In Response.

Abstract

We thank Drs Hoffman and Riordan1 for their thoughtful comment on our study.2 While we agree that more research is needed on the treatment of postdural puncture headache (PDPH) with epidural blood patch, it is important to point out that accidental dural puncture is not inevitable and could be prevented through better training and quality assurance. The recent root-cause analysis by Haller et al3 revealed that the absence of skilled assistance during epidural placement (ie, nurse anesthetist) and multiple insertion attempts are associated with an increased risk of PDPH.3 Although the current American Society of Anesthesiologists Task Force on Obstetric Anesthesia Practice Guidelines for Obstetric Anesthesia does not recommend any obstetric team composition for labor epidural placement, the Haller et al3 study suggests that having a skilled assistant to the anesthesiologist during the procedure might reduce the incidence of PDPH. Use of lumbar ultrasound imaging has been shown to decrease the number of epidural placement attempts. Given the heightened risk of major neurological complications associated with PDPH, it is sensible to recommend the use of ultrasound imaging for neuraxial anesthesia in obstetrics, particularly among women with known risk factors for difficult placement, such as difficult anatomical landmark palpation.4 The role of simulation training in acquiring and maintaining technical skills and reducing the number of epidural placement attempts also warrants investigation. Jean Guglielminotti, MD, PhDRuth Landau, MDDepartment of AnesthesiologyColumbia University College of Physicians and SurgeonsNew York, New York[email protected]Guohua Li, MD, DrPHDepartment of AnesthesiologyColumbia University College of Physicians and SurgeonsNew York, New YorkDepartment of EpidemiologyColumbia University Mailman School of Public HealthNew York, New York