural puncture: a retrospective cohort study. Int J Obstet Anesth 2022; 52:103590. [DOI: 10.1016/j.ijoa.2022.103590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 07/05/2022] [Accepted: 07/28/2022] [Indexed: 11/28/2022]
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DelPizzo K, Cheng J, Dong N, Edmonds CR, Kahn RL, Fields KG, Curren J, Rotundo V, Zayas VM. Post-Dural Puncture Headache is Uncommon in Young Ambulatory Surgery Patients. HSS J 2017; 13:146-151. [PMID: 28690464 PMCID: PMC5481263 DOI: 10.1007/s11420-017-9541-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 01/06/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND The incidence of post-dural puncture headache (PDPH) arising from spinal anesthesia in the general population is low. However, patients under 45 years have been shown to exhibit a higher incidence of PDPH, even with small needles. QUESTIONS/PURPOSES This study aimed to estimate the incidence of PDPH from a 27G pencil-point needle in ambulatory surgery patients between the ages of 15-45 years and compare incidence of PDPH by age group, sex, and history of headache. METHODS In this prospective cohort study, 300 patients (15-45 years old) who underwent simple knee arthroscopy under spinal anesthesia with a 27G pencil-point needle were enrolled. Verbal consent was obtained during the initial phone conversation between post-operative days (PODs) 2-5. A PDPH questionnaire was administered during this conversation and between PODs 7-10. Patients who reported a positional headache were contacted by a physician co-investigator, who determined PDPH diagnosis. RESULTS Five patients were excluded from analysis due to complicated operative procedures or spinal needle size. The overall PDPH incidence was 2.0% (95% CI 0.9-4.4; 6/295). PDPH incidence in 15-19-year-old patients was 16.7% (95% CI 4.7-44.8; 2/12). The crude relative risk of PDPH was 15.4 (95% CI 2.8-114.4) for patients with and without history of headache and 2.5 (95% CI 0.5-14.8) for females vs. males. Overall, 16.3% (95% CI 12.5-20.9) of patients reported post-operative, non-positional headaches. CONCLUSIONS There was a low overall incidence of PDPH among patients aged 15-45. Pre-planned subgroup analyses of PDPH incidence by age group revealed a high risk of PDPH among a small sample of 15-19-year-olds.
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Affiliation(s)
- Kathryn DelPizzo
- Department of Anesthesiology, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Jennifer Cheng
- Department of Anesthesiology, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Naomi Dong
- Department of Anesthesiology, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Chris R. Edmonds
- Department of Anesthesiology, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Richard L. Kahn
- Department of Anesthesiology, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Kara G. Fields
- Healthcare Research Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Jodie Curren
- Department of Anesthesiology, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Valeria Rotundo
- Department of Anesthesiology, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Victor M. Zayas
- Department of Anesthesiology, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
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Chau A, Bibbo C, Huang CC, Elterman KG, Cappiello EC, Robinson JN, Tsen LC. Dural Puncture Epidural Technique Improves Labor Analgesia Quality With Fewer Side Effects Compared With Epidural and Combined Spinal Epidural Techniques. Anesth Analg 2017; 124:560-569. [DOI: 10.1213/ane.0000000000001798] [Citation(s) in RCA: 121] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Loures V, Savoldelli G, Kern K, Haller G. Atypical headache following dural puncture in obstetrics. Int J Obstet Anesth 2014; 23:246-52. [DOI: 10.1016/j.ijoa.2014.04.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Revised: 04/09/2014] [Accepted: 04/17/2014] [Indexed: 11/26/2022]
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[Post-dural puncture headache and blood-patch: theoretical and practical approach]. ACTA ACUST UNITED AC 2013; 32:325-38. [PMID: 23566592 DOI: 10.1016/j.annfar.2013.02.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2012] [Accepted: 02/11/2013] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To review the current research and formulate a rational approach to the physiopathology, cause and treatment of post-dural puncture headache (PDPH). DATA SOURCES Articles published to December 2011 were obtained through a search of Medline for the MeSh terms "epidural blood-patch" and "post-dural puncture headache". STUDY SELECTION Six hundred and eighty-two pertinent studies were included and 200 were analysed. DATA SYNTHESIS Resulting of a dural tap after spinal anaesthesia or diagnostic lumbar puncture or as a complication of epidural anaesthesia, PDPH occurs when an excessive leak of cerebrospinal fluid leads to intracranial hypotension associated to a resultant cerebral vasodilatation. Reduction in cerebrospinal fluid volume in upright