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    Update On PDPH

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    Update On PDPH

    Uploaded by

    monir61
    67 views18 pages
    PDPH

    Original Title

    12. Update on PDPH

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    PDPH

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    © All Rights Reserved
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    Download as pdf or txt
    67 views18 pages

    Update On PDPH

    Uploaded by

    monir61
    PDPH

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 18

    5/8/2013

    AnUpdateonPostdural Puncture
    HeadacheAfteranEpiduralBlock
    JamesBates,PhD,MD
    AssociateProfessor
    DirectorofthedivisionofOBanesthesia
    ClinicalcoordinatorMOR
    DepartmentofAnesthesia
    UniversityofIowaCollegeofMedicine

    Disclosure
    Ihavenofinancialrelationshipswith
    manufacturersofpharmaceuticalsordevices.

    5/8/2013

    The First Spinal Anesthetic


    Augustus Bier, a German surgeon, was the first
    person to use intrathecal cocaine to produce
    surgical anesthesia.
    In a classic paper published in 1899 he described
    the performance of spinal anesthesia on himself
    (which because of technical difficulties, failed)
    and on his assistant Hildebrandt (which was very
    successful).
    These became also the first two described cases of
    post dural puncture headaches.

    The First Spinal Anesthetic


    Augustus Bier, a German surgeon, was the first
    person to use intrathecal cocaine to produce
    surgical anesthesia.
    In a classic paper published in 1899 he described
    the performance of spinal anesthesia on himself
    (which because of technical difficulties, failed)
    and on his assistant Hildebrandt (which was very
    successful).
    These became also the first two described cases of
    post dural puncture headaches.

    5/8/2013

    PDPH Diagnostic Criteria


    International Headache Society

    Develops within 5 days after dural puncture


    Worsens within 15 minutes after sitting or standing
    and improves within 15 minutes after lying down
    Accompanied by at least 1 of the following:
    neck stiffness
    nausea
    photophobia
    tinnitus
    hypoacusia
    Resolves either:
    spontaneously within 1 week
    within 48 hours after effective treatment of the
    spinal fluid leak (i.e. epidural blood patch)

    PDPH: Etiology
    DuralpuncturewithcontinuedCSFleak
    Decreasedintracranialpressure
    Presumedvascularexpansionasintracranial
    pressuredrops

    5/8/2013

    Risk factors for PDPH

    Largeboreneedles
    Multipleattempts(multipleholesindura)
    Youngadults>olderadults
    Adults>children
    Females>males
    Cuttingtipneedles>penciltipneedles
    Historyofmigraines,chronicHA,previousPDPH
    ?DiagnosticLP>spinalanesthesia

    1954 Dripps & Vandam


    10,098spinals,8460patients
    EveryspinalUniv.Pennfrom19481951
    %ofPts
    Allpatients
    Females
    Males
    16Gneedle
    19Gneedle
    20Gneedle
    22Gneedle
    24Gneedle

    56.2
    43.8
    9
    2
    29
    53
    7

    PDPH
    14%
    15%
    9%
    18%
    10%
    16%
    18%
    6%

    5/8/2013

    Needle Type and PDPH After Spinal


    Thetypeofneedlepointaffectsheadacherate:
    1951:Hart&Whitacre reportedlowerheadacherateswith
    newpencilpointneedle
    1987:Sprotte describes34950procedureswithnew24G&
    22GSprotte needleswithheadacherateof0.02%
    Therehavebeenmanystudiescomparingoneormoretypes
    ofpencilpointspinalneedleswithQuincke pointneedles
    thathaveconsistentlyshownlowerPDPHwithpencilpoint
    spinalneedles

    Quincke and Sprotte Dural Punctures

    Strupp et al. 2001 Neurology 57: 2310

    5/8/2013

    Proposed Methods to Reduce


    Accidental Dural Puncture
    and Post-Dural Puncture Headache

    Airvs salineforlossofresistancemedium
    CombinedSpinalEpidural(CSE)vs epidural
    Orientationofneedlebevel
    Epiduralneedledesign
    Ultrasoundguidedinsertion
    Conversiontocontinuousspinalanesthesia
    Prophylacticepiduralbloodpatches

