Accidental dural puncture

Accidental dural puncture :

What‘s next ?

PD Dr. Med Georges Savoldelli

ADP a headache for who ? the patient or the anesthesiologist ?

How do I manage the acute complication ? How do I provide

effective analgesia ?

Any prophylactic strategies to prevent occurrence of PDPH ?

Conservative or therapeutic treatment in case of PDPH ?

How do I make the diagnosis of PDPH ?

How do I manage the acute complication and the OB analgesia ?

Accidental dural puncture

Re-site the epidural at a different

interspace

Place an intrathecal catheter




interspace

Place an intrathecal catheter




interspace

Place a spinal catheter

What’s the best option ?

• Whatever your choice is: inject an intrathecal dose through the Tuohy needle (eg: bupi 1.25-2.5 mg +/- opioids)

• Is there evidence supporting one of the two options ?



interspace

Place a spinal catheter

Rationale for the placement of a intrathecal catheter

Theoretical advantages:

• Limit the loss of CSF

• Stimulate a fibrotic response (would result in a smaller hole)

• Avoid the risk of a second accidental dural puncture

• Provide effective analgesia (and anesthesia if needed)

Theoretical limitations and Risks:

• Infection/meningitis

• CSF leak by inadvertent disconnection

• Drug dosage errors/total spinal anesthesia

• Prophylactic epidural blood patch (EBP) will not be an option

Quantitative systematic review of retrospective studies

Apfel et al. BJA 2010; 105 (3): 255–63


Apfel et al. BJA 2010; 105 (3): 255–63


• Study results are heterogeneous

• Strong evidence for a publication bias

Conclusions:

“long-term intrathecal catheter might still be a treatment option…However, the direct or indirect evidence is insufficient to provide a strong recommendation”

Apfel et al. BJA 2010; 105 (3): 255–63

A recent retrospective study

Retrospective analysis single center (1997-2013)

• 128 events of witnessed ADP (0.43%) – 39 : epidural catheter placed at a different level

– 89 : spinal catheter for at least 24 h + saline infusion 2ml/h

• Results :

Epidural Spinal catheter OR (95% CI) P

PDPH 62 % 42 % 2.3 (1.04–4.86) 0.04

EBP 54 % 36 % 2.1 (0.97–4.46) 0.06

RCT multicentric study 115 women with ADP

58 assigned to repeat epidural 57 assigned to spinal catheter Randomization

11 did not receive epidural without complication 6 received spinal catheter 5 repeat ADP

7 did not receive spinal KT without complication 4 received epidural KT 1 received epidural + prophylactic BP 2 received spinal < 5h then epidural

48 assigned to protocol 50 assigned to protocol

NB: spinal KT was left in place for 24-36h

Incidence of dural puncture, headaches and epidural blood patches

Protocol compliant


Intention to treat


Author reassigned


Author reassigned

In the repeat epidural group > 1/3 of women suffered complications (3x greater than in the spinal catheter group)

Take home messages ♯1 : Consider placing a spinal catheter

• Heterogeneous retrospective trials suggest that placement of a spinal KT > 24h reduces PDPH and EBP

• One RCT trial does not support spinal KT placement to prevent PDPH and EBP

Spinal KT should be considered :

• If epidural space location was difficult

• If delivery is imminent

• To reduce risk of repeated ADP, but not to prevent PDPH !

if you decided to place a spinal catheter….

Should you leave the spinal KT in place for at least 24 h ?

• Benefit is unclear

• Risks exist / case reports of complications : – CSF leak after disconnection

– Meningitis

Should you inject intrathecal saline ?

• One small non obstetric non RCT studied the question

• 10 ml of saline injected immediately after ADP

Controls (21) Spinal saline (22) RR (95% CI) P

PDPH 62 % 32 % 0.51 (0.26–1.03) 0.07

EPD 43 % 4 % 0.11 (0.01–0.77) 0.004

Charlsey et al. Reg Anesth Pain Med 2001

if you decided to place a spinal catheter….

Should you leave the spinal KT in place for at least 24 h ?

• Benefit is unclear

• Risks exist / case reports of complications : – CSF leak after disconnection

– Meningitis

Should you inject intrathecal saline ?

• One small non obstetric non RCT studied the question

• 10 ml of saline injected immediately after ADP

Controls (21) Spinal saline (22) RR (95% CI) P

PDPH 62 % 32 % 0.51 (0.26–1.03) 0.07

EPD 43 % 4 % 0.11 (0.01–0.77) 0.004

Charlsey et al. Reg Anesth Pain Med 2001

In my opinion : Evidence is too scarce for any strong recommendation

I do not keep spinal KT > 24 h ! I do not inject spinal saline !

ADP a headache for who : the patient or the anesthesiologist ?






% of parturients who develop PDPH following ADP

Gaiser R. Curr Opin Anesthesiol 2013, 26:296–303

Two different populations of parturients !

