Epidural Blood Patch

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narcusprince

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I have done a limited amount of blood patches in my residency probably 3-4. What is the optimal position for the patient to be in when placing an epidural blood patch supine, lateral, prone? The other day I saw a case for a general anesthetic for blood patch placement and assumed it had to be in the lateral position. And after the patch is in place how long must the patient lay still?

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I have done a limited amount of blood patches in my residency probably 3-4. What is the optimal position for the patient to be in when placing an epidural blood patch supine, lateral, prone? The other day I saw a case for a general anesthetic for blood patch placement and assumed it had to be in the lateral position. And after the patch is in place how long must the patient lay still?

Like everything in anesthesia there is no right or wrong answer for what position is better, but common sense suggests that the best position is the sitting position since you usually want the blood to move down not up the epidural space.
Why would you need GA to do a blood patch? that sounds a little strange and possibly dangerous.
After the patch I require them to be flat for 2 hours, and I think that is the average time other anesthesiologists require, but again, there is no solid data on that either.
 
Position for the patch doesn't matter much. Sometimes the H/A is so severe the patient prefers the later position.

I usually only require 30-45 minutes of lying in the stretcher before sending the patient home. Others wait an hour or 2 before allowing the patient to ambulate.
 
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With the patient in the lateral position, the epidural space is located with a Tuohy needle at the level of the supposed dural puncture or an intervertertebral space lower. The operator should be prepared for the presence of CSF within the epidural space. Up to 30 ml of blood is then taken from the patient's arm and injecting slowly through the Tuohy needle. Should the patient describe lancinating pain of dermatomal origin the procedure must be stopped.27 There is no consensus as to the precise volume of blood required. Most practitioners now recognise that the 2–3 ml of blood originally described by Gormley is inadequate, and that 20–30 ml of blood is more likely to guarantee success.27 Larger volumes, up to 60 ml,97 have been used successfully in cases of spontaneous intracranial hypotension. At the conclusion of the procedure, the patient is asked to lie still for one1 33 or, preferably, 2 h,81 and is then allowed to walk.

http://bja.oxfordjournals.org/content/91/5/718.long
 
Can J Anaesth. 1994 Jan;41(1):23-5.
Duration of decubitus position after epidural blood patch.

Martin R, Jourdain S, Clairoux M, Tétrault JP.
Source

Department of Anaesthesia, University of Sherbrooke, Quebec.

Abstract

Thirty patients presenting with post-dural puncture headache (PDPH) were prospectively studied to determine the influence of the duration of the decubitus position after epidural blood patch on the efficacy of treatment. All patients received 12 ml of autologous blood. They were randomly distributed into three groups of ten patients. Patients in Group 1 were maintained in a decubitus position for 30 min after the epidural injection of autologous blood in the epidural space. Patients in Group 2 were maintained for 60 min in decubitus and patients in Group 3 for 120 min. Post-dural puncture headache was evaluated using a visual analogue scale before the epidural blood patch, at the time of initially adopting a standing position after the blood patch, and 24 hr later. The severity of PDPH in the three groups was reduced at the time of initially adopting a standing position and after 24 hr, in comparison with preblood patch VAS (P < 0.001). Patients in Group 3 presented less severe PDPH than patients in Group 1 at the time of initially standing up and 24 hr later (P < 0.05). We conclude that epidural blood patch was effective in treating PDPH but that the maintenance of a decubitus position for at least one hour and preferably for two hours after the blood patch was more effective than maintenance for 30 min.
 
Can J Anaesth. 1994 Jan;41(1):23-5.
Duration of decubitus position after epidural blood patch.

Martin R, Jourdain S, Clairoux M, Tétrault JP.
Source

Department of Anaesthesia, University of Sherbrooke, Quebec.