position may cause traction of the intracranial structure and stretching of vessels. Typically postural, headache may be associated to nausea, photophobia, tinnitus or arm pain and changes in hearing acuity. In severe cases, there may be cranial nerve dysfunction and nerve palsies secondary to traction on those nerves. The Epidural Blood-Patch (EBP) is considered as the "gold standard" in the treatment of PDHP because it induces a prolonged elevation of subarachnoid and epidural pressures, whereas such elevation is transient with saline or dextran. EBP should be performed within 24-48hours of onset of headache; the optimum volume of epidural blood appears to be 15-20mL. Severe complications following EBP are exceptional. The use of echography may be safety puncture. The optimum timing of epidural blood-patch, the resort of repeating procedure if the symptomatology does not disappear, the alternative to the conventional medical treatment need to be determined by future clinical trial.
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Rao DP, Rao VA. Morbidly obese parturient: Challenges for the anaesthesiologist, including managing the difficult airway in obstetrics. What is new? Indian J Anaesth 2011; 54:508-21. [PMID: 21224967 PMCID: PMC3016570 DOI: 10.4103/0019-5049.72639] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The purpose of this article is to review the fundamental aspects of obesity, pregnancy and a combination of both. The scientific aim is to understand the physiological changes, pathological clinical presentations and application of technical skills and pharmacological knowledge on this unique clinical condition. The goal of this presentation is to define the difficult airway, highlight the main reasons for difficult or failed intubation and propose a practical approach to management Throughout the review, an important component is the necessity for team work between the anaesthesiologist and the obstetrician. Certain protocols are recommended to meet the anaesthetic challenges and finally concluding with “what is new?” in obstetric anaesthesia.
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Affiliation(s)
- Durga Prasada Rao
- Department of Anaesthesiology, Siddhartha Medical College, Government General Hospital, Government of Andhra Pradesh, Vijayawada, India
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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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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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Cappiello E, O'Rourke N, Segal S, Tsen LC. A Randomized Trial of Dural Puncture Epidural Technique Compared with the Standard Epidural Technique for Labor Analgesia. Anesth Analg 2008; 107:1646-51. [DOI: 10.1213/ane.0b013e318184ec14] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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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: 111] [Impact Index Per Article: 6.9] [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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Viira DJ, Courtman S, Coghill J. Technical difficulties and complication rates associated with the use of combined spinal-epidural anaesthesia for caesarean section. Int J Obstet Anesth 2008; 17:86-7. [PMID: 17693081 DOI: 10.1016/j.ijoa.2007.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Soens MA, Birnbach DJ, Ranasinghe JS, van Zundert A. Obstetric anesthesia for the obese and morbidly obese patient: an ounce of prevention is worth more than a pound of treatment. Acta Anaesthesiol Scand 2008; 52:6-19. [PMID: 18173431 DOI: 10.1111/j.1399-6576.2007.01483.x] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The incidence of obesity has been dramatically increasing across the globe. Anesthesiologists, are increasingly faced with the care for these patients. Obesity in the pregnant woman is associated with a broad spectrum of problems, including dramatically increased risk for cesarean delivery, diabetes, hypertension and pre-eclampsia. A thorough understanding of the physiology, associated conditions and morbidity, available options for anesthesia and possible complications is therefore important for today's anesthesiologist. METHODS This is a personal review in which different aspects of obesity in the pregnant woman, that are relevant to the anesthesiologist, are discussed. An overview of maternal and fetal morbidity and physiologic changes associated with pregnancy and obesity is provided and different options for labor analgesia, the anesthetic management for cesarean delivery and potential post-partum complications are discussed in detail. RESULTS AND CONCLUSION The anesthetic management of the morbidly obese parturient is associated with special hazards. The risk for difficult or failed intubation is exceedingly high. The early placement of an epidural or intrathecal catheter may overcome the need for general anesthesia, however, the high initial failure rate necessitates critical block assessment and catheter replacement when indicated.
