Management Of Accidental Dural Puncture Research Articles

Changing Trends in the Management of Accidental Dural Puncture during Labor Epidural Analgesia: A Narrative Review and Recent Updates

Inadvertent or accidental dural puncture while attempting epidural for labor analgesia is a known anaesthetist complication with potential for post dural puncture headache, increased morbidity, prolonged hospitalisation and overall medical cost. Historically, following accidental dural puncture- resitation of the epidural catheter at another level was the norm. Over the last 2-3 decades, there is a paradigm shift in the management of dural puncture while attempting epidural.

"Changing Trends in the Management of Accidental Dural Puncture During Labor Epidural analgesia. A Narrative Review and Recent Updates"

"Changing Trends in the Management of Accidental Dural Puncture During Labor Epidural analgesia. A Narrative Review and Recent Updates"

Preliminary Findings and Outcomes Associated With the Use of a Continuous Spinal Protocol for Labor Pain Relief Following Accidental Dural Puncture

(Reg Anesth Pain Med. 2019;44:1098–1103) Anesthesiologists vary in their management of accidental dural puncture (ADP) and associated postdural puncture headache (PDPH). Possible interventions following ADP include the insertion of a spinal catheter or the administration of intrathecal normal saline. While each of these interventions has been studied alone, combining them into a single continuous spinal protocol for labor pain relief has not been evaluated. This study aimed to compare the outcomes after an ADP of using a standardized continuous spinal protocol versus resiting the epidural catheter.

The Management of Accidental Dural Puncture and Postdural Puncture Headache

Abstract Study Objective To evaluate the management of accidental dural puncture (ADP) and postdural puncture headache (PDPH) among obstetric anesthesiologists practicing in North America. Design Questionnaire survey of individual members of the Society for Obstetric Anesthesia and Perinatology (SOAP). Setting University hospital. Measurements In June 2008, a 4-part, 83-item electronic survey was distributed to all North American members of SOAP. It contained questions about respondent demographics, epidural catheter and intrathecal catheter management after ADP, PDPH management, epidural blood patch (EBP) management, and patient follow-up. Main Results Of the 843 United States and Canadian members of SOAP who were surveyed, 160 responses were collected. Respondents reported placing an epidural 75% of the time and an intrathecal catheter 25% of the time following ADP. Common prophylactic and conservative treatment strategies included hydration, caffeine, and opioids by mouth; 76% of respondents leave an intrathecal catheter in place for 24 hours to reduce the frequency of headache. Epidural blood patches are placed by 81% of practitioners less than 24 hours after headache onset. Conclusions Protocols for ADP management are rare. There is wide variation in catheter management after dural puncture, measures used to prevent and treat a resultant headache, and EBP management.

Management of Accidental Dural Puncture and Postdural Puncture Headache After Labor

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The management of accidental dural puncture and postdural puncture headache: a North American survey

Study Objective To evaluate the management of accidental dural puncture (ADP) and postdural puncture headache (PDPH) among obstetric anesthesiologists practicing in North America. Design Questionnaire survey of individual members of the Society for Obstetric Anesthesia and Perinatology (SOAP). Setting University hospital. Measurements In June 2008, a 4-part, 83-item electronic survey was distributed to all North American members of SOAP. It contained questions about respondent demographics, epidural catheter and intrathecal catheter management after ADP, PDPH management, epidural blood patch (EBP) management, and patient follow-up. Main Results Of the 843 United States and Canadian members of SOAP who were surveyed, 160 responses were collected. Respondents reported placing an epidural 75% of the time and an intrathecal catheter 25% of the time following ADP. Common prophylactic and conservative treatment strategies included hydration, caffeine, and opioids by mouth; 76% of respondents leave an intrathecal catheter in place for 24 hours to reduce the frequency of headache. Epidural blood patches are placed by 81% of practitioners less than 24 hours after headache onset. Conclusions Protocols for ADP management are rare. There is wide variation in catheter management after dural puncture, measures used to prevent and treat a resultant headache, and EBP management.

Headache in the parturient: Pathophysiology and management of post-dural puncture headache

