SURVEY OF TURKISH PRACTICE EVALUATING THE MANAGEMENT OF POSTDURAL PUNCTURE HEADACHE

IN THE OBSTETRIC POPULATION

Berrin Günaydın, MD, PhDDepartment of Anesthesiology

Gazi University Faculty of MedicineANKARA-TURKEY

GAZI GAZI UNIVERSITYUNIVERSITY

FACULTY OF MEDICINEFACULTY OF MEDICINE

Background

• Surveys and meta-analysis concerning the management of PDPH in the obstetric population have been published

– Choi et al. Examining the evidence in anaesthesia literature: a survey and evaluation of obstetrical Postdural puncture headache reports. Can. J. Anesth., 49, 49–56, 2002.

– Baraz and Collis. The management of accidental dural puncture during labour epidural analgesia: a survey of UK practice. Anaesthesia, 60, 673-679, 2005.

Aim

• Primarily to determine the current practice in the management of PDPH in a small sample reflecting roughly the commonly preferred approaches

• Secondly to provide awareness of the responders with this particular entity

Methods

• Questionnaire including 24 questions similar to Baraz and Collis’s were given to the participants

• Participants were asked to submit their surveys either to the surveyors or send it via e-mail to the contact person later

• Microsoft Excel® software was used for data analysis

• Results were presented as n and/or %

Questionnaire

Results

• 78 out of 111 surveys returned

(Response rate was 70%)

• The responders consisted of – 21 (26.92%) residents– 25 (32.05%) fellows– 21 (26.92%) academic staff – 11 (14.10%) did not identify any degree

Results

• Rate of auditing inadvertent dural puncture during labour or cesarean was 35%

• Having written guidelines for the management of accidental dural puncture – Yes: 10%– N: 64%– Under the process of writing: 4%– No reply: 22%

50% stated that it was necessary at the end of the survey

Prophylactic measures to prevent PDPH following recognized accidental dural puncture

During delivery • Nothing (19.2%) • Others (80.8%)*

– Leave spinal catheter for 24 h – Avoid pushing – Variable – Limit 2nd stage

After delivery* • Fluid intake and/or

paracetamol/NSAID/codeine (59-81%)

• Blood injection before catheter removal (10%)

• Epidural crystalloid infusion before catheter removal (19%)

• Prophylactic blood patch within 24 h of delivery (12%)

• Variable (15%)

*one or more of the options have been chosen

Results - During delivery

• When accidental dural puncture during epidural insertion was recognized

– epidural catheter was left in situ to use as a spinal catheter (36%)

Kuczkowski K.M., Decreasing the incidence of post-dural puncture headache: an update. Acta Anaesthesiol. Scand., 49, 594, 2005.

or

– epidural catheter was re-sited at a different level (64%)

Gunaydin and Karaca. Prevention strategy for PDPH. Acta Anaesth. Belg., 57, 163-165, 2006.

Possible reasons for using an epidural catheter as an intrathecal catheter

No recommendation (62%)

Possible reasons according to preferance order (38%)*

Allow immediate analgesia for labour Avoid another dural puncture Reduce the incidence and/or severity of PDPH Only in difficult cases (e.g. obesity & multiple attempts)

Kuczkowski K.M., Post-dural puncture headache in the obstetric patient: an old problem. New solutions. Minerva Anestesiol., 70, 823-830, 2004.

Kuczkowski and Benumof. Decrease in the incidence of post-dural puncture headache: maintaining CSF pressure. Acta Anaesthesiol. Scand., 47, 98-100, 2003.

*one or more of the options have been chosen

Results - After delivery Non-invasive methods for PDPH treatment

• In addition to the encouragement of fluid intake and/or paracetamol/NSAID/codeine – Caffeine (oral/iv)– Theophylline (oral) – IV hydrocortisone– IM ACTH– SC sumatriptin – Strong opioids

Ambulation after delivery following accidental dural puncture

• As early as possible: 7%

• Bed rest:6 h (3%),12 h (15%) or 24 h (36%)

• No idea: 49%

Methods routinely used for PDPH treatment

• 1st option is the conservative treatment

• Blood patch was mostly preferred after failed conservative treatment

• Blood patch as soon as PDPH diagnosed is less preferred

• Different measures can be selected

HistoryHistory (Gormley 1960, DiGiovanni & Dunbar 1970)

Mechanism of actionMechanism of actionPlug theoryPlug 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 hypothesisPressure patch hypothesis

Volume of blood injected into epidural space increases CSF pressure leading to reduction in the traction of the pain sensitive brain structures

Epidural Blood Patch (Epidural Blood Patch (EBPEBP))

EBPEBP

Contraindications Contraindications Infection on the back Sepsis Coagulopathy Raised white cell

count Prexia Patient refusal

TimingTiming Beyond 24 h after

dural puncture

RRecumbent ecumbent positioningpositioning

For 2 h after patching may improve the efficacy

EBPEBP

Complication rate is rare ~35% backache Success rate is ~94% (70-98%)

90% initial relief 61-75% persistent relief

Repeat EBP has a similar success rate Reverse complications of dural puncture

TreatmentTreatment It is recommended not to delay EBP more than 24 h

after the diagnosis of severesevere PDPH

EBP

• Mostly performed in the recovery room

• Sometimes in the labour ward

• Rarely in the patient’s room

• Generally performed with the help of a resident or a staff member

• Rarely performed by one person

Gunaydin et al. Acta Anaesthesiol Belg 2008

EBP

• Intravenous access before EBP (69%)

• ECG (58%)

• Blood pressure (65%) and

• Pulse oxymeter (63%) were performed by the majority of the responders

Gunaydin et al. Acta Anaesthesiol Belg 2008

Advices at discharge after a successfull EBP

• Discharge – After EBP 1 (4%), 2 (15%) or 3-6 hours (44%)

• Follow-up – Before full mobilization 2 (47%) or 4 hours (23%)

of bed rest– Increase fluid intake– Keep intervention side clean– Contact whenever headache reoccurs and report

fever, weakness or numbness

Gunaydin et al. Acta Anaesthesiol Belg 2008

After an unsuccessfull EBP

• Rate of never considering another EBP (36%)

• Rate of repeating EBP (37%)

• No recommendation (27%)

• If two EBPs were unsuccessfull, further investigations were considered (63%)

Gunaydin et al. Acta Anaesthesiol Belg 2008

Conclusion

• According to the present survey, re-siting epidural catheter at a different intervertebral space or using epidural catheter as an intrathecal catheter was preferred for the prevention of PDPH in case of recognized accidental dural puncture

• Non-invasive methods consisting of encouragement of fluid intake and drugs were routinely used for the treatment of PDPH

Conclusion

• Although these results showed the current practice of this small sample, in order to follow the change in these strategies and to catch almost a standard approach for the prevention and management of PDPH, further surveys including most of the centers are required.

Thank you