///Accidental Dural Puncture
Accidental Dural Puncture2018-04-28T01:56:03+00:00

Accidental Dural Puncture and Post Dural Puncture Headache Management: Intrathecal Catheter Placement vs. Therapeutic Epidural Blood Patch vs. Prophylactic Epidural Blood Patch

The management of an accidental dural puncture (ADP) and post-dural puncture headache (PDPH) in the peripartum period remains controversial.1, 2 Due to limited published randomized-controlled trials, no strong evidence based recommendations have been made for the ideal management of an ADP and treatment for PDPH. There is wide variation in catheter management after an ADP.  Prevention and treatment of PDPH also varies among obstetric anesthesia providers.1,2,3  According to a North American survey conducted on US and Canadian SOAP members, when an ADP occurs, an epidural catheter is ultimately placed 75% of the time and an intrathecal catheter 25% of the time.1  There are the three recognized strategies for the management of an ADP, prevention and treatment of a PDPH , each with varying degree of success:

  1. Intrathecal Catheter Placement
  2. Therapeutic Epidural Blood Patch
  3. Prophylactic Epidural Blood Patch

A summarized table for the management of ADP and PDPH used by different institutions is included (see Table).  For an extensive discussion regarding the incidence, pathophysiology, clinical presentation, diagnosis, prevention, management and treatment options of an ADP and PDPH, please refer to the previously published SOAP Expert Opinion entitled Post-Dural Puncture Headache Management in the members section of the Society for Obstetric Anesthesiology and Perinatology (SOAP) website.

Intrathecal Catheter Placement:
A National survey conducted by Harrington et al.2 reported the rates of intrathecal catheter use after an ADP among US, UK and Australian Obstetric Anesthesia practitioners as 18%, 28% and 35% respectively.2 In a prospective controlled study of continuous spinal analgesia versus repeat epidural analgesia after accidental dural puncture in labour, Russell4 concluded that converting to spinal analgesia after ADP did not reduce the incidence of PDPH or blood patch but was associated with the establishment of neuraxial analgesia for labor. The advantages and disadvantages of placing an intrathecal catheter after an ADP are the leading causes for its favorable or unfavorable utility by Obstetric Anesthesiologists. The main advantages of placing an intrathecal catheter after an ADP are:

  1. Rapid, predictable, and titratable analgesia for labor.4,5
  2. Decreased risk of a patchy block.5
  3. Can provide anesthesia for cesarean birth.3
  4. Lower dose of local anesthetic needed for effective analgesia.5
  5. Decreased likelihood of a local anesthetic overdose or toxicity.3
  6. A decreased incidence of PDPH if the intrathecal catheter is left in-situ for 24 hours.6
  7. Elimination of multiple subsequent attempts especially in a technically difficult patient.2
  8. Elimination of other potential complications associated with repeated attempts such as paresthesia, hematoma, soft tissue injury, etc.

In a meta-analysis of nine reports investigating placement of intrathecal catheters after accidental dural puncture, Heesen et al.7 concluded that placement of an intrathecal catheter significantly reduced the risk for an epidural blood patch, however, the incidence of PDPH was not significantly reduced.  Disadvantages of an intrathecally placed catheter include a high spinal block, and possible inadvertent administration of an epidural dose of local anesthetic intrathecally leading to respiratory insufficiency, cardiovascular collapse and death.
Prevention of an iatrogenic administration of an epidural dose of local anesthetic via an intrathecal catheter can be done by taking the following safety precautions:

  1. Use of bright color signs and labels not normally used for an epidural catheter to indicate that an intrathecal catheter is in place.
  2. Large bright color sign posted on the patient’s door indicating that the patient has an intrathecal catheter.
  3. Bright color labels placed at the:
    1. Catheter injection port
    2. On the epidural pump
  4. Communication about the presence of the intrathecal catheter with:
    1. The patient and family members
    2. Other team members including Obstetricians and Labor and Delivery Room personnel.