    Drug Therapies to Treat


    or Prevent PDPH

    Analgesics
    Caffeine
    Theophyline
    Sumatriptan
    Cosyntropin (ACTH)
    Epiduralmorphine

    5/8/2013

    Prevention of PDPH in Parturients


    2012 Meta-analysis:
    40 RCTs (n=11,536 epidural insertions) studying
    different methods to reduce PDPH

    combined spinalepidurals (CSEs)


    loss of resistance medium
    prophylactic epidural blood patches
    needle bevel orientation
    different types of epidural needles
    ultrasound-guided insertion
    administration of cosyntropin (ACTH)
    continuous spinal analgesia (wet-tap CSA)

    Bradbury et al. 2012 Acta Anaes Scand (eprint ahead of publ)

    Effect of Interventions
    Reduced incidence of ADP
    None found
    Reduced incidence of PDPH
    Prophylactic blood patch
    Lateral orientation of the needle bevel during insertion
    Use non cutting point epidural needle
    Epidural morphine
    Administration of cosyntropin
    No statistically significant reduction of either ADP or PDPH
    CSE
    Medium used for loss of resistance technique
    Ultrasound or acoustic device to assist epidural insertion
    Continuous spinal analgesia

    5/8/2013

    Five methods reduced PDPH


    1. Prophylactic epidural blood patch
    4 trials of varying quality

    2.
    3.
    4.
    5.

    Lateral orientation of needle bevel on insertion*


    Pencil-tip epidural needles*
    Epidural morphine*
    Cosyntropin (ACTH)*
    * each based on a single RCT

    Converting to CSA After ADP


    Bradburyetal.2012metaanalysisfoundnobenefitto
    convertingtoCSA,basedonasingleRCT(Russell2012).
    Inanother(simultaneous)metaanalysis(Heesen etal.2013),
    foundabenefit.Itincluded9studies:
    2RCT(includingRussell2012)
    7whereallocationwasnotrandom

    5/8/2013

    RCT Protocol (Russell 2012)

    19MaternityunitsinUK
    Randomizedbymaternityunit;reversedinyr 2
    97womenwithaccidentaldural puncture(ADP)
    Randomizedto:
    repeatepidural
    threadingcatheterthroughdural punctureforCSA

    PatientswithADP
    DevelopedPDPH
    ReceivedEBP

    RepeatEpid
    47
    62%
    55%

    CSA
    50
    72%
    50%

    p
    ns
    ns

    Conversion to CSA: Effect on PDPH


    MetaanalysisbyHeesen,etal.2013Int JObstet Anesth.22:26.

    Intrathecalcatheterizationandtheincidenceof
    postdural punctureheadache.

    5/8/2013

    Conversion to CSA: Effect on EBP


    MetaanalysisbyHeesen,etal.2013

    Intrathecalcatheterizationandtheneedforepiduralbloodpatch.

    RCTs of PEBP
    Previousstudieslackedrandomization,blinding,proper
    protocolstopreventbiasandpowerofsuggestion.
    3RandomizedcontrolledtrialsofPEBPinOBpatients.

    1.

    2.
    3.

