OBSTETRIC ANALGESIA
ORIGINAL ARTICLE
Accidental Dural Puncture Management 10-Year Experience at an Academic Tertiary Care Center Norman Bolden, MD* and Ermias Gebre, MD† Background and Objectives: The use of spinal catheters for extended periods after accidental dural puncture (ADP) and administration of intrathecal saline via spinal catheters have been advocated to decrease the incidence of postdural puncture headache and the subsequent need for epidural blood patch (EBP), with mixed results observed. Methods: We reviewed the medical records of 218 patients with ADP who either had the epidural resited or had a spinal catheter (with or without the administration of intrathecal saline). We compared the incidence of headache and the need for blood patch between these groups. We also assessed complications when a standard lidocaine epidural test dose was administered intrathecally and compared this with complications when a solution normally used for labor combined spinal epidurals was administered. Results: There was no difference in the incidence of postdural puncture headache between the resited epidural group and the spinal catheter group, 68.0% versus 55.9% (odds ratio [OR], 1.7; 95% confidence interval [95% CI], 1.0–2.9; P = 0.07). Resiting the epidural catheter was associated with a significant increase in the number of EBPs when compared with using a spinal catheter, 52.0% versus 20.3% (OR, 4.2; 95% CI, 2.4–7.6; P < 0.001) and when compared with spinal catheters with intrathecal saline, 52.0% versus 8.1% (OR, 12.3; 95% CI, 4.3–35.4; P < 0.001). There was a significant difference in the number of blood patches between normal body mass index patients and morbidly obese patients, 55.2% versus 25.0% (OR, 3.7; 95% CI, 1.2–11.2; P = 0.02). Complications (hypotension prompting pressors, high spinal, and emergency cesarean delivery because of nonreassuring fetal status) occurred more frequently when a lidocaine test dose was immediately administered after ADP versus administering a labor combined spinal epidural solution. Conclusions: Insertion of spinal catheters after ADP and administration of intrathecal normal saline via spinal catheters reduce the need for EBP compared with resiting the epidural. Administration of the standard epidural test dose intrathecally is associated with frequent and significant complications. (Reg Anesth Pain Med 2016;41: 169–174)
E
pidural analgesia is a very effective and widely used technique for the managmeent of pain associated with labor. One of the most common and problematic complications of epidural placement is accidental dural puncture (ADP) and subsequent development of postdural puncture headache (PDPH). Immediate treatment options after ADP include “resiting” (repeating) the epidural or inserting the epidural catheter into the intrathecal space and using the spinal catheter to provide labor analgesia.1 It has been suggested that inserting a spinal catheter and leaving the catheter in place for an extended period might decrease From the *Department of Anesthesiology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH; and †Department of Anesthesiology, Kingman Regional Medical Center, Kingman, AZ. The authors declare no conflict of interest. Address correspondence to: Norman Bolden, MD, Department of Anesthesiology, MetroHealth Medical Center, 2500 MetroHealth Dr, Cleveland, OH 44109 (e‐mail: [email protected]). Copyright © 2016 by American Society of Regional Anesthesia and Pain Medicine ISSN: 1098-7339 DOI: 10.1097/AAP.0000000000000339
PDPH and the requirement for subsequent epidural blood patch (EBP).2–4 Similarly, injection of intrathecal saline (with or without a spinal catheter) has been reported to decrease the incidence of PDPH and the need for EBP.5 The primary objective of this study was to examine the impact of the use of spinal catheters and the administration of intrathecal saline on the incidence of PDPH and the need for subsequent EBP during a 10-year period at an academic tertiary care facility. The secondary goals include examining the incidence of complications when customary epidural test doses (lidocaine 45 and epinephrine 15 μg6,7) or combined spinal epidural (CSE) labor solutions were administered immediately after ADP and the success rate of EBP in relieving PDPHs.