Therapeutic Epidural Blood Patch (TEBP):
Based on current practice among Anesthesiologists in the USA, a TEBP is widely accepted as an effective treatment for PDPH, however the manner in which the procedure is performed lacks consistency.2  Autologous blood is considered the gold standard for TEBP. Nevertheless, there is a lack of consensus regarding the optimal amount of blood that should be injected into the epidural space.8  In a multi-institutional randomized, blinded clinical trial, Paech et al.8 recommend administration of 20 mL of autologous blood for the treatment of PDPH after an ADP in obstetric patients.  In 66.8% of respondents surveyed by Harrington et al.2 he reported using a volume between 16 to 20 mL of autologous blood.2  Few studies encourage the use of volumes greater than 20mL and most report an increase incidence of failure or recurrence of symptoms when less than 10mL of autologous blood is used.8  The timing between the ADP, PDPH and the TEBP also remains debatable.2   The majority of practitioners wait at least 24 hours after the onset of symptoms to perform a TEBP.2  Most patients report immediate relief of symptoms after a TEBP. However, inadequate relief of symptoms can occur.  Patients with persistent symptoms of PDPH may require a second TEBP and patients with persistent symptoms after a second TEBP should be considered for a detailed neurological work-up before any further intervention. The major drawback to the use of a TEBP is that it can increase the risk of complications such as backache, radicular pain, and ADP.  For a detailed description of TEBP technique, please see a previous SOAP Expert Opinion entitled Post-Dural Puncture Headache Management on the SOAP website under the members section.

Prophylactic Epidural Blood Patch (PEBP):
The resite or placement of an epidural catheter at a different interspace is the most common clinical practice after an ADP.1  A major advantage of placing an epidural catheter after an ADP is that in the postpartum period, the epidural catheter can be used for a PEBP.  In two published surveys, both Baysinger et al.1 and Harrington et al.2 reported that only 8-10% of surveyed respondents perform PEBP respectively.1,2  Unlike a TEBP which is regarded as “the gold standard” for PDPH treatment, the use of a PEBP remains controversial.9  A PEBP may not prevent the development of a PDPH or preclude the need for a TEBP, but it may provide benefit by decrease the duration and severity of symptoms of a PDPH.9  A PEBP reduced the length of a PDPH from a median duration of 5 days to 2 days.9  For a detailed description of the PEBP technique please see a previous SOAP Expert Opinion entitled Post-Dural Puncture Headache Management on the SOAP website in the members section.

Accidental Dural Puncture Headache (ADP) Management Table

References:

  1. Baysinger CL, Pope JE, Lockhart EM, Mercaldo ND: The management of accidental dural puncture headache: a North American survey. J Clin Anesth 2011; 23: 349-360.
  2. Harrington BE, Schmitt AM: Meningeal (postdural) puncture headache, unintentional dural puncture, and the epidural blood patch. A national survey of United States practice. Reg Anesth Pain Med 2009; 34:430-7.
  3. Apfel CC, Saxena A, Cakmakkaya OS, Gaiser R, George E and Radke O: Prevention of postdural puncture headache after accidental dural puncture: a quantitative systematic review. British journal of anaesthesia 2010; 105(3):255-63.
  4. Russell IF. A prospective controlled study of continuous spinal analgesia versus repeat epidural analgesia after accidental dural puncture in labour. Int J Obstet Anesth 2012;21:7-16
  5. Rutter SV, Shields F, Broadbent CR, Popat M, Russell R: Management of accidental dural puncture in labour with intrathecal catheters: an analysis of 10 years’ experience.  Int J Obstet Anesth 2001;10: 177-81.
  1. Ayad S, Demian Y, Nar ouze SN, Tetzlaff JE: Subarachnoid catheter placement after wet tap for analgesia in labor: influence on the risk of headache in obstetric patients. Reg Anesth Pain Med 2003;28: 512-5.
  1. Heesen M, Klöhr S, Rossaint R, Walters M, Straube S, van de Velde M: Insertion of an intrathecal catheter following accidental dural puncture: A meta-analysis. Int J Obstet Anesth 2012;Dec 4. pii: S0959-289X(12)00137-9. doi: 10.1016/j.ijoa.2012.10.004.
  2. Paech MJ, Doherty DA, Christmas T, Wong CA: The volume of blood for epidural blood patch in obstetrics: a randomized, blinded clinical trial. Anesth Analg 2011; 113: 126-33.
  3. Agerson AN, Scavone BM: Prophylactic epidural blood patch after unintentional dural puncture for the prevention of postdural puncture headache in parturients. Anesth Analg 2012; 115: 133-6.