Abstract

Thirty patients presenting with post-dural puncture headache (PDPH) were prospectively studied to determine the influence of the duration of the decubitus position after epidural blood patch on the efficacy of treatment. All patients received 12 ml of autologous blood. They were randomly distributed into three groups of ten patients. Patients in Group 1 were maintained in a decubitus position for 30 min after the epidural injection of autologous blood in the epidural space. Patients in Group 2 were maintained for 60 min in decubitus and patients in Group 3 for 120 min. Post-dural puncture headache was evaluated using a visual analogue scale before the epidural blood patch, at the time of initially adopting a standing position after the blood patch, and 24 hr later. The severity of PDPH in the three groups was reduced at the time of initially adopting a standing position and after 24 hr, in comparison with preblood patch VAS (P < 0.001). Patients in Group 3 presented less severe PDPH than patients in Group 1 at the time of initially standing up and 24 hr later (P < 0.05). We conclude that epidural blood patch was effective in treating PDPH but that the maintenance of a decubitus position for at least one hour and preferably for two hours after the blood patch was more effective than maintenance for 30 min.

This study is grossly underpowered with only 30 patients (10 in each group). Anyone looking for a research topic/clinical investigation has a good one here. I would do 2 groups. One at 1 hour and a second at 2 hours.
I also would include at least 50 patients in each group.

What matters most is the repatch rate/second blood patch and not just the subjective mild, residual headache. In other words, does lying flat for an extra hour reduce the likelihood the patient will return for a second blood patch?
 
Autologous blood,
12 ml, was injected into the lumbar epidural space of
all patients, at the site of or one space above or below
the site of the dural puncture. The technique was standardized
for all patients and was performed in the lateral
decubitus position, using sterile precautions.
The blood
was injected at the rate of 1 ml per 2 sec approximately.
If the patient complained of pain in the back or in the
legs at the time of the injection, the rate of injection was
reduced.
 
"The presence of fever, infection on the back, coagulopathy, or patient refusal are contraindications to the performance of an epidural blood patch.1 As a precautionary measure, a sample of the subject’s blood should be sent to microbiology for culture.27"


Are any of you sending the patient's blood for culture prior to doing a routine Epidural blood patch?
 
Epidural Blood Patch: A Rapid
Coagulation Response
Key Words: BLOOD, COAGULATION.
COMPLICATIONS, HEADACHE+pidUral patch.
To the Editor:
Postspinal headache can be treated with autologous blood
patch placed into the epidural space. The ability of this
epidural blood patch to relieve postlumbar puncture headache
accounts for the mechanism of action but not the
speed of the clinical response (1). In a controlled model
simulating the mixing of blood and cerebrospinal fluid
(CSF) at a dural leakage site, we have found that a clot
forms in an average of only 22 s. This is some four times
faster than even an activated clotting time.
Method. A Litton Datamedix Thromboelastograph D
(TEG)2 was set up according to manufacturer’s instructions
and used to record the coagulation of unmixed blood and of
a CSF-blood mixture. Cerebrospinal fluid and blood samples
were obtained from six animals, with 360 pL of blood
being placed in a TEG coagulation pot and 180 pL of blood
followed by 180 pL of CSF mixed in a similar pot. These
were placed in the TEG and recording was simultaneously
begun at a paper speed of 2 mdmin.
Results. The results are summarized in Table 1. Variables
measured using a TEG include R, which represents onset
and formation of the clot via proliferation of coagulation
factors, the K-value, which represents the strengthening of
the clot by intrinsic plasma and platelet factors, and the R t
K value, which is equivalent to the clotting time. MA and
a-angle were measured, the former representing maximal
elasticity of the clot and the latter clot formation rate.
The R, K, and R + K values all showed significant
decreases, indicating an effect on coagulation and platelet
factors (2). Acceleration of the onset of coagulation and a
stronger clot were observed.
Discussion. It appears that when CSF and blood mix, an
acceleration of the coagulation cascade occurs. A previously
demonstrated procoagulant activity of CSF has generally
involved CSF altered by disease processes, pooled samples,
and coagulation activity of hemorrhage into CSF (3). We
used individual CSF samples and blood from healthy
animals without coagulation abnormalities. We used a TEG
that allowed us to show that it is mostly the R-time that is
affected in the formation of clot. In a previous study,
epidural blood patches were tested for leaks at a wide range
of CSF pressures, and, on examination of the puncture site
in the dural samples, some plugs were described (4). We
have observed a rapidity of clotting more in keeping with
the nearly immediate relief of spinal headache treated with
epidural blood patches, and suggest that there may be
coagulation at this interface of blood and CSF that causes
almost instantaneous formation of a plug.
We believe the
reproducibility of our results, not seen in some previous
studies, can be attributed to careful control of the experimental
model. Human in vitro studies are planned.
Mark A. Cook, DO
J. M. Watkins-Pitchford, MD, FFARCS
Department of Anesthesiology
University of Michigan Hospitals
1 G32310048
1500 East Medical Center Drive
Ann Arbor, MI 48109
 
Don't know what the "right way" to do it is, but I usually go lateral, inject blood until the patient has an uncomfortable sensation of pressure in their back, 30 min FLAT supine following procedure, and recommend the patient not do anything active overnight.