METHODS Approval was obtained from the institutional review board of MetroHealth Medical Center at Case Western Reserve University for this retrospective cohort study. The study was exempt from requiring informed consent. As part of our departmental quality assurance program, the Department of Anesthesiology maintains a database of anesthesia-related complications that was used to identify patients for this study. All patients who have neuraxial anesthesia attempted in our Labor and Delivery Suite receive postprocedure follow-up visits and are questioned for the possibility of PDPH. All ADP, PDPH, and patients who require EBP are entered into the departmental quality assurance database. All headaches classified as PDPH had a positional component to the headache (worse when upright). Patients with headaches suspected by the obstetrician to be related to preeclampsia or headaches not exacerbated by the upright position and felt to be tension headaches or migraine headaches were excluded. During the 10-year period from January 2001 through December 2010, there were 218 patients with documented ADP during epidural placement for labor analgesia at our institution. The medical records of these 218 patients were reviewed for the management choice opted for by the staff anesthesiologist. There was no fixed protocol for management of ADP, and the staff anesthesiologist chose either to resite (repeat) the epidural catheter or to insert the epidural catheter into the intrathecal space and use it as a continuous spinal technique for labor. The resited epidural catheters were removed soon after delivery. The spinal catheters were either removed immediately after delivery or removed at variable periods up to 30 hours after delivery. A subset of the patients who received a spinal catheter also received an injection of preservative-free normal saline through the spinal catheter. The medical records were abstracted to collect data on patient characteristics, the occurrence of PDPH, need for EBP, and outcome of EBP. The medical records were also examined for visits/encounters after discharge that may have been related to PDPH to increase the chance of capturing PDPHs that manifest after discharge. If the epidural needle was clearly inserted into the subarachnoid space (“wet tap”), the patients received a 3-mL solution prepared for intrathecal administration during labor CSE (fentanyl 15 μg, bupivacaine 1.25 mg, and epinephrine 0.1 mg). In a subset of patients, there was no clear evidence that the epidural needle
Regional Anesthesia and Pain Medicine • Volume 41, Number 2, March-April 2016
169
Copyright © 2016 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
Regional Anesthesia and Pain Medicine • Volume 41, Number 2, March-April 2016
Bolden and Gebre
was inserted into the subarachnoid space, and ADP was only detected on administration of the standard epidural test dose via the spinal catheter. These patients received a test dose of lidocaine 45 mg with epinephrine 15 μg intrathecally. Data were collected from the anesthesia records associated with lidocaine test dose or labor CSE solution administration immediately after spinal catheter placement. Data were collected regarding “hypotension prompting pressors” (decrease in baseline blood pressure by >20% prompting administration of pressors by the practitioner, with no other complications), high spinal (documented by the anesthesiologist, with all patients noting shortness of breath, sensory level higher than T4, and pressors administered in response to hypotenstion), or emergency cesarean delivery because of nonreassuring fetal status (NRFS). The characteristics of the 218 subjects were described using summary statistics. The primary outcomes were analyzed using χ2 tables and univariable logistic regression with the χ2 test. The Cochran-Armitage Trend test was used to evaluate the trend between the body mass index (BMI) group and incidence of blood patch. In the secondary analysis, descriptive statistics were used to describe the incidence of complications after standard lidocaine test dose and labor CSE solution administration. The association between complication type and test dose type was examined using the Fisher exact test.