    AckermanWE,Juneja MM,Kaczorowski DM.Prophylacticepiduralbloodpatchfor


    thepreventionofpostdural punctureheadacheintheparturient.Anesthesiol Rev
    1990;17:459
    ColonnaRomanoP,ShapiroBE.Unintentionaldural punctureandprophylactic
    epiduralbloodpatchinobstetrics.Anesth Analg 1989;69:5223
    Scavone BM,WongCA,SullivanJT,Yaghmour E,Sherwani SS,McCarthyRJ.Efficacyof
    aprophylacticepiduralbloodpatchinpreventingpostdural punctureheadachein
    parturients afterinadvertentdural puncture.Anesthesiology2004;101:14227

    10

    5/8/2013

    Prophylactic Epidural Blood Patch


    Ackerman et al. 1990

    Randomized,controlled,partiallyblinded(observer
    butnotsubject)trial
    21OBpatientswithADP
    PEBPviacatheterasitwasremovedafterlabor
    After24hrs offeredtherapeuticEBP
    DevelopedPDPH
    ReceivedEBP

    PEBP
    1/ 10
    1/10

    Control
    7/11
    5/11

    P
    0.02
    ns

    Prophylactic Epidural Blood Patch


    Colonna-Romano & Shapiro, 1989

    Randomizedcontrolledunblinded trial
    39OBpatientswithADP
    15mlPEBPviacatheterasitwasremovedvs oral
    hydration&bedrest.

    DevelopedPDPH
    ReceivedEBP

    PEBP
    4/ 19
    3/ 19

    Control
    16/20
    7/20

    P
    <0.001
    ns

    11

    5/8/2013

    Prophylactic Epidural Blood Patch


    Scavone et al. 2004

    Randomizedcontrolleddoubleblindedtrial
    64OBpatientswithADP
    15mlPEBPviacathetervs shaminjection.
    StandardizedcriteriatodeterminationneedforEBP

    DevelopedPDPH
    ReceivedEBP

    PEBP
    18/ 32
    11/ 32

    Control
    18/ 32
    15/ 32

    P
    ns
    ns

    Prevention of PDPH in Parturients


    Bradbury2012Metaanalysis,inthesection:
    DoesprophylacticEBPreducePDPH?
    Includedfourstudies:
    3RCTs(Ackerman,ColonnaRomano,Scavone)
    1abstractofastudystillunpublished
    Foundaneffectthatappearedboth
    statisticallyandclinicallysignificant.
    Ifabstractremovedfromanalysis:
    Nostatisticaldifference.

    12

    5/8/2013

    Cochrane 2010 Meta-analysis


    Anotherearliermetaanalysisthatconcludedtherewas
    abenefitofprophylacticbloodpatch
    6trialsinvolving265subjects(incl.4inBradburyanalysis)
    NotrestrictedtoOBoraccidentaldural puncture
    ProphylacticepiduralbloodpatchdecreasedPDPH.
    SeverePDPHwascomparable withorwithout
    prophylacticepiduralbloodpatch.

    Boonmak &Boonmak 2010CochraneDatabaseofSystematicReviews2010:CD001791

    Effect of epidural needle type on PDPH


    Prospective RCT to epidural catheter insertion with a
    17G Tuohy or 18G Special Sprotte needle.
    1077 parturients requesting epidural analgesia at 3
    tertiary obstetrical units, randomized between 2 needles
    No difference in patient variables, technique variables,
    or PDPH characteristics.

    Epidural Sprotte needle (aka Special Sprotte)


    Morley-Forster et al. 2006 Can J Anaesth; 53: 572.

    13

    5/8/2013

    Accidental dural punctures (ADP)


    Group
    Tuohy (n=537)Sprotte (n=532)
    ADP
    10(1.9%)
    18(3.4%) P=NS
    RecognizedADP
    8(80%)
    11(61%)
    P=NS
    UnrecognizedADP
    2(20%)
    7(39%)
    P=NS

    Incidence of PDPH and EBP after ADP


    Group
    Tuohy (n=10) Sprotte (n=18)
    DevelopedPDPH
    10(100%)
    10(55.5%) P=0.025*
    PDPHafterCSFseen
    8(100%)
    3(27.2%) P=0.003*
    ReceivedEBP
    7(70%)
    3(16.6%) P=NS
    Special Sprotte needle: trend to more ADP but with lower PDPH rate
    Morley-Forster et al. 2006 Can J Anaesth; 53: 572