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MESH Headings
- Adult
- Anesthesia, Epidural/adverse effects
- Anesthesia, Epidural/methods
- Anesthesia, General/adverse effects
- Anesthesia, General/methods
- Anesthesia, Obstetrical/adverse effects
- Anesthesia, Obstetrical/methods
- Anesthesia, Spinal/adverse effects
- Anesthesia, Spinal/methods
- Cesarean Section
- Continuous Positive Airway Pressure
- Death, Sudden, Cardiac/etiology
- Death, Sudden, Cardiac/prevention & control
- Dyspnea/etiology
- Dyspnea/physiopathology
- Female
- Fetal Diseases/prevention & control
- Hemodynamics
- Humans
- Obesity/physiopathology
- Obesity, Morbid/physiopathology
- Obstetric Labor Complications/physiopathology
- Postoperative Complications/prevention & control
- Pregnancy
- Pregnancy Complications/physiopathology
- Puerperal Disorders/prevention & control
- Respiratory Aspiration/prevention & control
- Respiratory Mechanics
- Risk
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Affiliation(s)
- Mieke A Soens
- Department of Anesthesiology, Perioperative Medicine and Pain Management, Jackson Memorial Hospital, Miami, FL 33136, USA
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Ho KY, Gan TJ. Management of persistent post-dural puncture headache after repeated epidural blood patch. Acta Anaesthesiol Scand 2007; 51:633-6. [PMID: 17430328 DOI: 10.1111/j.1399-6576.2007.01283.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- K-Y Ho
- Department of Anaesthesia and Surgical Intensive Care, Singapore General Hospital, Outram Road, Singapore 169608.
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Karaman S, Akercan F, Akarsu T, Firat V, Ozcan O, Karadadas N. Comparison of the maternal and neonatal effects of epidural block and of combined spinal–epidural block for Cesarean section. Eur J Obstet Gynecol Reprod Biol 2005; 121:18-23. [PMID: 15989982 DOI: 10.1016/j.ejogrb.2004.08.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2004] [Revised: 07/01/2004] [Accepted: 08/05/2004] [Indexed: 11/27/2022]
Abstract
BACKGROUND Combined spinal-epidural block (CSEB) has aroused increasing interest, as it combines the reliability of a spinal block and the flexibility of an epidural block (EB). We have conducted a comparative investigation of the maternal and fetal effects of CSEB and of EB administered for Cesarean section. METHODS Eighty pregnant women at term were randomized into two groups. Women in the CSEB group (N = 40) were each given 1.5-1.8 mL 0.5% hyperbaric bupivacaine intrathecally, followed by 10 mL 0.25% bupivacaine and 50 microg fentanyl through the epidural catheter 10 min later. Women in the EB group (N = 40) received 14-16 mL 0.5% bupivacaine and 100 microg fentanyl. The quality and side effects of surgical anesthesia and the hemodynamic parameters, Apgar scores, and postoperative duration of pain were compared between the two groups. RESULTS The time for the block to reach the T-4 level differed significantly between the two groups (8.02 +/- 3.4 versus 18.34 +/- 4.6; P < 0.01). More women in the CSEB group achieved complete motor blockade (Bromage score 3), and it was reached earlier than in the EB group (P < 0.05). Muscle relaxation and motor block were better in the CSEB group than in the EB group (P < 0.01). Apgar scores were 7 or more in almost all newborns in both groups. There were no significant differences between the groups in the incidences of adverse effects such as hypotension or nausea and vomiting, but the patients in the EB group experienced more shivering (P < 0.001). The time to postoperative pain was significantly shorter in the CSEB group. CONCLUSION We decided that CSEB, and more specifically spinal anesthesia with supporting epidural anesthesia, has greater efficacy and fewer side effects than EB when administered for Cesarean section.
