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///2016 Abstract Details
2016 Abstract Details2019-07-15T10:10:51-05:00

Dilemmas of a Repeat Dural Puncture during Attempted Epidural Blood Patch for Post-Dural Puncture Headache: A Case Report

Abstract Number: F-58
Abstract Type: Case Report/Case Series

Caroline Martinello MD1 ; Rovnat Babazade MD2; Mindy S Milosch MD3; Elva B Bian MD4; Hripsime Avagyan MD5; Rakesh B Vadhera MD6

Epidural blood patch (EBP) is an effective treatment for postural puncture headache (PDPH) [1]. After accidental dural puncture (ADP) extradural fluid accumulation [1] may complicate EBP procedure by masking appropriate epidural space identification. We describe an approach to this situation, using local anesthetic to confirm catheter position prior to EBP

Case report: 23 years old, G4P3 term parturient with preeclampsia requested epidural analgesia for labor. Epidural placement at L3-4 interspace was complicated by ADP. An intrathecal (IT) catheter was placed. Patient was comfortable throughout labor, vaginal delivery was uneventful and IT catheter was removed after 24 hours. On postpartum day (PPD) 2 patient was developed symptoms consistent with PDPH. After failed conservative treatment, patient agreed to proceed with EBP on PPD3. Using a 17G Tuohy needle the epidural space was identified at L3-4 level using loss of resistance (LOR) to saline technique. Free CSF flow was noted. An 18G epidural catheter was threaded 5cm into the space. During insertion of catheter a marked reduction in CSF flow was noted. CSF aspiration was slow but positive through the catheter. A test dose of 45 mg of lidocaine with 15 mcg of epinephrine was given. It did not produce any sensory/motor block, leading authors to believe the catheter was in the epidural space. Subsequently, 10 ml of 0.125% bupivacaine was administered over 20 minutes and a T10 sensory block was obtained, confirming that catheter was most likely in epidural space. On PPD4 after confirmation that the catheter was still at same depth and aspiration of the catheter was negative for fluid, 23 ml of blood drawn under sterile condition was injected through the epidural catheter. Patient had immediate resolution of headache. Catheter was removed at the end of procedure and patient was discharged on same day.

The optimal timing for EBP following ADP is yet to be determined [1, 2]. Some evidence suggests that early EBP might be related to increased failure rate [2]. Leaking and accumulation of CSF into epidural space may contribute to this failure [2], although significant amount of CSF is not normally seen during an attempted EBP, especially when performed after 24 hours. Chances of a second ADP in a patient whose epidural space is expanded with CSF is less likely, therefore possibility of a large CSF leak in epidural space during a possible second dural puncture must be considered. Giving small-diluted amount of local anesthetics to achieve limited sensory block can help differentiate the location of catheter clinically. Inserting an epidural catheter provides the benefit of having a channel for slow titration of local anesthetic and blood during EBP, and also decreases number of attempts to perform EBP when fluid is encountered, what is associated with less risk of infection [1] and decreasing risks of repeat ADP and its implications

Ref.

1. AA Case Rep.2015;5:115-6

2. Anaesthesia.2015;70:135-41

SOAP 2016