Preventing Post Dural Puncture Headache (PDPH) - Surely prophylactic treatment after inadvertent dural puncture (IDP) should be available by now!
Abstract Number: F-9
Abstract Type: Original Research
Does prophylactic intrathecal saline reduce the incidence of PDPH? If so what is the optimal dose. A Prospective Randomized Blinded study to assess whether saline injected through a spinal catheter prior to removal decreases the incidence of PDPH after IDP with an 18g Tuohy needle. IDP occurs in 1.5% of parturients with the subsequent risk of PDPH being 52.1%.1 Various methods to decrease the incidence of the potentially severe and debilitating headache have been investigated. The goal of these studies were to prevent the PDPH developing. The treatment of choice for a severe headache, which has stood the test of time, is an epidural blood patch (EBP) performed at least 24 hours later.
Following an IDP one option is to place an intrathecal catheter. “This is what the cool young kids are doing” a quote from a NYPGA (2011) presentation of spinal catheters placed after wet taps.2 This has been shown to provide excellent analgesia for labor and can be converted quickly and reliably to surgical anesthesia for cesarean section. The PDPH risk still remains. Encouraging research, in small trials, has shown a decrease in incidence and severity of headache with intrathecal saline.3,4
Standard practice at our institution, when an IDP occurs, is to place a spinal catheter. A continuous infusion is then started for labor analgesia. Following IRB approval women with a continuous spinal catheter are asked to participate in the study, and consent obtained. Women are randomized to 1 of 4 groups: 0,10,15 or 20 ml of saline injected into the catheter prior to its removal. This is done after delivery and resolution of block. Women are evaluated for evidence of PDPH at 24 and 48 hours, and treated as per standard protocol. Conservative treatment is followed by an EBP if the severity of the headache warrants this or at the women’s request. This study was started in March 2010 and is ongoing.
29 women have been enrolled in the study thus far, 5 of whom were excluded because of poorly functioning spinal catheters.
0 ml - 63% (5/8)
10ml - 33% (2/6)
15ml - 50% (3/6)
20ml - 75% (3/4)
Our data suggests, at this early point in our study, that 10mls of saline may be the optimum amount to reduce the incidence of PDPH after IDP. On the surface this appears counterintuitive because we speculated that increasing amounts of saline would reduce the risk of PDPH. I am certain that inadvertent dural punctures will continue but at least we may be able to make women more comfortable following the event, and decrease the incidence of PDPH.
1) Can J Anesth 2003;50:460-9
2) I. Velickovic 2011 NYPGA
3) Acta Anaesth Scand 2003;47:98-100
4) Reg Anesth Pain Med 2001;26:301