RCT double blinded involving 64 parturients with ADP

Prophylactic EBP (PEBP 20 ml blood) versus Sham EBP (blood not injected)

Incidence of PDPH

Authors concluded that PEBP: 1) did not decrease the incidence of PDPH or need for TEBP 2) did shorten the duration of PDPH symptoms

Duration of PDPH and pain intensity-duration (AUC)

RCT 116 parturients with ADP

Prophylactic EBP (PEBP)

Versus

Therapeutic EBP (TEBP)

• 7 excluded in TEBP group

• No blinding

• Additional conservative ttt was not standardized

Main results

In the PEBP group: • 60 (100 %) received a PEBP • 6 (10%) received a 2nd EBP

In the TEBP group : • 36 patients (73.4%) received an EBP • 4 (11.1%) received 2nd EBP

“NNT to prevent PDPH = 1.6 “

“NNT to prevent PDPH ≈ 2 “

Courtesy of G. Haller

Meta-analysis of RCT in OB anesthesia: 5 RCT median quality score = 2 (2-5) One RCT published as abstract only *

*

Effect of prophylactic EBP on the incidence of PDPH

Take home messages ♯2 : Prophylactic epidural blood patch (PEBP)

• PEBP helps reducing the development and the severity of PDPH

• Not clear whether PEBP reduces the number of therapeutic EBPs required

• Use of PEBP is not uncommon but varies greatly :

– 41-46 % in North America (surveys in 1998 and 2009)

– 1 % in UK (survey in 2005)

– < 15 % in France

Keep in mind that :

• PEBP may be unnecessary in approximately 50% of patients

• Injection of blood is made through a possibly contaminated epidural KT

• May put patients at risk for neuraxial canal infection (not reported so far)







Diagnostic criteria of PDPH

A. Headache that worsens within 15min after sitting or standing and

improves within 15min after lying, with at least one of the following and

fulfilling criteria C and D:

– neck stiffness; tinnitus; hypoacusia; photophobia; nausea

B. Dural puncture has been performed

C. Headache develops within 5 days after dural puncture

D. Headache resolves either1:

– spontaneously within 1 week

– within 48 hours after effective treatment of the spinal fluid leak (usually by epidural blood patch)

1 in 95% of cases this is so. When headache persists, causation is in doubt.

International Headache Society Classification ICHD-II

Atypical “non postural” PDPH is not rare

IJOA 2014. 23, 246–252

• 27’365 parturients with neuraxial procedures • 142 patients suffered from PDPH • Atypical “Non postural” PDPH had an incidence of 5.6% (95% CI 1.7–9.4%) • Associated symptoms: stiffness and pain in the cervical, thoracic or lumbar

vertebral area, visual disturbances and vertigo

Even neuropsychiatric disorders can occur…

V Loures, GL Savoldelli, C Alberque, G Haller. BJA 2012,108 (3): 529-530

When should I perform an MRI of the brain (spine) ?

• If headache is atypical and diagnosis is unclear

• If history or examination suggest possible IC pathology

• if the character of headache changes

• if two EBPs did not provide relief (even if PDPH is typical)

• MRI features :

– diffuse brain swelling, downward displacement of the brain and brain stem, flattening of the pons, descent of cerebellar tonsils, subdural effusions

– After contrast: pachymeningeal enhancement, venous sinus engorgement, enlargement of the pituitary gland, dilatation of the cervical venous plexus

Take home messages ♯3

• See all patients in the postpartum period (regardless of ADP)

• If patient had ADP (regardless of symptoms) or if the patient had symptoms of PDPH, follow daily until discharge

• PDPH differential includes: Pre-eclampsia, meningitis, intracranial thrombosis or hematoma, migraine, tension headache,…

• Consider making a post-discharge telephone call







Serious complications do occur !

• Cranial nerve palsy (VI; III; IV)

• Intracranial hematoma (subdural, intracerebral,…)

• Cerebral venous sinus thrombosis

• Subdural effusions, hygroma

• Increased risk of chronic headache (?)

PDH a self limiting condition BUT !

Timing of Therapeutic EBP (TEBP) ?

0

20

40

60

80

100

Day 1 Day 5 Day 7 Day 36

% of patients with spontaneous resolution of PDPH after spinal puncture

Vandam et al. J Am Med Assoc 1956; 161:586–91

Clinical course is affected by several factors: Needle size and type, patient’s age, gender, …

• Intracranial hypotension and PDPH are usually self-limited

• Ideal timing of TEBP is therefore difficult to predict individually

• Success rate: “early (<48h) ” TEBP < “delayed (>48h) ” TEBP

• Recommendations in OB anesthesia if PDPH develops :

– Risks/benefits of TEBP should be discussed with the patient

– If the patient agrees: TEBP should be performed (no time limit)

Timing of TEBP in the OB population after an ADP

Gaiser R. Curr Opin Anesthesiol 2013, 26:296–303 Kokki et al. IJOA 2013; 22: 303–309

1. EBP is an effective treatment for PDPH after ADP

2. The procedure is performed under strict sterile conditions (2 operators)

3. Complications of EBP may include the following :

– Back pain (80%)

– Another ADP

– Extremely rare: arachnoïditis, radiculopathy, cranial nerve palsy, sub-dural hematoma, infection

4. “At the maternity of the HUG the “success” of an TEBP is approximately” :

– 65-75 % for the 1st EBP

– 25-25 % for the 2nd EBP

– 2-3 % of the patient will need a 3rd EBP

What do I tell the patient about TEBP ?

