PREVENTION STRATEGY FOR POSTDURAL PUNCTURE HEADACHE PDPH Berrin
PREVENTION STRATEGY FOR POSTDURAL PUNCTURE HEADACHE (PDPH) Berrin Gunaydin, MD, Ph. D Department of Anesthesiology and Reanimation Faculty of Medicine-Gazi University Ankara-Turkey
AIM § Anesthetic management of a parturient after unintentional dural puncture during epidural insertion for cesarean delivery and strategy to prevent PDPH 10/21/2021 Gunaydin & Karaca. Acta Anaesthesiol Belg 2006; 70: 823 -30
Case Report Parturient § ASA II, 26 year-old primigravid § 38 weeks of gestation § 69 kg and 167 cm Preparation for Epidural Anesthesia § 10 ml/kg Ringer lactate infusion § 10 mg metoclopramide and 50 mg ranitidin iv § Monitorization (heart rate, blood pressure, peripheral oxygen saturation) 10/21/2021 Gunaydin & Karaca. Acta Anaesthesiol Belg 2006; 70: 823 -30
Case Report Epidural Anesthesia § Epidural 18 G Touhy needle, 20 G catheter § Loss of resistance to saline § Between L 2 -3 intervertebral space § Sitting position by midline approach § Accidental dural puncture at 4. 5 cm depth § Suddenly spontaneous backflow of CSF in the loss of syringe 10/21/2021 Gunaydin & Karaca. Acta Anaesthesiol Belg 2006; 70: 823 -30
Management § Initially, CSF in the syringe was injected back into the subarachnoid space § 7. 5 mg of hyperbaric bupivacaine with 20 µg of fentanyl was injected into the subarachnoid space through epidural needle § Then, epidural needle was removed 10/21/2021 Gunaydin & Karaca. Acta Anaesthesiol Belg 2006; 70: 823 -30
Resiting epidural catheter • • 10/21/2021 Between L 3 -4 intervertebral space for further top-up and/or postoperative analgesia Sensory block level was T 10 Therefore, following epidural test dose administration (3 ml 2% lidocaine including 5 µg/ml adrenaline) 3 ml 0. 5% plain bupivacaine was given through the epidural catheter Then, sensory block reached to T 4 and surgery was allowed Gunaydin & Karaca. Acta Anaesthesiol Belg 2006; 70: 823 -30
Further Management • • Epidural catheter was kept in situ for 48 hours When sensory blocked regressed to T 10, PCA pump was connected PCA settings • 4 ml/h basal infusion of 0. 125% bupivacaine with 2 µg/ml fentanyl • 10 min lock-out • 6 ml bolus on demand • 35 ml for 4 h limit 10/21/2021 Gunaydin & Karaca. Acta Anaesthesiol Belg 2006; 70: 823 -30
Further Management • • • Epidural catheter was removed after 48 hours Parturient received 370 ml PCA solution No PDPH was observed 10/21/2021 Gunaydin & Karaca. Acta Anaesthesiol Belg 2006; 70: 823 -30
Pathophysiology of PDPH § Total volume of CSF in an adult 150 m. L § 50% of which is in the cranium § 75 ml supraspinal, 75 ml spinal § 450 -500 m. L of CSF is produced daily (0. 35 ml/min) § CSF pressure in the lumbar region § in the supine position is between 5 to 15 cm. H 2 O § in the vertical position it exceeds 40 cm. H 2 O 10/21/2021
Mechanism of PDPH There are no pain receptors in the brain itself Headaches are often caused by irritation of dura CSF cushions the brain by filling the subarachnoid space 10/21/2021
Mechanism of PDPH § Persistent CSF loss through the hole § Decrease in the CSF volume and/or pressure leading to shift of the intracranial contents and traction on the pain sensitive structures § Loss of cushion effect 10/21/2021
Mechanism of PDPH Continuous CSF loss/leakage Subarachnoid pressure may be reduced to 4 cm. H 2 O Activation of adenosine receptors (arterial and venous vasodilatation) rate of CSF loss (0. 084 -4. 5 ml/sec) rate of CSF production > PDPH 10/21/2021 (0. 35 ml/min=0. 0058 ml/sec)
Symptoms of PDPH Severe cephalgia Photophobia Dizziness Nausea-vomiting PDPH Tinnitus Diplopia Hearing loss 10/21/2021 Neck stiffness
WHAT HAPPENS? CSF Loss/leakage Intracranial hypotension Intracranial haemorrhage 10/21/2021