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Affiliation(s)
- Semra Karaman
- Department of Anesthesiology and Reanimation, Ege University Faculty of Medicine, Izmir, Turkey
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Van de Velde M, Teunkens A, Hanssens M, Vandermeersch E, Verhaeghe J. Intrathecal Sufentanil and Fetal Heart Rate Abnormalities: A Double-Blind, Double Placebo-Controlled Trial Comparing Two Forms of Combined Spinal Epidural Analgesia with Epidural Analgesia in Labor. Anesth Analg 2004; 98:1153-1159. [PMID: 15041616 DOI: 10.1213/01.ane.0000101980.34587.66] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
UNLABELLED Combined spinal epidural analgesia (CSE) for labor pain relief has become increasingly popular. However, the effect of intrathecal sufentanil on the incidence of uterine hyperactivity and fetal heart rate (FHR) abnormalities remains controversial. We hypothesized that the use of intrathecal sufentanil in a dose of 7.5 microg is more likely to induce a nonreassuring FHR tracing than a small dose of spinal sufentanil combined with bupivacaine or epidural analgesia. Three-hundred parturients were randomized into three groups. In the first group, epidural analgesia was initiated with 12.5 mg of bupivacaine, 12.5 microg of epinephrine, and 7.5 microg of sufentanil in a volume of 10 mL (EPD group). In Group 2, initial intrathecal analgesia consisted of 2.5 mg of bupivacaine, 2.5 microg of epinephrine, and 1.5 microg of sufentanil (BSE group); in Group 3, spinal analgesia consisted of 7.5 microg of sufentanil (SUF group). Analgesia was maintained in all groups with patient-controlled epidural analgesia using bupivacaine 0.125%, 1.25 microg/mL of epinephrine, and 0.75 microg/mL of sufentanil (bolus, 4 mL; lockout, 15 min). Cardiotocography was monitored continuously 15 min before analgesia and for 60 min after the start of analgesia. The quality of analgesia, labor, and neonatal outcome and side effects were recorded. Twenty-four percent of patients in the SUF group developed FHR abnormalities (bradycardia or late decelerations) during the first hour after initiation of analgesia compared with 12% in the BSE group and 11% in the EPD group. Uterine hyperactivity occurred in 12% of parturients in the SUF group but in only 2% in the other groups. Onset of analgesia was more rapid in both CSE groups as compared with the EPD group. However, 29% of patients in the BSE group developed severe hypotension, requiring IV ephedrine (29% in the BSE group versus 7% and 12% in the EPD and SUF groups, respectively). All these differences reached statistical significance. The present data corroborate previous recommendations of caution when performing CSE using a large dose (7.5 microg or more) of spinal sufentanil because of the risk of uterine hyperactivity and FHR abnormalities. IMPLICATIONS Combined spinal epidural analgesia (CSE) produces pain relief during labor. Fetal heart rate changes after CSE using intrathecal sufentanil have been reported. We performed a randomized, blinded trial confirming that fetal heart rate changes are more frequent after CSE using 7.5 micro g of intrathecal sufentanil as compared with other forms of neuraxial labor analgesia.