    Users Preferred Tuohy


    Group
    Usersatisfaction(%satisfied)
    Insertionattempts(n)
    Excellentlossofresistancetoair(%)
    Paresthesia (catheterinsertion%)
    Bloodinneedle(%)
    Failedblocks(%)
    Switchedneedles(%)

    Tuohy (n=537) Sprotte (n=532)


    84.7 17.3
    68.2 25.3**
    1.4 0.8
    1.4 0.7
    66.6
    36.8**
    2.2
    0.8
    8.7
    6.3
    2.8
    7.0**
    0
    3.2**
    **P<0.001

    14

    5/8/2013

    EpiduralMorphineDecreasesRateofPDPH
    50OBpatientswithrecognizedADP
    Epiduralmorphine300mgq24hr x2before
    catheterremoved.

    DevelopedPDPH
    ReceivedEBP

    Epid MS
    3/ 25
    0/ 25

    Control
    12/ 25
    4/ 25

    P
    0.014
    ?

    IntravenousACTHDecreasesRateofPDPH
    90OBpatientswithrecognizedADP
    30minutesafterdeliveryandcatheterremoval,
    patientsrandomizedto
    1mgcosyntropin (syntheticACTH)[iv]vs placebo.
    DevelopedPDPH
    ReceivedEBP

    ACTH
    15/ 45
    5/ 45

    Control
    31/ 45
    13/ 45

    P
    0.001
    0.035

    15

    5/8/2013

    Drug Therapy to Treat PDPH


    2011CochranemetaanalysisofRCTsassessingany
    pharmaceuticaltreatmentofPDPH.
    7RCTs,200subjects,mostlyspinalanesthesia.
    Caffeine(ivorpo),gabapentin,theophyllineshowed
    evidenceofpainreliefvs placebo.
    Hydrocortisone+conventionaltreatmentwasbetter
    thanconventionaltreatmentalone.

    Basurto Ona etal.2011,CochraneDatabaseofSystematicReviews2011:CD007887

    Oral Caffeine
    Camann etal.1990Anes Analg 70:181

    40PostpartumpatientswithPDPH
    29/40=26GQuincke,11/40=17Gepidural
    Oralcapsuleof300mgcaffeineorplacebo
    Numberofpatientsbetterorworseat4hours
    #WORSE#BETTER
    18

    2 Caffeine
    8
    -10

    12

    Placebo
    -5

    10

    15

    20

    VAS4hr

    VAS24hr EBP

    36.1 5.5

    41 835%

    10.9 6.7

    31 1055%

    P=0.014

    P=nsP=ns

    16

    5/8/2013

    Best Volume of Blood for EBP


    Whatisthebestvolumeofbloodtouse?
    Gormley (1960)had100%successwith23ml
    Numerousobservationalstudiesfoundvolumesfrom
    7.520mltobeeffective,someclaimingbetter
    successwithlargervolumes.
    Largervolumesmaybemoreassociatedwithback
    painoninjection.
    Randomizedcontrolledtrialsarefew.

    Volume of Epidural Blood Patch


    RCT;121OBpatientsin10centerswithADPwho
    developedPDPHrandomizedtoEBPwith15,20,or
    30mlautologousblood.
    Similarefficacybetweengroups.Painscoreswere
    betterinthe20and30mlgroups,butthe95%
    confidenceintervalsoverlapped.

    Paech etal.2011,Anesth Analg 113:126

    17

    5/8/2013

    Headache Relief by EBP

    P=0.01forgroup15mLversusgroups20and30mL.

    Summary: What Works


    ToAvoidADP:
    Notechniquechangestherate

    ToLessentherateofPDPH:

    Maybe prophylacticEBP
    Maybe threadingcatheterforCSA
    Maybe usingSprotte epiduralneedle
    Maybe epiduralmorphineorivACTH
    Caffeinegivessometemporaryrelief
    TherapeuticEBPworkswell.
    EBPwith20mlgivesmaximumbenefit.

    18

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