Diagnosis Patient history & symptoms § Usually frontal in origin, radiates to occiput § Exacerbated by sitting or standing (postural) § Dramatically relieves in the supine position (standard diagnostic criterion) 10/21/2021 § Diagnostic lumbar puncture § § Low CSF opening pressure “dry tap” Slightly raised CSF protein Rise in CSF lymphocyte § MRI § extradural collection of CSF § CT myelography § Retrograte radionuclide myelography § Csyternography
Differential Diagnosis § Non-specific headache § Migraine § Caffeine withdrawal headache § Meningitis § chemical or infective § Sinus headache § Drugs § amphetamine, cocaine 10/21/2021 § § § Pneumocephalus Preeclampsia Pituitary apoplexy Cerebral vein thrombosis Subdural hematoma Intracranial tumour
Prevention Strategies Prevention strategies differ depending on the timing of dural puncture §After intentional spinal §After unintentional epidural needle insertion into subarachnoid space 10/21/2021
Preventive Concepts After intentional dural puncture Use § atraumatic spinal needles without age limits § proper needle material § finer gauge in predisposed patients 10/21/2021
Prevention Strategies For inadvertent dural puncture during epidural Baraz & Collis. Management of accidental dural puncture. A survey of UK practice. Anaesthesia 2005 § Insertion of the epidural catheter into the subarachnoid space through the hole § Resiting the epidural catheter § Bed rest & supportive therapy § Drug therapy § Prophylactic § epidural saline § İntrathecal saline § epidural blood patch (EBP) 10/21/2021
Intrathecal catheters § Leaving the catheter promote an inflammatory response to seal the hole § Norris & Leighton Failed to show it because they removed the catheter immediately after vaginal delivery § Liu § left the catheter in place for 12 -24 h § demonstrated low risk of developing PDPH 10/21/2021
Sequential Strategy for intrathecal catheter use 1. Injection of CSF back into subarachnoid space through the epidural needle 2. Insertion of an epidural catheter into subarachnoid space 3. injection of saline of 3 -5 m. L into subarachnoid space through the subarachnoid catheter 4. Administration of bolus, then continuous intrathecal analgesia 5. Leaving the catheter in situ in the subarachnoid space for a total of 12 -20 h 10/21/2021 Kuczkowski & Bneumof. Acta Anaesthesiol Scand 2003; 47: 98 -100 (n=7, 14%) Kuczkowski. Minerva Anestesiol 2004; 70: 823 -30 (n=15, 6. 6%)
§ 11 trials, among 1723 patients § Immediate mobilization vs bed rest § 31% bed rest vs (27%) early mobilization 10/21/2021
Sudlow &Warlow Cochrane Database Syst Rev 2002 Posture & fluids for preventing PDPH § § § Comfortable position should be encouraged Supine? ? ? Prone is advocated 10/21/2021
10/21/2021
Drug therapy § § Caffeine (oral/iv) Theophylline (oral) Sumatriptin (SC) Vasopressine (IM) § Synthetic analog, DDAVP=Desmopressine acetate, IM § ACTH 10/21/2021 Thurnbull & Shephard. Br J Anaesth 2003; 91: 718 -29
Drug therapy Caffeine Crosses blood brain barier Central nerve system stimulant Cerebral vasoconstrictor 300 -500 mg oral/iv once/twice daily t 1/2=3 -7. 5 h, LD 50=150 mg/kg – at 4 h, decrease in the severity of symptoms – at 24 h, no difference in severity of symptoms – no difference in the need for EBP 50 -100 mg caffeine 330 m. L 0. 150 g/L caffeine § § § 49. 5 mg caffeine/330 ml 10/21/2021
Drug therapy § § Theophylline Member of methylxantine family Long acting oral preparations Potent cerebral vasoconstrictor Increase CSF production by stimulating the Na-K pumps 10/21/2021 Sumatriptin § § § 5 HT 1 D receptor agonist Cerebral vasoconstrictor Advocated for migraine Expensive SC injection (6 mg) t 1/2= 2 h Kuczkowski. Arch Gynecol Obstet 2006