Headache in the postpartum period is common and multifactorial in origin. Apart from primary causes such as tension headaches and migraine, secondary headaches such as post-dural puncture headache (PDPH) are increasingly common because of increasing use of regional anaesthesia and analgesia during childbirth. Preventive measures for PDPH include the use of smaller gauge pencil-point needles for spinal blocks; epidural needles of 18 G or less; using saline rather than air for epidural space identification and the use of ultrasound guidance, especially for difficult cases such as morbid obesity and spinal deformities. In case of accidental dural puncture (ADP), the choice is between inserting the catheter in an adjacent space or intrathecal catheterization. Current evidence seems to be in favour of inserting the epidural catheter into the subarachnoid space and using the intrathecal catheter for analgesia/anaesthesia after prominently labelling it as intrathecal, to prevent misuse. It should be removed after at least 24 hours and a 10 ml bolus of saline injected before removal of catheter may be helpful. Either way, having written protocols for the management of accidental dural puncture helps to reduce the incidence of PDPH. PDPH can be disabling in severity and can mar the whole experience of childbirth. In addition, severe untreated PDPH can cause complications such as nerve palsies, subdural hematoma and cerebral venous thrombosis. Conservative methods of treatment should be tried first such as adequate hydration, paracetamol, caffeine, sumatriptan or ACTH/hydrocortisone. Epidural blood patching is the most effective treatment for PDPH. It is more effective if done 24-48 hours after dural puncture. It is an invasive procedure with its own complications as well as a failure rate of up to 30%, so that a second or even third patch may be necessary. Both these facts should be intimated to the patient beforehand. Meticulous follow-up and evaluation of these patients is an important responsibility of the obstetric and anaesthetic team. Persistent headache, loss of the postural nature of the headache, altered sensorium, onset of focal neurological deficits and seizures are all features necessitating further investigation including neuroradiological imaging.

Management of accidental dural puncture and post-dural puncture headache after labour: a Nordic survey

a major risk with epidural analgesia is accidental dural puncture (ADP), which may result in post-dural puncture headache (PDPH). This survey was conducted to explore the incidence of ADP, the policy for management of PDPH and the educational practices in epidural analgesia during labour in the Nordic countries. a postal questionnaire was sent to the anaesthesiologist responsible for Obstetric anaesthesia service in all maternity units (n=153) with questions relating to the year 2008. the overall response rate was 93%. About 32% (22-47%) of parturients received epidural analgesia for labour. There were databases for registering obstetric epidural complications in 13% of Danish, 24% of Norwegian and Swedish, 43% of Finnish and 100% of hospitals in Iceland. The estimated incidence of ADP was 1% (n approximately 900). Epidural blood patch (EBP) was performed in 86% (n≈780) of the parturients. The most common time interval from diagnosis to performing EBP was 24-48 h. The success rate for EBP was >75% in 67% (62-79%) of hospitals. The use of diagnostic CT/MRI before the first or the second EBP was exceptional. No major complication was reported. Teaching of epidurals was commonest (86%) in the non-obstetric population and 53% hospitals desired a formal training programme in obstetric analgesia. we found the incidence of ADP to be approximately 1%. EBP was the commonest method used for its management, and the success rate was high in most hospitals. Formal training in epidural analgesia was absent in most countries and trainees first performed it in the non-obstetric population.

Intrathecal catheterization by epidural catheter: management of accidental dural puncture and prophylaxis of PDPH

Accidental or inadvertent dural puncture during epidural anaesthesia results in high incidence of post dural puncture headache (PDPH). Spinal or intrathecal catheter in such a situation, provides a conduit for administration of appropriate local anaesthetic for rapid onset of intraoperative surgical anaesthesia and postoperative pain relief. This procedure prevents PDPH if catheter left in situ for > 24 hrs and also avoids the associated risks with a repeat attempts at epidural analgesia. Primary aim of this study was to observe the effect of spinal catheter on incidence of PDPH, and to assess early and delayed complications of spinal catheterization by epidural catheter. In prospective clinical study 34 patients who had accidental dural puncture during epidural anaesthesia were included. The catheter meant for epidural use was inserted in spinal space and used for spinal anaesthesia and postoperative analgesia. Catheter was removed between 24-36hrs after surgery. The incidence of accidental dural puncture was 4%(34/846). Two patients 5.88% (2/34) had transient paresthesia during spinal catheter insertion. Post dural puncture headache occurred in 11.76% (4/34) patients. Two patients required epidural blood patch and two patients were managed with conservative treatment. No patient had any serious intraoperative or postoperative side effects. Epidural catheter can be used as spinal catheter to manage accidental dural puncture without serious complications, and it also prevents PDPH.

Accidental dural puncture and post dural puncture headache in obstetric anaesthesia: presentation and management: A 23‐year survey in a district general hospital

Post dural puncture headache can be a debilitating complication of epidural and subarachnoid anaesthesia for a new mother. In a survey of 18,337 epidurals and 5021 subarachnoid blocks performed for obstetric procedures over a 23-year period in a district general hospital maternity unit, there were 167 recognised accidental dural punctures after epidurals (0.91%), with 147 patients (88%) developing post dural puncture headache. In addition there were 52 post dural puncture headaches after subarachnoid blocks (1.04%). Successful management of accidental dural puncture and post dural puncture headache requires adherence to clear policies and protocols, with close follow-up of patients by an experienced obstetric anaesthetist.

The Management of Accidental Dural Puncture During Labor Epidural Analgesia

Survey of Anesthesiology: August 2006 - Volume 50 - Issue 4 - p 186-187 doi: 10.1097/01.sa.0000234689.71926.fd

The Management of Accidental Dural Puncture

The Management of Accidental Dural Puncture

The Management of Accidental Dural Puncture during Labour Epidural Analgesia: A Survey of UK Practice

The Management of Accidental Dural Puncture during Labour Epidural Analgesia: A Survey of UK Practice

The management of accidental dural puncture in pregnant women: what does an obstetrician need to know?