- pod
 
I usually do them sitting because it's technically easier for me. 1) I do nearly 100% of my epidurals sitting, 2) often the reason they have the HAs in the first place was a difficult or multiply-attempted epidural or LP, so I set myself up with optimal positioning from the start.

Inject until they complain of pain, or 20 mLs. Supine for >30 minutes, home with instructions not to do any lifting or straining for 24 hrs.
 
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I usually do them sitting because it's technically easier for me. 1) I do nearly 100% of my epidurals sitting, 2) often the reason they have the HAs in the first place was a difficult or multiply-attempted epidural or LP, so I set myself up with optimal positioning from the start.

Inject until they complain of pain, or 20 mLs. Supine for >30 minutes, home with instructions not to do any lifting or straining for 24 hrs.

Based on the scarce literature review I will be keeping my blood patch patients at least one hour in the supine position. Whether you do the patch in the sitting or the lateral decubitus position appears to make no difference in the success rate.

What matters most is the volume of blood injected into the epidural space and perhaps, just perhaps, the length of time the patient is supine before resuming walking or any activity.
 
I usually do them sitting because it's technically easier for me. 1) I do nearly 100% of my epidurals sitting, 2) often the reason they have the HAs in the first place was a difficult or multiply-attempted epidural or LP, so I set myself up with optimal positioning from the start.

Inject until they complain of pain, or 20 mLs. Supine for >30 minutes, home with instructions not to do any lifting or straining for 24 hrs.

If they can tolerate sitting up for the length of time it takes to perform a blood patch, do they really need a blood patch?
 
The only person I would do a sedated/GA blood patch on is a child who could not sit still for the procedure.
Also, I wouldn't do it myself. I'd make one of the peds pain people do the injection.
How much blood would you inject if they were under GA. I've done a fair amount of blood patches, mostly courtesy of military ED physicians and their "r/o meningitis" cutting 22g needles. I've had one guy complain of pain at 7ccs and several at 12-15. I usually did 20 and called it a day. 2 hours supine and 24 hours of light duty. No way I'd do it on an adult asleep, and if some alignment of the stars happened and I did, I guess I would inject 10cc.
 
I've done the Epidural patch both ways. Since the procedure takes 8-9 minutes most patient can tolerate their severe H/A for that long.

Patients have to go to the bathroom and I've yet to see ONE PDPH patient use the bed pan over the toilet; no matter how severe the H/A they manage to get to the can. Thus, they can manage to endure an 8-9 minute procedure.
 
The only person I would do a sedated/GA blood patch on is a child who could not sit still for the procedure.
Also, I wouldn't do it myself. I'd make one of the peds pain people do the injection.
How much blood would you inject if they were under GA. I've done a fair amount of blood patches, mostly courtesy of military ED physicians and their "r/o meningitis" cutting 22g needles. I've had one guy complain of pain at 7ccs and several at 12-15. I usually did 20 and called it a day. 2 hours supine and 24 hours of light duty. No way I'd do it on an adult asleep, and if some alignment of the stars happened and I did, I guess I would inject 10cc.


http://www.ncbi.nlm.nih.gov/pubmed/20495590
 
We did a blood patch on a Jehovah's Witness. Made a continuous circuit from fresh peripheral IV (done sterile), to syringe, to Tuohy, using pressure tubing. Not all JH's will accept blood that's been extracorporeal, even in a continuous closed circuit, but this pt did.
 
If they still want it after my extensive discussion of the risks, the. I give it to them. I would guess that somewhere in the neighborhood of 50-60% decline after a discussion of the risks and benefits.

-pod
 
If they still want it after my extensive discussion of the risks, the. I give it to them. I would guess that somewhere in the neighborhood of 50-60% decline after a discussion of the risks and benefits.