RESULTS During the 10-year study period, we noted 218 ADPs out of 24,531 total epidural and CSE blocks performed at our institution, resulting in an ADP rate of 0.89%. The characteristics of the 218 ADP subjects can be found in Figure 1 and Tables 1 and 2. A total of 134 subjects (61.5%) had a documented PDPH, and 76 (56.7%) of 134 PDPH patients received a blood patch. Headache improved after the first EBP in 65 (85.5%) of 76 patients. Of the 11 patients without improvement in headache after initial EBP, 5 received a second blood patch, with all 5 achieving subsequent relief. We did not find a significant difference in the incidence of documented headache between the subjects with resited epidural
TABLE 1. Summary Statistics of Subject Characteristics Trait Age, y Height, inches Weight, lb BMI, kg/m2
n
Mean Median SD Minimum, Maximum
218 25.8 218 34.1 218 188.5 218 32.2
25.0 64.0 182.0 31.0
6.5 3.1 46.3 7.1
14.0, 44.0 52.0, 72.0 107.0, 400.0 18.4, 62.6
catheters and those subjects with spinal catheters 68.0% versus 55.9% (odds ratio [OR], 1.7; 95% confidence interval [95% CI], 1.0–2.9; P = 0.07) (Table 3). The incidence of documented headache was not significantly affected by the number of hours that the spinal catheter was left in place (Table 3). Subjects' BMI did not change the incidence of documented headache, and the incidence of headache was not significantly different in patients who were morbidly obese compared with patients who were of normal BMI (Table 3). Resiting the epidural catheter was associated with a significant increase in the number of EBPs when compared with using a spinal catheter, 52.0% versus 20.3% (OR, 4.2; 95% CI, 2.4–7.6; P < 0.001). This difference was even more pronounced when we compared resiting the epidural with the subjects who received saline boluses through the spinal catheter, 52.0% versus 8.1% (OR, 12.3; 95% CI, 4.3–35.4; P < 0.001). Interestingly, there was also a significant difference in the number of EBPs between subjects who had spinal catheters without saline boluses and subjects who received saline boluses through their spinal catheters, 25.9% versus 8.1% (OR, 4.0; 95% CI, 1.2–13.4; P = 0.03). In patients with spinal catheters, the number of EBPs did not change with the number of hours that the catheter was left in place (Table 4). When resiting the epidural, 25 (25%) of 100 required 2 or more attempts to establish adequate neuraxial analgesia versus 17 (15.2%) of 118 in the spinal catheter group (P = 0.07). Five percent (5 of 100) of patients in the resited group experienced a second ADP.
FIGURE 1. Management options after accidental dural puncture.
170
© 2016 American Society of Regional Anesthesia and Pain Medicine
Copyright © 2016 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
Regional Anesthesia and Pain Medicine • Volume 41, Number 2, March-April 2016
TABLE 2. Summary Statistics of Dural Puncture Management Dural Puncture Management (2001–2010) Intrathecal catheter Saline bolus given via intrathecal catheter Time spinal catheter left in place
Documented headache Blood patch performed if headache documented Headache improved after first blood patch Second blood patch performed Type of test dose in subjects with spinal catheters
Frequency (%) Yes No (resited) Yes No 0–9 h 10–19 h 20–30 h Yes No Yes No Yes No Yes No Lidocaine CSE solution
118 (54.1) 100 (45.9) 37 (31.4) 81 (68.6) 45 (38.1) 14 (11.9) 59 (50.0) 134 (61.5) 84 (38.5) 76 (56.7) 58 (43.3) 65 (85.5) 11 (14.5) 5 (6.7) 71 (93.4) 25 (21.2) 93 (78.8)
There was a significant difference in the number of EBPs between normal-BMI patients and morbidly obese patients, 55.2.% versus 25.0% (OR, 3.7; 95% CI, 1.2–11.2; P = 0.02) (Table 4). The 2-sided Cochran-Armitage Trend test looking at BMI and the need for EBP showed a significant trend of decreasing need for EBPs with increasing BMI (P = 0.01) (Table 4). There were significantly more complications with the use of the standard lidocaine test dose compared with the CSE solution when administered intrathecally after ADP (including high spinal and emergency cesarean delivery caused by NRFS) (Figs. 2 and 3).