• Multicenter, international study

• 121 women with and PDPH were randomized

• EBP with 15, 20, or 30 ml of blood (injection stopped if patient reported back pain during EBP)

• Authors concluded that: optimal volume of autologous blood remains to be determined but results support an attempt to administer 20 ml

Volume of blood in the EBP ?

Peach et al. Anesth Analg. 2011 Jul;113(1):126-33

Permanent or partial relief

Complete relief % who received the

assigned volume

15 ml 61 % 10 % 98 %

20 ml 73 % 32 % 81 %

30 ml 67 % 26 % 54 %

• Most of the blood of an EBP spreads in the cephalic direction

• EBP should be performed at the same

interspace or one level below the ADP

At which interspace do I perfom the EBP ?

A&A 1997. 84(3):585-590

Take home messages ♯4 TEBP

• Is an effective treatment for PDPH after ADP

• Risk/benefits should be discussed as soon as PDPH develops

• “Early TEBP” are less effective than “delayed TEBP”

• Should be performed at the same or one spine level below ADP

• Attempt to inject 20 ml of bood

Symptomatic treatments that do not change the course of PDPH

• Strict decubitus

• Hyperhydration

• Codeine

• Triptans

Fournet-Fayard & Malinovsky. AFAR 2013; 32: 325–338

Symptomatic treatments that have limited efficacy on PDPH

• Paracetamol

• NSAID

• Cafeine

• Gabapentine

• Arnold’s nerve block – Appears very effective but no comparison to EBP

– 3 publications: Case reports, one RCT of 50 patients mixed surgical population (including cesarean but no vaginal delivery)

Fournet-Fayard & Malinovsky. AFAR 2013; 32: 325–338

Epidural morphine

Al-metwalli RR. Anaesthesia 2008;63:847–50

RCT 50 patients with ADP and vaginal delivery Epi Mo 3mg 2 doses (24 hours interval) vs. saline Incidence PDH: 12 % (Mo) vs. 48 % (saline) P = 0.014 Therapeutic EBP: 0 (Mo) vs 25 % (saline) P = 0.022 Side effects (pruritus, NV): Mo >> saline

Critics: Impressive results (too good ?), not replicated so far…. Frequent benign side effects (NV, pruritus) Potential for increased risk of respiratory depression after ADP ?

NNT = 2.8

Cosyntropin (Synacthen)

• RCT of 90 parturients with ADP and vaginal delivery

• Prophylactic administration of 1 mg of cosyntropin iv vs. placebo

• Good quality study

• PDPH: 33.3% in ttt group vs. with 68.9% in control (P = 0.001) NNT = 2.8

• TEBP: 11.1% in ttt group vs. 28.9% (P = 0.035) NNT = 5.8

Critics: No clear explanation why it works (increased CSF production ??) Dose used is unusualy high (4 time the dose used in synacthen test) Possible side-effects: brady-tachycardia, hypertension, hypersensitivity, seizures, thromboembolism Excretion in breast milk and effect on newborn are unknown

Hakim SM. Anesthesiology 2010;113(2):413-20

Take home messages ♯5

• Strict decubitus, Hyperhydration, Codeine and Triptans are not recommended

• Traditional symptomatic treatments (paracetamol, NSAID, bed rest, cafeine, etc..) have limited efficacy

• Arnold’s block may be proposed if patient refuses EBP

• Epidural morphine should be used after Cesarean delivery (part of the multimodal analgesia) can be considered after vaginal delivery

• Synacthen/gabapentin may be considered if mother does not breast feed

Proposed management algorithm after ADP

ADP in a parturient

Inject spinal analgesic dose

Was space location difficult? Is delivery is imminent ?

Continuous spinal analgesia Re-site epidural KT

Consider: Epidural morphine 3 mg (2 doses) Prophylactic EBP

Withdraw spinal KT after delivery

Inform patient and follow daily

Delivery Delivery

YES NO

Proposed management algorithm after ADP

If typical PDPH develops discuss risks/benefits of EBP (if atypical consider imaging)

Perform EBP

Conservative treatment consider:

Arnold’s nerve block Synacthen (if not breast feeding)

Gabapentin (if not breast feeding)

Patient accepts EBP

Recovery

Perform 2nd EBP

Cerebral (spine) MRI

IC hypotension confirmed

Perform 3nd EBP

Neurosurgical consult

Documents

Accidental dural puncture