-pod

Wow. 50% decline? That's huge considering how severe these H/A can be.
Do you show them the needle? I bet that would get the "decline" number to 50%.


sell_Epidural_needle.jpg
 
Epidural_needle_insertion_2_c_4x5.JPG


Do you guys allow the significant other to "hold" the patient like in this picture? I've had two spouses faint on me. I'm just curious.
 
Epidural_needle_insertion_2_c_4x5.JPG


Do you guys allow the significant other to "hold" the patient like in this picture? I've had two spouses faint on me. I'm just curious.

I don't. They have to sit.
I've lost one BIG dude during an epidural, and he was just standing nearby. 2 others during c/s. Sit. Stay. I'll tell you when to look up and see the magic moment.
 
LOS ANGELES - A California woman is suing a hospital for wrongful death because her husband fainted and suffered a fatal injury after helping delivery room staff give her a pain-killing injection.

Jeanette Passalaqua, 32, filed the suit against Kaiser Foundation Hospitals and Southern California Permanente Medical Group Inc. in San Bernardino County state court last week.

In June 2004, Passalaqua’s husband, Steven Passalaqua, was asked by Kaiser staff to hold and steady his wife while an employee inserted an epidural needle into her back, court papers said.

The sight of the needle caused Steven Passalaqua, 33, to faint and he fell backward, striking his head on an aluminum cap molding at the base of the wall.

Jeanette Passalaqua delivered the couple’s second child, a boy, later that day. Steven Passalaqua, however, suffered a brain hemorrhage as a result of his fall and died two days later, the lawsuit said.

The suit seeks unspecified damages related to Steven Passalaqua’s death and to Jeanette Passalaqua’s emotional distress at being widowed with two young children.

Because Passalaqua was solicited by Kaiser to assist in the epidural, the lawsuit said, the hospital “owed him a duty to exercise reasonable care to prevent foreseeable injuries resulting from his participation."

A spokesman for Oakland, California-based Kaiser Permanente called the death “a tragic accident.”

“Some of the allegations in the lawsuit are simply that --allegations. The legal process is under way and we should respect that,” said Kaiser spokesman Jim Anderson.
 
From August, 1988 to January, 1989, 135 epidurals for
labour were established, by a single anaesthetist (ETC),
with partners attending. Four fathers (2.9 per cent)
fainted. When interviewed after the incident, all the
fathers reported that, despite an admonition not to do so,
they had watched some part of the procedure. All four
described a typical vaso-vagal syncopal episode. No
father suffered an injury.
This incidence of fainting is similar to the reported
incidence of severe paternal bradycardic episodes during
Caesarean section, 2.6 per cent. 2
There is one case report in the literature of a father who
sustained a non-depressed skull fracture during a vagally
mediated fainting episode, while attending his wife
during an epidural insertion) We recommend that parthers
who wish to be present during the establishment of an
epidural be specifically warned about the potential for
fainting. Further, we recommend that the fathers be
strongly discouraged from observing any part of the
procedure, with an appropriate explanation.
We have found that the majority of the fathers tolerate
the experience extremely well and that the mothers are
grateful for their presence.
Edward T. Crosby Bsc, MD, FRCPC
Stephen H. Halpem Mr), r~cec
Department of Anaesthesia
Women's College Hospital
 
I don't. They have to sit.
I've lost one BIG dude during an epidural, and he was just standing nearby. 2 others during c/s. Sit. Stay. I'll tell you when to look up and see the magic moment.

Our RNs hold pt, unless we go lateral - then they're not sure what to do (academic place, not used to it). Which is why I love the lateral position.

I kick out family, unless it's a really immature teenager and the parent seems helpful. Which is rare.

1 family member for C/S and must sit. Too many dropped pops in our institution for that.
 
Yup, I knew this would happen. So anyway, when an ob nurse wants a husband in the room when I am putting an epidural in, I give only one option. They will have to wait for an epidural until another anesthesiologist can come and do it. I don't have the time to deal with this type of stupidity. People can sue for anything. I can't be dealing with the husband at the same time as the mother and baby.

For C-sections, I tell the husbands they are only allowed in the room if they are sitting down and not looking over the drapes. The moment they stand up I kick them out of the room, no ands ifs or buts.
 