DISCUSSION More than 70% of practitioners elect to withdraw and resite the epidural needle after ADP rather than inserting a spinal catheter for labor,8 and ADP is associated with a very high incidence of PDPH.1,9 Studies evaluating the impact of spinal catheters in decreasing the incidence of PDPH have produced conflicting results. Although a number of studies showed a reduction in PDPH with spinal catheters,2–4,10–13 other studies did not find a reduction in PDPH with spinal catheters.1,14–16 Leakage of cerebrospinal fluid from the hole created during the ADP, with resulting cerebral hypotension and traction on
Accidental Dural Puncture Management
dural structures, is the presumed pathophysiology and mechanism behind the development of PDPH.5,17,18 It stands to reason that prompt or timely replacement of the cerebrospinal fluid volume might prevent the development of the PDPH. Charsley and Abram5 reported a significant reduction in the development of PDPH and the subsequent need for EBP when 10 mL saline was administered intrathecally either directly via the epidural needle or via a spinal catheter. This study was limited by the small number of subjects but seemed to show promise for a technique that might have a significant impact on decreasing PDPH and EBP. Although there were more PDPHs in the resited epidural group (68.0%) compared with the spinal catheter group (55.9%), this did not reach a level of statistical significance with our study size (P = 0.09). However, in agreement with Paech et al,4 we did find that the need for EBPs was significantly lower when spinal catheters were used compared with resiting the epidural catheter. Our observed difference in EBPs was magnified when we compared resited catheters with spinal catheters where saline boluses were injected. Our results of decreased EBPs in the spinal catheter group, with a reduced yet not statistically significant difference in PDPH, are also consistent with recent findings from the metaanalysis performed by Heesen et al.19 Two additional studies recently found that spinal catheters decreased the incidence of PDPH compared with resited epidurals yet were unable to demonstrate a significant difference in the EBPs.12,13 This further highlights the controversies that remain in this area, and additional prospective randomized studies are needed to better define the best practices in limiting PDPH after ADP. Interestingly, our data (and that of Russell1) contrasted with the findings of Ayad et al2 and the length of time the spinal catheter was left in place did not seem to have an effect on the development of PDPH or the need for subsequent EBPs. When technical difficulty is encountered in placing epidurals, the patient is understandably at greater risk for ADP. Russell1 reported a 40% incidence of patients requiring 2 or more attempts after resiting of the epidural needle to achieve adequate analgesia, and a 9% incidence of repeat ADP. In our series, 25% of patients in the resited group required 2 or more attempts to establish adequate neuraxial anesthesia versus 15.2% in the spinal catheter group. Five percent of patients in our resited group sustained a second ADP on resiting. We also looked at the effect of the patients' BMI on PDPH incidence and the need for EBPs. Unlike Peralta et al,20 we were unable to demonstrate fewer PDPHs with increasing BMI. We did however find that increasing BMI was associated with a decreased incidence of EBP, whereas Peralta et al20 found no difference in EBP between BMI groups. Because various studies20–22
TABLE 3. Predictors of Headache Headache, n (%) No Headache, n (%) OR (95% CI) Resited Spinal catheter without saline Spinal catheter with saline Spinal catheter left in for
ORIGINAL ARTICLE
Accidental Dural Puncture Management 10-Year Experience at an Academic Tertiary Care Center Norman Bolden, MD* and Ermias Gebre, MD† Background and Objectives: The use of spinal catheters for extended periods after accidental dural puncture (ADP) and administration of intrathecal saline via spinal catheters have been advocated to decrease the incidence of postdural puncture headache and the subsequent need for epidural blood patch (EBP), with mixed results observed. Methods: We reviewed the medical records of 218 patients with ADP who either had the epidural resited or had a spinal catheter (with or without the administration of intrathecal saline). We compared the incidence of headache and the need for blood patch between these groups. We also assessed complications when a standard lidocaine epidural test dose was administered intrathecally and compared this with complications when a solution normally used for labor combined spinal epidurals was administered. Results: There was no difference in the incidence of postdural puncture headache between the resited epidural group and the spinal catheter group, 68.0% versus 55.9% (odds ratio [OR], 1.7; 95% confidence interval [95% CI], 1.0–2.9; P = 0.07). Resiting the epidural catheter was associated with a significant increase in the number of EBPs when compared with using a spinal catheter, 52.0% versus 20.3% (OR, 4.2; 95% CI, 2.4–7.6; P < 0.001) and when compared with spinal catheters with intrathecal saline, 52.0% versus 8.1% (OR, 12.3; 95% CI, 4.3–35.4; P < 0.001). There was a significant difference in the number of blood patches between normal body mass index patients and morbidly obese patients, 55.2% versus 25.0% (OR, 3.7; 95% CI, 1.2–11.2; P = 0.02). Complications (hypotension prompting pressors, high spinal, and emergency cesarean delivery because of nonreassuring fetal status) occurred more frequently when a lidocaine test dose was immediately administered after ADP versus administering a labor combined spinal epidural solution. Conclusions: Insertion of spinal catheters after ADP and administration of intrathecal normal saline via spinal catheters reduce the need for EBP compared with resiting the epidural. Administration of the standard epidural test dose intrathecally is associated with frequent and significant complications. (Reg Anesth Pain Med 2016;41: 169–174)
E
