PDPH

Report
PDPH Treatment
Olivia Dziadek, MS4
When does it occur and whose at
risk?
• Commonly occurs within 15 to 48 hours of
dural puncture
• Dural puncture can occur during spinal
anesthesia and epidural anesthesia
• Obstetric patients at risk due to use of large
bore needles, 16 or 18 gauge
• Leakage of CSF may be increased by rise in
intra-abdominal pressure during labor
PDPH Symptoms
• Patient often complains of fronto-occipital
headache that worsens on standing and
improves on laying supine
• Tinnitus, low frequency hearing loss, diplopia,
photophobia, nausea, vomiting, may
accompany PDPH
Risk factors
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Incidence of PDPH is related to needle size and type
female gender
younger age (20-40 years old)
Lower BMI (weight as a protective factor)
History migraines, headaches
using a loss-of-resistance to air (vs. saline) technique to
identify the epidural space
• Cephalad or caudad orientation of the needle bevel
• Midline approach to dural sac
• Less operator experience
PDPH
• Resolves spontaneously without treatment in
1-2 weeks
• Untreated can cause cranial nerve palsies
• Headache can persist for months or years
Treatment
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Conservative treatment for the first 24 hours:
Recumbent position
Hydration to increase CSF pressure
oral analgesics
caffeine sodium benzoate-500 mg/l of lactated
ringer
• Encourage patient hydration (3 L/24hours)
• Abdominal binders
• After 24 hours:
EBP=gold standard therapy for PDPH
Figure 3. Structured protocol for the management of postdural puncture headache (PDPH)
after epidural space identification with the loss-of-resistance to air technique.
Somri M et al. Anesth Analg 2003;96:1809-1812
©2003 by Lippincott Williams & Wilkins
Mechanism of EBP
• Efficacy of first blood patch 70-98%
• Autologous blood is injected into the epidural
space
• Mechanism of action: dural compression with
translocation of CSF to the intracranial
compartment and formation of a clot over the
puncture site that diminishes CSF egress
• Subarachnoid and epidural pressures are
transiently elevated for 20 min after EBP and
mass effect resolves over several hours
Side Effects of EBP
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Pain from the injection
Pressure around the neck area
Slight increase in temperature
Perforation of dura
Infection, bleeding, nerve damage
Contraindications
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Blood thinners
Infection at injection site
Septicemia
Active Neurological disease
EBP
• Ideal blood patch volume and timing after dural
puncture are under investigation and appear to be 1520 ml and greater than 24 hours after the puncture
occurred
• Follow up visits and phone calls should be made until
resolution of symptoms
• EBP may be repeated after 24-48 hours if the cure if
incomplete or if headache recurs
• Failure of second patch should prompt investigation
into other causes of headachecerebral venous
thrombosis, pituatary apoplexy, intracranial tumors,
migraine and chemical or infective meningitis
Opinions
• Gaiser et al, state that an epidural blood patch
should not be performed until 24 h after dural
puncture to increase its success; however, it
should not be delayed beyond that period in
the symptomatic patient, as this delay
increases the amount of time the patient
suffers.
Technique for EBP
• Prep: confirmation of PDPH; informed consent
• Procedure:
-IV line placement
-Monitors placed
-Consider anxiolytic or analgesic (midazolam 12 mg, fentanyl 25-100 ug, IV)
-Patient positioned in lateral recumbent
position with IV arm in nondependent position
Technique for EBP cont.
-Venipuncture site identified, prepared
aseptically, and draped
-Vertebral interspace where dural rent occurred
is identified, aseptically prepared and draped
-Epidural space identified with loss-of-resistance
to saline technique
-Venipuncture performed and autologous blood
obtained (10-20 ml)
-Administration of blood, stopping if moderate
back discomfort or radicular pain occurs)
Post-procedure
• Written instructions for contact and care given
• Follow up visits or phone calls until resolution
• Patients must be instructed to return to the
hospital if worsening back pain, sensory or
motor weakness, or bladder/bowel
dysfunction develops
• Decubitus position 1-2 hours following EBP
may be of benefit
Summary of treatment options
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Psychologic support
Bedrest
Abdominal binder
Hydration
Caffeine
Analgesics
EBP
Epidural saline injection
Injection of a few milliliters of saline may produce
immediate resolution of a headache, but the effects will
be temporary
Factors to consider
• Higher needle gage (and smaller needle bore)
and orientation of the needle bevel parallel to
the longitudinal fibers of the dura have clearly
been shown to decrease the incidence of
PLPHA
• Threading an epidural catheter into the
intrathecal space and leaving it in situ for 24
hours has also been reported to reduce the
incidence of headache, efficacy not tested in
randomized trial
References
• Wong et al. Spinal and Epidural Anesthesia,
“Complications and Side Effects of Central
Neuraxial Techniques” 161-163.
• Up to Date,
http://www.uptodate.com/home/about/index
.html

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