I imagine Blade at a 4 screen workstation like rads, with SDN on 2 screens, Pubmed on another, and maybe Guns N Ammo on the 4th. Don't disappoint me if this is false.
 
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If they still want it after my extensive discussion of the risks, the. I give it to them. I would guess that somewhere in the neighborhood of 50-60% decline after a discussion of the risks and benefits.

Really? What do you tell them?

I've never had one decline. I suppose part of that is our patch patients are usually pre-screened by the ER and have already failed conservative therapy and are back, so they're miserable. I tell them that IF the cause of their headache was the dural puncture, about 90% of the time the headache goes away. The risks I explain are the same as any other epidural, plus failure to relieve the headache, worsening or prolonging the headache via another wet tap / chronic CSF leak.


BladeMDA said:
Do you guys allow the significant other to "hold" the patient like in this picture? I've had two spouses faint on me. I'm just curious.

Here, they sit on a chair in front of mom. RN is right next to them charting (endlessly charting). I had a mom choke out her husband during an epidural a few months ago. She was holding on to his neck so tight he passed out. Not funny then, funny now.

For sections, I make them sit until delivery, then they can walk over to the peds corner and check out the kid.


5 or 6 years ago at my residency program a dad passed out, hit his head, and suffered an intracranial bleed. Amazingly enough policy didn't change, almost all of the labor epidurals I did during residency had family standing in front of mom holding her like your pic. (Unlike your pic, we put a drape up on her back.)
 
Use of aseptic techniques: The literature is insufficient regarding
the efficacy of aseptic techniques during neuraxial
procedures (e.g., removal of jewelry, hand washing, and
wearing of caps, masks, and sterile gloves) in reducing
infectious complications (Category D evidence). Studies
with observational findings indicate that infections occur
even when aseptic techniques are used (Category B2 evidence),
38–40 and case reports indicate similar outcomes
(Category B3 evidence).12,19,25–27,30,41– 64
The literature is insufficient regarding the choice of specific
antiseptic solutions in reducing infectious complications associated
with neuraxial techniques (Category D evidence). However,
two randomized controlled trials indicate that the rate of positive
bacteriologic cultures is reduced when the patient’s skin is
prepared with chlorhexidine compared with povidone-iodine
before epidural catheterization (Category A2 evidence).65,66
Two
randomized controlled trials report reduced bacterial growth on
the skin and/or on catheters and needles when alcohol is combined
with povidone-iodine compared with povidone-iodine
alone (Category A2 evidence).66,67
Both consultants and ASA members strongly agree that
aseptic techniques should always be used during the placement
of neuraxial needles and catheters, including hand
washing, wearing of sterile gloves, wearing of caps, wearing of
masks covering both the mouth and nose, use of individual
packets of skin preparation, and sterile draping of the patient.
In addition, both consultants and ASA members agree that
aseptic techniques should include removal of jewelry, and
they are equivocal regarding the wearing of gowns. Finally,
consultants agree and ASA members are uncertain regarding
whether aseptic techniques should include changing masks
before each new case.
 
I agree with all the ASA recommendations on Epidural placement (no jewelry, hand washing, aseptic technique, Chlorhexidine with alcohol, etc)
except the drape. I'm not sure adding the drape makes much difference if you do a wide prep. The most likely contamination is your forearm touching the catheter itself.

That said, until you have place over 1,000-1500 Epidurals I think the drape is a splendid idea. Once you can drop that Epidural or spinal in under 5 minutes the drape becomes less important.

FWIW, I've got no issues with the anal retentives out there who insist on draping every patient. But, it is was my wife, daughter or me getting the block I'd much rather have you wash your hands well and use Chlorhexedine with alcohol liberally then be concerned over the drape.

If it was a Resident, SRNA, CRNA, new attending, etc. I'd want the drape as well.
 
This is in a non-pre screened non-conservitavely treated population. Given that this is an elective procedure with a not always clear indication (is it really a PDPH or not) that can be treated by other means, I hit the risks really hard. The one that almost always gets them is this one.

"There is a chance that this is not a PDPH. If I stick a needle in your back there is a chance that I will give you a real PDPH on top of whatever headache you already have. It may take a couple of tries to resolve your PDPH and every time I stick a needle in your back increases your risk of a real PDPH."