pidural analgesia is a very effective and widely used technique for the managmeent of pain associated with labor. One of the most common and problematic complications of epidural placement is accidental dural puncture (ADP) and subsequent development of postdural puncture headache (PDPH). Immediate treatment options after ADP include “resiting” (repeating) the epidural or inserting the epidural catheter into the intrathecal space and using the spinal catheter to provide labor analgesia.1 It has been suggested that inserting a spinal catheter and leaving the catheter in place for an extended period might decrease From the *Department of Anesthesiology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH; and †Department of Anesthesiology, Kingman Regional Medical Center, Kingman, AZ. The authors declare no conflict of interest. Address correspondence to: Norman Bolden, MD, Department of Anesthesiology, MetroHealth Medical Center, 2500 MetroHealth Dr, Cleveland, OH 44109 (e‐mail: [email protected]). Copyright © 2016 by American Society of Regional Anesthesia and Pain Medicine ISSN: 1098-7339 DOI: 10.1097/AAP.0000000000000339
PDPH and the requirement for subsequent epidural blood patch (EBP).2–4 Similarly, injection of intrathecal saline (with or without a spinal catheter) has been reported to decrease the incidence of PDPH and the need for EBP.5 The primary objective of this study was to examine the impact of the use of spinal catheters and the administration of intrathecal saline on the incidence of PDPH and the need for subsequent EBP during a 10-year period at an academic tertiary care facility. The secondary goals include examining the incidence of complications when customary epidural test doses (lidocaine 45 and epinephrine 15 μg6,7) or combined spinal epidural (CSE) labor solutions were administered immediately after ADP and the success rate of EBP in relieving PDPHs.
METHODS Approval was obtained from the institutional review board of MetroHealth Medical Center at Case Western Reserve University for this retrospective cohort study. The study was exempt from requiring informed consent. As part of our departmental quality assurance program, the Department of Anesthesiology maintains a database of anesthesia-related complications that was used to identify patients for this study. All patients who have neuraxial anesthesia attempted in our Labor and Delivery Suite receive postprocedure follow-up visits and are questioned for the possibility of PDPH. All ADP, PDPH, and patients who require EBP are entered into the departmental quality assurance database. All headaches classified as PDPH had a positional component to the headache (worse when upright). Patients with headaches suspected by the obstetrician to be related to preeclampsia or headaches not exacerbated by the upright position and felt to be tension headaches or migraine headaches were excluded. During the 10-year period from January 2001 through December 2010, there were 218 patients with documented ADP during epidural placement for labor analgesia at our institution. The medical records of these 218 patients were reviewed for the management choice opted for by the staff anesthesiologist. There was no fixed protocol for management of ADP, and the staff anesthesiologist chose either to resite (repeat) the epidural catheter or to insert the epidural catheter into the intrathecal space and use it as a continuous spinal technique for labor. The resited epidural catheters were removed soon after delivery. The spinal catheters were either removed immediately after delivery or removed at variable periods up to 30 hours after delivery. A subset of the patients who received a spinal catheter also received an injection of preservative-free normal saline through the spinal catheter. The medical records were abstracted to collect data on patient characteristics, the occurrence of PDPH, need for EBP, and outcome of EBP. The medical records were also examined for visits/encounters after discharge that may have been related to PDPH to increase the chance of capturing PDPHs that manifest after discharge. If the epidural needle was clearly inserted into the subarachnoid space (“wet tap”), the patients received a 3-mL solution prepared for intrathecal administration during labor CSE (fentanyl 15 μg, bupivacaine 1.25 mg, and epinephrine 0.1 mg). In a subset of patients, there was no clear evidence that the epidural needle
Regional Anesthesia and Pain Medicine • Volume 41, Number 2, March-April 2016
169
Copyright © 2016 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
Regional Anesthesia and Pain Medicine • Volume 41, Number 2, March-April 2016
Bolden and Gebre
was inserted into the subarachnoid space, and ADP was only detected on administration of the standard epidural test dose via the spinal catheter. These patients received a test dose of lidocaine 45 mg with epinephrine 15 μg intrathecally. Data were collected from the anesthesia records associated with lidocaine test dose or labor CSE solution administration immediately after spinal catheter placement. Data were collected regarding “hypotension prompting pressors” (decrease in baseline blood pressure by >20% prompting administration of pressors by the practitioner, with no other complications), high spinal (documented by the anesthesiologist, with all patients noting shortness of breath, sensory level higher than T4, and pressors administered in response to hypotenstion), or emergency cesarean delivery because of nonreassuring fetal status (NRFS). The characteristics of the 218 subjects were described using summary statistics. The primary outcomes were analyzed using χ2 tables and univariable logistic regression with the χ2 test. The Cochran-Armitage Trend test was used to evaluate the trend between the body mass index (BMI) group and incidence of blood patch. In the secondary analysis, descriptive statistics were used to describe the incidence of complications after standard lidocaine test dose and labor CSE solution administration. The association between complication type and test dose type was examined using the Fisher exact test.
