… in patients with post–dural puncture headache
An alternative approach to traditional epidural blood patch administration in patients with post–dural puncture headache who have an indwelling catheter has passed its first test.
Although current fine-gauge needles have reduced the incidence of PDPH, the adverse event still occurs, and depends on several factors, including needle size and type, patient demographics, and the experience level of the proceduralist.
When PDPH is treated via an epidural blood patch, the procedure can be uncomfortable for the patient. “Traditionally, you would have to place another epidural needle, which presents another risk of dural puncture and further complications,” said Eric Michel, DO, the study’s primary author, who is an anesthesiologist at State University of New York’s Upstate Medical University, in Syracuse. “For another placement, the patient needs to be in position for an epidural, which means she has to sit up on the bed, which means her headache and other symptoms will likely come back,” said Dr. Michel, who presented the findings at the 70th PostGraduate Assembly in Anesthesiology.
Testing an Alternative Option
PDPH occurs from puncture of the dura mater, a complication seen following spinal or epidural anesthesia, and is associated with severe headache (particularly while in an upright position), nausea, dizziness, vomiting, tinnitus, visual disturbances and other symptoms.
Dr. Michel and his colleagues studied a case of a 30-year-old woman who underwent an open right partial nephrectomy for resection of a renal cyst. The patient had a history of attention-deficit/hyperactivity disorder, asthma and tobacco use. She received a thoracic epidural for postoperative pain control as part of her anesthetic plan. While no “wet tap” was reported during the epidural placement, three attempts were required for successful placement of the catheter.
“While the patient’s thoracic epidural worked well for her pain,” Dr. Michel said, “we were consulted by the urology services on post-op day 2 to evaluate her for a headache.” The patient’s symptoms were consistent with PDPH. The next day, when conservative symptom management consisting of fluid replacement and Fioricet (Actavis Pharma; a combination of acetaminophen, butalbital and caffeine) had not relieved symptoms, the decision was made to administer an epidural blood patch.
“Because we already had this access to her epidural space,” Dr. Michel said, “we thought why not use it as a means to administer the blood. It functioned in the way a standard epidural would, without having to put her through the procedure itself. All she got was another needle stick and blood draw.”
Further Data Needed
The patient was able to remain in a supine position during the procedure; and upon evaluation two hours later, she was found to have full resolution of symptoms—while seated and standing.
According to Dr. Michel, the benefits of this procedure include cost savings, due to the ability to bypass paying for a second epidural kit, and patient comfort. “Further study is necessary,” he added, “but this has potential to become standard of care for patients with an indwelling epidural catheter.”
However, the unique circumstances of this case may make it difficult to replicate frequently. “Because this scenario is not very typical, it is going to be tough to get many numbers,” said Dr. Michel, clarifying that the ideal scenario “would require multiple institutions on board—those that do more thoracotomies, open nephrectomies, Whipple disease, etc.” The key, Dr. Michel noted, may require keeping a catheter in place after surgery to see whether a headache develops. “It would be helpful if we could get institutions involved who place multiple epidural catheters, and in any instance where they think there was a difficult placement, or wet tap, that they keep the catheter in place until a two- to three-day period has gone by to see whether the patient develops a PDPH,” he said. “If not, take out the catheter. But if they do, you now have that access to be able to treat it without needing to put the patient through an additional procedure.”
Other experts agree the data are promising. “The authors have described a novel noninvasive treatment option for PDPH,” said Vandana Sharma, MD, assistant professor of anesthesiology at Upstate Medical University. “The use of an existing epidural catheter for blood patch has not been reported in the literature. This introduces a new noninvasive modality for management of PDPH in situations such as postpartum PDPH.”
According to Dr. Sharma, “the question arises if similar results could be reproduced if saline or colloid solution was injected through this catheter, as suggested alternatives to blood patch in previous case reports.”
Dr. Michel noted that sterility of the catheter was another potential concern. “In theory, the catheter remains sterile, but we should study further to confirm,” he said.