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MESH Headings
- Adult
- Analgesia, Epidural/adverse effects
- Analgesia, Obstetrical/adverse effects
- Analgesia, Patient-Controlled
- Analgesics, Opioid/administration & dosage
- Analgesics, Opioid/adverse effects
- Anesthetics, Local
- Apgar Score
- Bupivacaine
- Dose-Response Relationship, Drug
- Double-Blind Method
- Female
- Heart Rate/drug effects
- Heart Rate, Fetal/drug effects
- Humans
- Infant, Newborn
- Injections, Spinal
- Nerve Block
- Pain Measurement
- Pregnancy
- Pregnancy Outcome
- Sufentanil/administration & dosage
- Sufentanil/adverse effects
- Uterine Contraction/drug effects
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Affiliation(s)
- M Van de Velde
- Departments of *Anesthesiology and †Obstetrics and Gynecology, University Hospitals Gasthuisberg, Katholieke Universiteit Leuven, Herestraat, Belgium
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Abstract
In <25 years, intrathecal administration of opioids (i.e. spinal analgesia) has evolved from an experimental model into an important therapy for obstetric analgesia and anaesthesia. A small dose of opioid delivered into the CSF provides almost immediate relief from labour pain with minimal risks to the mother and fetus. Careful attention, and prompt treatment when needed, can ameliorate the adverse effects of fetal bradycardia, respiratory depression and pruritus. The major limitation of intrathecal opioids for labour analgesia is the short duration of effect: 90-180 minutes under ideal circumstances. To address this problem, and to increase flexibility for anaesthesia as well as analgesia, the combined spinal-epidural (CSE) technique was developed. The CSE technique involves injection of drugs into the CSF and placement of an epidural catheter. An intrathecally administered opioid provides a rapid onset of labour analgesia without motor block or significant haemodynamic perturbation. The epidural catheter allows ongoing administration of medications to maintain labour analgesia and provides a means of delivering anaesthesia for operative delivery. This review will focus on intrathecally administered opioids as used as part of CSE analgesia. Considerable research has focused on the optimum dose of opioids when delivered intrathecally, with or without adjuncts, in the CSE technique. Fentanyl and sufentanil, two of the lipophilic synthetic opioids, have emerged as the most useful. Bupivacaine, a long-acting local anaesthetic, is often added to prolong the duration of analgesia, although this tends to increase the likelihood of motor blockade of the lower extremities. Comparisons of the CSE technique with standard epidural practices have shown that both are effective means of providing analgesia during labour. Controversy revolves around the incidence of fetal bradycardia following CSE and whether this phenomenon increases the rate of operative deliveries. The rapid onset of analgesia with intrathecally administered opioids must be balanced against the added risks of dural puncture and considered in the context of the whole duration of labour. Ultimately, the decision to choose a CSE technique depends on the experience of the anaesthesia provider and the local availability of drugs, equipment and monitoring capabilities.
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Affiliation(s)
- Peter DeBalli
- Division of Women's Anesthesia, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina 27710, USA.
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Abstract
In recent years, the use of regional anaesthesia techniques for surgery, obstetrics and post operative pain management have increased in popularity. The combined spinal-epidural (CSE) technique has attained widespread popularity for patients undergoing major surgery below the umbilicus who may require prolonged and effective postoperative analgesia. The CSE technique is now well established in several institutions. This chapter includes the clinical experience, advantages and potential problems, and discusses future perspectives of the CSE technique.
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Affiliation(s)
- Narinder Rawal
- Department of Clinical Medicine, Division of Anaesthesiology, Orebro University Hospital, SE - 701 85 Orebro, Sweden
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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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Van de Velde M. Neuraxial opioids for labour analgesia: analgesic efficiency and effect on labour. Curr Opin Anaesthesiol 2002; 15:299-303. [PMID: 17019216 DOI: 10.1097/00001503-200206000-00004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Neuraxial opioids have changed the practice of obstetric anaesthesia and analgesia dramatically. Excellent analgesia with minimal side effects started an era of ever increasing numbers of women who opt for the 'painless birth experience'. Several papers have been reported during 2001 that examine analgesic efficacy, maternal side effects, and effect on foetal well-being of epidural and spinal opioids. Foetal bradycardia following intrathecal opioid analgesia, an increasingly popular technique, has attracted particular attention over the past few years. The present review addresses recently reported work that, according to the author, is key to this field.
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Affiliation(s)
- Marc Van de Velde
- Department of Anesthesiology, University Hospitals Gasthuisberg, Katholieke Universiteit Leuven, Leuven, Belgium.
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