I figure that if they still want it after that, they probably really do have a PDPH and we proceed. I want to make sure that patients really want to do entirely elective and not entirely benign procedures.

Relatives sit down period. If they want to see the equipment I show them afterward. I love the picture of the anesthesiologist with cap and mask and dad leaning over mom's shoulder with no cap or mask. :laugh:

- pod
 
I imagine Blade at a 4 screen workstation like rads, with SDN on 2 screens, Pubmed on another, and maybe Guns N Ammo on the 4th. Don't disappoint me if this is false.

I have seen that workstation... It is like the batcave. Six screens and I believe the arrangement is SDN, pubmed, car forum#1, car forum #2, gun forum, and nurse anesthesia on the last.

- pod
 
If they can tolerate sitting up for the length of time it takes to perform a blood patch, do they really need a blood patch?

Not a bad question actually.

Sitting the patient up can be very uncomfortable.

And honestly, I have found that often times getting the blood can be the most time consuming part.

If I get into the epidural space, i'll give my resident/partner about 3 or 4 minutes to get blood. If they are struggling, I'll thread the epidural catheter so I can lay the patient down, and we can then both work on getting the blood...taking our time calmly, while the patient isn't suffering.

Pushing blood through the catheter isn't easy, but it is doable.
 
TREATMENT:
Current treatment modalities for PDPH include theophylline, caffeine, sumatriptan, epidural saline, epidural dextran, and epidural blood patch (EBP) (Table 4)". However, only the EBP has apparent benefits3-7.

v34n4a07tab4.gif
Psychological:
PDPH during the postpartum period is almost always a complication of regional anesthesia. The obstetric patient is usually aware that her headache is an iatrogenic problem, and she may be angry, resentful and/or depressed. Headache may make it difficult to care for the newborn and to interact with other family members. It is therefore important to give the parturient a thorough explanation of the reason for the headache, the anticipated time course, and the therapeutic options available3
Caffeine:
Caffeine is a central nervous system stimulant, which produces cerebral vasoconstriction. It is available in an oral and intravenous form. The oral preparation is well absorbed from oral mucosa with peak blood levels reached in approximately 30 minutes3. Caffeine easily crosses the blood-brain barrier and has a long half-life of 3-8 hours. Several studies however, showed that the beneficial effect of caffeine might be transient. Caffeine appears in breast milk in very small amounts.
Sumatriptan:
Sumatriptan is a serotonin agonist that affects predominantly type 1-D receptors. It promotes cerebral vasoconstriction in a similar way to caffeine. Sumatriptan has been advocated to the treatment of migraine and recently, for PDPH3-7. This drug is expensive and must be given by subcutaneous injections.
Epidural saline:
It has been speculated that an epidural injection of saline would, in theory, produce the same «mass effect» as autologous epidural blood patch, and restore normal CSF dynamics. Advocates of an epidural saline infusion (or boluses) maintain that the lumbar injection of saline raises epidural and subarachnoid pressures8. However, to date no studies have demonstrated either a sustained rise in CSF pressure or accelerated closure of the dural hole (tear) following administration of epidural saline3. It is therefore difficult to conclude from the evidence that epidural saline administration will restore normal CSF dynamics.
Epidural dextran:
It has been implied that the high viscosity and high molecular weight of dextran may slow its removal from the epidural space. However, it is unlikely that dextran would act any differently to normal saline in the epidural space3,4. Any pressure increase with the epidural and subarachnoid space would, like saline, be short lived. Additionally, it has been reported that dextran does not demonstrate any inflammatory response that would promote the dura healing process.
Subarachnoid catheters:
Following unintentional dural puncture with a large gauge epidural needle, it has been suggested that placement of a subarachnoid catheter through the dural hole may provoke an inflammatory reaction that will seal the puncture site5,8,15-17,19-23. Histological animal and human studies with long-term subarachnoid catheters confirm the presence of an inflammatory reaction at the catheter insertion site. Further studies are needed.
Epidural blood patch:
Two theories have been proposed to explain EBP efficiency in the treatment of PDPH4,5,11,13. The first theory suggests that the autologous blood injected in the epidural space forms a clot, which adheres to the dura mater and directly patches the hole. The second theory suggests that the volume of blood injected in the epidural space increases CSF pressure, thus reducing traction of pain sensitive brain structures, leading to relief of symptoms. The optimal volume of blood to be injected in the epidural space remains controversial.
 