RESULTS During the 10-year study period, we noted 218 ADPs out of 24,531 total epidural and CSE blocks performed at our institution, resulting in an ADP rate of 0.89%. The characteristics of the 218 ADP subjects can be found in Figure 1 and Tables 1 and 2. A total of 134 subjects (61.5%) had a documented PDPH, and 76 (56.7%) of 134 PDPH patients received a blood patch. Headache improved after the first EBP in 65 (85.5%) of 76 patients. Of the 11 patients without improvement in headache after initial EBP, 5 received a second blood patch, with all 5 achieving subsequent relief. We did not find a significant difference in the incidence of documented headache between the subjects with resited epidural
TABLE 1. Summary Statistics of Subject Characteristics Trait Age, y Height, inches Weight, lb BMI, kg/m2
n
Mean Median SD Minimum, Maximum
218 25.8 218 34.1 218 188.5 218 32.2
25.0 64.0 182.0 31.0
6.5 3.1 46.3 7.1
14.0, 44.0 52.0, 72.0 107.0, 400.0 18.4, 62.6
catheters and those subjects with spinal catheters 68.0% versus 55.9% (odds ratio [OR], 1.7; 95% confidence interval [95% CI], 1.0–2.9; P = 0.07) (Table 3). The incidence of documented headache was not significantly affected by the number of hours that the spinal catheter was left in place (Table 3). Subjects' BMI did not change the incidence of documented headache, and the incidence of headache was not significantly different in patients who were morbidly obese compared with patients who were of normal BMI (Table 3). Resiting the epidural catheter was associated with a significant increase in the number of EBPs when compared with using a spinal catheter, 52.0% versus 20.3% (OR, 4.2; 95% CI, 2.4–7.6; P < 0.001). This difference was even more pronounced when we compared resiting the epidural with the subjects who received saline boluses through the spinal catheter, 52.0% versus 8.1% (OR, 12.3; 95% CI, 4.3–35.4; P < 0.001). Interestingly, there was also a significant difference in the number of EBPs between subjects who had spinal catheters without saline boluses and subjects who received saline boluses through their spinal catheters, 25.9% versus 8.1% (OR, 4.0; 95% CI, 1.2–13.4; P = 0.03). In patients with spinal catheters, the number of EBPs did not change with the number of hours that the catheter was left in place (Table 4). When resiting the epidural, 25 (25%) of 100 required 2 or more attempts to establish adequate neuraxial analgesia versus 17 (15.2%) of 118 in the spinal catheter group (P = 0.07). Five percent (5 of 100) of patients in the resited group experienced a second ADP.
FIGURE 1. Management options after accidental dural puncture.
