Management practices for postdural puncture headache in obstetrics: a prospective, international, cohort study

BACKGROUND

Accidental dural puncture is an uncommon complication of epidural analgesia and can cause postdural puncture headache (PDPH). We aimed to describe management practices and outcomes after PDPH treated by epidural blood patch (EBP) or no EBP.

METHODS

Following ethics committee approval, patients who developed PDPH after accidental dural puncture were recruited from participating countries and divided into two groups, those receiving EBP or no EBP. Data registered included patient and procedure characteristics, headache symptoms and intensity, management practices, and complications. Follow-up was at 3 months.

RESULTS

A total of 1001 patients from 24 countries were included, of which 647 (64.6%) received an EBP and 354 (35.4%) did not receive an EBP (no-EBP). Higher initial headache intensity was associated with greater use of EBP, odds ratio 1.29 (95% confidence interval 1.19-1.41) per pain intensity unit increase. Headache intensity declined sharply at 4 h after EBP and 127 (19.3%) patients received a second EBP. On average, no or mild headache (numeric rating score≤3) was observed 7 days after diagnosis. Intracranial bleeding was diagnosed in three patients (0.46%), and backache, headache, and analgesic use were more common at 3 months in the EBP group.

CONCLUSIONS

Management practices vary between countries, but EBP was more often used in patients with greater initial headache intensity. EBP reduced headache intensity quickly, but about 20% of patients needed a second EBP. After 7 days, most patients had no or mild headache. Backache, headache, and analgesic use were more common at 3 months in patients receiving an EBP.

Failed epidural for labor: what now?

Labor epidural failure is a challenging situation for the obstetric anesthetist, especially when associated to high risk of caesarean delivery, obesity, and difficult airway predictors. Labor epidural failure is still not standardly defined, consequently its incidence is uncertain: improving the knowledge of risk factors related to failure will increase epidural block success rate. Prolonged labors, previous history of epidural failure, and repeated top-ups needed during labor are recognized risk factors for failure. Clinical experience and the use of modern equipment (ultrasound guided blocks), as well as the choice of neuraxial technique (epidural versus combined spinal-epidural) may affect failure rate. Software-controlled infusion pumps seem to increase epidural analgesia success rate. Among non-technical skills, good communication among medical team members and parturient women is another pivotal point to achieve a satisfactory analgesia for labor. Clear algorithms should be promoted where epidural failure during labor or caesarean delivery may occur.

Neuromuscular block in Italy: a survey of current management

BACKGROUND

Little is known about current use of neuromuscular blocking agents by Italian anesthetists. This paper reports the results of a survey conducted to obtain information about current management of neuromuscular block in Italy.

METHODS

A questionnaire was given to Italian Anesthetists attending the 64nd National Congress of the Italian Society of Anesthesia, Intensive Care, Analgesia and Intensive Therapy S.I.A.A.R.T.I. (Parma, 13th-16th October 2010). Collected data were stratified by age, geographical location, and the total number of surgical procedures performed in the hospitals concerned.

RESULTS

One thousand four hundred forty patients correctly compiled questionnaires were collected. 50% of respondents used clinical tests to monitor the level of neuromuscular blockade. The main clinical tests cited for the evaluation were: keeping the head lifted up for 5 seconds, protruding the tongue and opening the eyes. Train-of-four was used by 50% of respondents on a routine basis. Only 33% of anesthetists reply that a train-of-four ratio of 90% or more is the safe level prior to extubation.

CONCLUSION

Clinical signs are used by most of the Italian anesthetists to assess the recovery from neuromuscular blockade. There is poor awareness about their inability to indicate even a significant degree of residual neuromuscular block. A more extensive use of quantitative instrumental monitoring is required for the more rational use of neuromuscular blocking agents.

Knowledge of residual curarization: an Italian survey

BACKGROUND

The use of neuromuscular blocking agents (NMBAs) is widespread in anesthetic practice; little is known about the current use of these drugs in Italy. This survey was conducted to obtain information about the most commonly used clinical tests and the train-of-four (TOF) ratios that are considered as being reliable for assessing recovery from neuromuscular blockade at the end of anesthesia and the estimated occurrence rates of post-operative paralysis in Italian hospitals.

METHODS

The questionnaire was given to Italian anesthesiologists attending the 62nd National Congress of the Italian Society of Anesthesia, Analgesia and Intensive Therapy. Collected data were stratified by age and the total number of surgical procedures performed in the hospitals concerned.

RESULTS

Seven hundred and fifty-four correctly compiled questionnaires were collected (response rate 88.7%). Seventy three percent of the respondents only used clinical tests for monitoring the level of neuromuscular blockade. The main clinical tests cited for the evaluation of residual paralysis were keeping the head lifted up for 5 s, protruding the tongue and opening the eyes. TOF was used by 35% of the respondents on a routine basis. Only 24% of the interviewed anesthesiologists reported that before extubation, a TOF ratio of at least 0.9 should be reached.

CONCLUSIONS

Most Italian anesthetists assess the recovery from neuromuscular blockade only by clinical signs. There is poor awareness about the inability of such techniques to indicate even a significant amount of residual neuromuscular block. A more extensive use of quantitative instrumental monitoring is required for the more rational use of NMBAs.