Conclusions

A case study, by definition, is not conducted in a rigorous scientific manner (ie. a prospective, double blind, randomized study, having a control group and large sample size) and yet it can provide insight and practical observations useful to the practitioner. This case report of the treatment of PDPH with a sumatriptan-Fioricet combination experienced a success rate of 81%. The authors believe this technique can be used as a first line therapy for PDPH, while keeping epidural blood patch in reserve for resistant cases and patients with cranial nerve palsies, and cardiovascular disease
 
The efficacy and safety of sumatriptan in the treatment of migraine attacks has been established.3 However, coronary spasm, acute myocardial infarction, cardiac arrest and dysrrhythmias have been reported from its use.4-9 Sumatriptan should be avoided in patients with known coronary artery disease or with significant cardiovascular risk factors. Cardiovascular monitoring and resuscitation equipments are mandatory.
 
The patient received 6 mg of sumatriptan by the subcutaneous route while electrocardiography, blood pressure and pulse oximetry were continuously monitored for one hour. NPS was noted after one hour of the initial therapy. Fioricet at a dosage of one tablet every four hours was prescribed on an as-needed basis by the oral route for three days. If the patient had no relief from the initial dose of sumatriptan, an option of a second dose of sumatriptan or epidural blood patch was offered to the patient. After twenty-four hours, all patients were followed up via telephone by the pain clinic nurse and numerical pain scale rating was noted. A final follow-up was done after an elapsed time of between one and six months after initial therapy.
 
The patient received 6 mg of sumatriptan by the subcutaneous route while electrocardiography, blood pressure and pulse oximetry were continuously monitored for one hour. NPS was noted after one hour of the initial therapy. Fioricet at a dosage of one tablet every four hours was prescribed on an as-needed basis by the oral route for three days. If the patient had no relief from the initial dose of sumatriptan, an option of a second dose of sumatriptan or epidural blood patch was offered to the patient. After twenty-four hours, all patients were followed up via telephone by the pain clinic nurse and numerical pain scale rating was noted. A final follow-up was done after an elapsed time of between one and six months after initial therapy.

For those patients refusing a Blood patch this Sumatriptan/Fioricet combo seems like a reasonable alternative (non invasive). Is anyone just prescribing one or two doses of Sumatriptan (along with Fioricet) and sending the patient home? Or, will you monitor the first Sub Q injection in the PACU as described in the above study?
 
View Full Article (HTML) Get PDF (131K)

Keywords:


  • sumatriptan;
  • dural puncture headache;
  • epidural blood patch;
  • epidural


Objective.–To determine the efficacy of sumatriptan in the management of patients presenting for an epidural blood patch for the management of postdural puncture headache.

Background.–Postdural puncture headache can be quite severe, requiring invasive therapy (ie, epidural blood patch). Sumatriptan has been used successfully in patients with postdural puncture headache, however, its use has not been investigated in a controlled fashion.

Methods.–Ten patients with postdural puncture headache presenting for an epidural blood patch were given either saline or sumatriptan subcutaneously. The severity of the headache was evaluated at baseline and 1 hour following injection. If the headache remained severe, an epidural blood patch was performed.

Results.–Only one patient in each group received relief from the injection.

Conclusions.–We do not recommend sumatriptan in patients who have exhausted conservative management of postdural puncture headache.
 
6. Other Pharmacological agents
i) Intravenous Caffeine (500 mg) has been shown to be
beneficial in relieving PDPH in an ill controlled study
with inadequate sample size.7 Non availability of IV
caffeine in many hospitals led to its oral use and a
double blind, placebo controlled study claimed definite
advantages of 300 mg of oral caffeine in PDPH
patients.8
ii) Another study inferred that oral Theophylline relieved
symptoms of PDPH probably through its cerebral vaso
constrictive effects.9
iii) Two controversial studies providing evidence, one
for and the other against the usage of cerebral
vasoconstrictor, serotonin agonist, Sumatriptan for the
treatment of PDPH are available.10,11
iv) Isolated evidential reports are available on the
beneficial effects of steroids and ACTH in PDPH
patients but no RCTs have ever been conducted.12,13
 
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