Drug therapy Drugs targeting mast-cell inactivation § § § ACTH Presumably downregulation of CRH (potent mast-cell activator) 1. 5 µg/kg infusion Hydroxycine Antihistaminic drug established for premedication Mast-cell stabilising and anxiolytic properties Tricyclic antidepressants (amitriptylin, doxepin) Analgesic (partially by mast-cell inhibitory effect) Selective CB-2 -R agonists Not yet available, but promising 10/21/2021
Prophylactic epidural/intrathecal saline § § § Prophylactic epidural saline/RL 1 -1. 5 liter/24 h is started on the 1 st day after dural puncture It is infused up to 35 ml/h for 24 -28 h Prophylactic intrathecal saline Immediate injection of 10 ml intrathecal saline after wet tap significantly reduced PDPH Charsley et al. Reg Anesth Pain Med 2001; 26: 301 -305 10/21/2021
Sudlow &Warlow Cochrane Database Syst Rev 2002 EBP for preventing & treating PDPH § § Epidural blood patch (n=32) vs sham patch (n=32) No decrease in the incidence of PDPH No need for therapeutic EBP was detected Prophylactic EBP did shorten PDPH symptoms
Treatment Goals for PDPH § Replace the lost CSF fluid § Seal the puncture site § Control the vasodilation with cerebral vasoconstrictor drugs 10/21/2021
Clinical presentation of PDPH Severity of PDPH should be evaluated § Mild PDPH (VNS score 1 -3) § slight restriction of daily activities § the patient is not bedridden, no associated symptoms § Moderate PDPH (VNS score 4 -7) § significant restriction of daily activities § the patient is bedridden part of the day § associated symptoms may or may not be present § Severe PDPH (VNS score 8 -10) § incapacitating headache § impossible to sit up § associated symptoms are always present 10/21/2021
Treatment After established PDPH Epidural saline Epidural Dextran 40 § Infusion/bolus § infusion or bolus § Inert/sterile § High molecular weight § Mass effect § Viscosity § 30 ml bolus saline once § Sustained tamponade § 10 -120 ml bolus saline via around dural perforation caudal epidural § No inflammatory response that would promote healing § Saline may induce an inflammatory reaction 10/21/2021
Epidural Blood Patch (EBP) § History (Gormley 1960, Di. Giovanni & Dunbar 1970) § Mechanism of action Plug theory Clot is formed by injecting 15 -20 ml autologous blood in the epidural space to provide adherence to the dura mater and directly patches the hole Pressure patch hypothesis Volume of blood injected into epidural space increases CSF pressure leading to reduction in the traction of the pain sensitive brain structures 10/21/2021
EBP Contraindications of EBP § Infection on the back § Sepsis § Coagulopathy § Raised white cell count § Prexia § Patient refusal 10/21/2021 Indication § Failed conservative treatment Timing § Beyond 24 h after dural puncture Recumbent positioning § For 2 h after patching may improve the efficacy
EBP § Complication rate is rare § ~35% transient backache § Success rate is ~94% (70 -98%) § 90% initial relief § 61 -75% persistent relief § Repeat EBP has a similar success rate § Reverse the complications of dural puncture 10/21/2021
Treatment § It is recommended not to delay EBP more than 24 h after the diagnosis of severe PDPH 10/21/2021
Fibrin glue § May be placed blindly or CT guided percutanous injection Crul et al. Anesthesiology 1999; 91: 576 -7 10/21/2021
Conclusions Gunaydin & Karaca. Acta Anaesthesiol Belg 2006; 70: 823 -30 PDPH is of interest in the obstetric population undergoing cesarean delivery In the event of recognized wet tap during epidural insertion, prevention of PDPH should be considered Initial intrathecal saline injection might prevent immediate CSF loss and intrathecal drug injection allows onset of anesthesia Resiting the epidural catheter and then keeping it postoperatively connected to PCA pump might decrease the incidence of PDPH 10/21/2021
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