Post-dural puncture headache (PDPH) also known as spinal (or post-spinal) headache still remains a disabling complication of needle insertion into the subarachnoid space. Pregnant women are at particular risk of dural puncture, and the subsequent headache, because of sex, young age, and the widespread application of regional anesthesia. Accidental dural puncture complicating epidural anesthesia varies in incidence from 0.19 to 4.4%. The incidence of epidural needle-induced PDPH headache in pregnant women has been reported to range 76-85%. The classic symptoms of PDPH consist of photophobia, nausea, vomiting, neck stiffness, tinnitus, diplopia, and dizziness in addition to the often, severe cephalgia. This article reviews the current literature on the pathophysiology, incidence, prevention, and treatment of PDPH in pregnant women.

The management of accidental dural puncture

I read with interest the recent article by Baraz and Collis [1] discussing the management of accidental dural puncture during labour epidural analgesia in the United Kingdom. The authors are to be congratulated for conducting such an interesting and clinically useful survey of current management of this complication. In my practice of obstetric anaesthesia at the University of California, San Diego, accidental dural puncture is followed by injection of the CSF in the glass syringe back into the subarachnoid space through the epidural needle, insertion of a epidural catheter into the subarachnoid space, injection of a small amount of preservative free saline (3–5 ml) into the subarachnoid space through the intrathecal catheter, administration of a bolus and then continuous subarachnoid labour analgesia, and leaving the catheter in situ in the subarachnoid space for a total of 12–20 h [2, 3]. These five manoeuvers decreased the incidence of epidural needle-induced, postdural puncture headache in parturients following dural puncture with a large bore (for example 18 G) epidural needle from the textbook-referenced 76–85%[4] to 6.6%[3].

The Management of Accidental Dural Puncture during Labour Epidural Analgesia: A Survey of UK Practice

The Management of Accidental Dural Puncture during Labour Epidural Analgesia: A Survey of UK Practice

The management of accidental dural puncture during labour epidural analgesia: a survey of UK practice*

The management of accidental dural puncture and postdural puncture headache in obstetric practice continues to be of great interest. This survey aims to explore the current management of this complication in the United Kingdom and compares the findings to a similar survey undertaken in 1993. A postal questionnaire was sent to all maternity units (n = 248). The return rate was 71%. Of these, 144 units (85%) now have written guidelines for the management of accidental dural puncture compared to 58% in 1993. In 47 units (28%), the epidural catheter is now routinely placed intrathecally following accidental dural puncture; in 69 units (41%) the catheter is re-sited and in the remaining 53 units (31%) either option is allowed. This is in contrast to the previous survey, which found that catheters were re-sited in 99% of units. Only 31 units (18%) now limit the second stage of labour and 19 (11%) avoid pushing and deliver by ventouse or forceps, whilst 116 units (69%) allow labour to take place without any intervention. Only 44 units (26%) now treat postdural puncture headache with an epidural blood patch as soon as it is diagnosed, whereas in 120 units (71%) the blood patch is performed only after failure of conservative measures. Due to the large increase in the use of the intrathecal catheter following this complication, a follow-up questionnaire was posted 5 months later to those units (n = 99) that reported this practice in the initial survey, with a 94% response rate. The two most commonly cited reasons for intrathecal catheterisation were to avoid further dural puncture (76%) and to allow immediate analgesia for labour (75%).

Management of accidental dural puncture in labour with intrathecal catheters: an analysis of 10 years’ experience

The records of 15 030 labour epidural blocks were analysed. Seventy-two accidental dural punctures (ADP) were recognised at the time of the procedure. In 34 women an epidural catheter was inserted intrathecally through the Tuohy needle and continuous spinal analgesia provided. In a further 37 women the primary management of ADP was to resite an epidural catheter. One woman who received a microspinal catheter later in labour was excluded from analysis. There were no significant differences in maternal characteristics, quality of labour analgesia and anaesthesia, or mode of delivery between the groups. Three repeat ADPs occurred during attempts to resite the epidural. Two women developed high blocks after epidural resiting, one of whom required intubation and ventilation. There was one high block in the intrathecal catheter group. The incidence of postdural puncture headache was 71% in the intrathecal catheter group compared with 81% in the non-intrathecal catheter group (P = 0.45). Epidural blood patch was performed on 50% of women managed with intrathecal catheters compared with 73% of those managed without (P = 0.08). Following ADP in labour an intrathecal catheter is a simple and effective alternative to resiting an epidural. Recognition of ADP is important as it allows appropriate management avoiding possible complications of administering epidural top-ups in the presence of a dural tear.

Management of accidental dural puncture in labour with intrathecal catheter

Management of accidental dural puncture in labour with intrathecal catheter

An Alternative Method for Management of Accidental Dural Puncture for Labor and Delivery

An Alternative Method for Management of Accidental Dural Puncture for Labor and Delivery