170
© 2016 American Society of Regional Anesthesia and Pain Medicine
Copyright © 2016 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
Regional Anesthesia and Pain Medicine • Volume 41, Number 2, March-April 2016
TABLE 2. Summary Statistics of Dural Puncture Management Dural Puncture Management (2001–2010) Intrathecal catheter Saline bolus given via intrathecal catheter Time spinal catheter left in place
Documented headache Blood patch performed if headache documented Headache improved after first blood patch Second blood patch performed Type of test dose in subjects with spinal catheters
Frequency (%) Yes No (resited) Yes No 0–9 h 10–19 h 20–30 h Yes No Yes No Yes No Yes No Lidocaine CSE solution
118 (54.1) 100 (45.9) 37 (31.4) 81 (68.6) 45 (38.1) 14 (11.9) 59 (50.0) 134 (61.5) 84 (38.5) 76 (56.7) 58 (43.3) 65 (85.5) 11 (14.5) 5 (6.7) 71 (93.4) 25 (21.2) 93 (78.8)
There was a significant difference in the number of EBPs between normal-BMI patients and morbidly obese patients, 55.2.% versus 25.0% (OR, 3.7; 95% CI, 1.2–11.2; P = 0.02) (Table 4). The 2-sided Cochran-Armitage Trend test looking at BMI and the need for EBP showed a significant trend of decreasing need for EBPs with increasing BMI (P = 0.01) (Table 4). There were significantly more complications with the use of the standard lidocaine test dose compared with the CSE solution when administered intrathecally after ADP (including high spinal and emergency cesarean delivery caused by NRFS) (Figs. 2 and 3).
DISCUSSION More than 70% of practitioners elect to withdraw and resite the epidural needle after ADP rather than inserting a spinal catheter for labor,8 and ADP is associated with a very high incidence of PDPH.1,9 Studies evaluating the impact of spinal catheters in decreasing the incidence of PDPH have produced conflicting results. Although a number of studies showed a reduction in PDPH with spinal catheters,2–4,10–13 other studies did not find a reduction in PDPH with spinal catheters.1,14–16 Leakage of cerebrospinal fluid from the hole created during the ADP, with resulting cerebral hypotension and traction on
Accidental Dural Puncture Management
dural structures, is the presumed pathophysiology and mechanism behind the development of PDPH.5,17,18 It stands to reason that prompt or timely replacement of the cerebrospinal fluid volume might prevent the development of the PDPH. Charsley and Abram5 reported a significant reduction in the development of PDPH and the subsequent need for EBP when 10 mL saline was administered intrathecally either directly via the epidural needle or via a spinal catheter. This study was limited by the small number of subjects but seemed to show promise for a technique that might have a significant impact on decreasing PDPH and EBP. Although there were more PDPHs in the resited epidural group (68.0%) compared with the spinal catheter group (55.9%), this did not reach a level of statistical significance with our study size (P = 0.09). However, in agreement with Paech et al,4 we did find that the need for EBPs was significantly lower when spinal catheters were used compared with resiting the epidural catheter. Our observed difference in EBPs was magnified when we compared resited catheters with spinal catheters where saline boluses were injected. Our results of decreased EBPs in the spinal catheter group, with a reduced yet not statistically significant difference in PDPH, are also consistent with recent findings from the metaanalysis performed by Heesen et al.19 Two additional studies recently found that spinal catheters decreased the incidence of PDPH compared with resited epidurals yet were unable to demonstrate a significant difference in the EBPs.12,13 This further highlights the controversies that remain in this area, and additional prospective randomized studies are needed to better define the best practices in limiting PDPH after ADP. Interestingly, our data (and that of Russell1) contrasted with the findings of Ayad et al2 and the length of time the spinal catheter was left in place did not seem to have an effect on the development of PDPH or the need for subsequent EBPs. When technical difficulty is encountered in placing epidurals, the patient is understandably at greater risk for ADP. Russell1 reported a 40% incidence of patients requiring 2 or more attempts after resiting of the epidural needle to achieve adequate analgesia, and a 9% incidence of repeat ADP. In our series, 25% of patients in the resited group required 2 or more attempts to establish adequate neuraxial anesthesia versus 15.2% in the spinal catheter group. Five percent of patients in our resited group sustained a second ADP on resiting. We also looked at the effect of the patients' BMI on PDPH incidence and the need for EBPs. Unlike Peralta et al,20 we were unable to demonstrate fewer PDPHs with increasing BMI. We did however find that increasing BMI was associated with a decreased incidence of EBP, whereas Peralta et al20 found no difference in EBP between BMI groups. Because various studies20–22
TABLE 3. Predictors of Headache Headache, n (%) No Headache, n (%) OR (95% CI) Resited Spinal catheter without saline Spinal catheter with saline Spinal catheter left in for
