Epidural Blood Patch

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Nothing fancy. 75% of these are said to go away with no treatment in the first week (Of my patients who refuse blood patch I believe it is closer to 90%)

Fluids, caffeine (oral), bedrest and naproxen.

Re-evaluate at 24 hours and add Maxalt if patient is still symptomatic and reluctant to undergo blood patch. The neurologists do not monitor low-risk patients for the intial triptan dose so neither do I.

I will be switching to Mirtazapine instead of Maxalt in the near future and may use it first line.

- pod

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Nothing fancy. 75% of these are said to go away with no treatment in the first week (Of my patients who refuse blood patch I believe it is closer to 90%)

Fluids, caffeine (oral), bedrest and naproxen.

Re-evaluate at 24 hours and add Maxalt if patient is still symptomatic and reluctant to undergo blood patch. The neurologists do not monitor low-risk patients for the intial triptan dose so neither do I.

I will be switching to Mirtazapine instead of Maxalt in the near future and may use it first line.

- pod

I have been using Cosyntropin for those who refuse the patch or those with a failed patch and in my opinion it is very effective.
 
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In a study comparing cosyntropin therapy to caffeine therapy, rates for successful treatment without need for rescue therapy were 56% and 80%, respectively. This was done with a sample size of nearly 40 patients, which left the study underpowered. The confidence intervals were very large, suggesting that the appropriate conclusion is probably that both caffeine and cosyntropin may have a role in relieving PDPH but that there wasn't a statistically significant difference between the two therapies.21 It has been suggested that perhaps an initial combination of both pharmacotherapies would be the best course of action preceding blood patch.
 
Should we be giving the ACTH analog to all patients (except Diabetics) after accidental dural puncture(ADP)? It appears this really works well in reducing the need for a blood patch.

Should I send all ADP patients to the PACU for one hour so they can get an infusion of 1.0mg of cosyntropin over 30-45 minutes? Then discharge them with some caffeine if their headache is mild or no caffeine if the headache is non existent?


http://journals.lww.com/anesthesiol...pin_for_Prophylaxis_against_Postdural.25.aspx
 
What We Already Know about This Topic

❖ Adrenocorticotrophic hormone or its analogues have been used to treat postdural puncture headache, but they have not been studied for prophylaxis

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What This Article Tells Us That Is New

❖ In 90 parturients with accidental dural puncture during epidural needle placement for labor analgesia, the incidence of postdural puncture headache was halved, from 69% with placebo to 33% by prophylaxis with 1 mg cosyntropin
❖ Cosyntropin also reduced the need for epidural blood patch from 30% to 11%.
 
The existing clinical data suggest 300 mg of oral caffeine as a single dose, or 500 mg caffeine sodium benzoate powder diluted in 1 liter of intravenous fluid and administered over 1 hour, can be effective therapeutic options for PDPH. Readministration of intravenous caffeine therapy may be considered if needed 4-8 hours after the initial dose. Further trials evaluating the use of caffeine for treatment of PDPH may bee needed to fully evaluate caffeine's efficacy as an alternative therapy.
 
Those of you prescribing Caffeine Tablets how much are you recommending per day? 300mg PO once per day? 300 mg PO BID? Anyone giving 500 mg PO QD or BID?

POD, Are you using the newer drugs to get the same effect as Caffeine tablets without the side-effects? Is that why you chose MAXALT?
 
Why is this medication prescribed?

Rizatriptan is used to treat the symptoms of migraine headaches (severe, throbbing headaches that sometimes are accompanied by nausea and sensitivity to sound and light). Rizatriptan is in a class of medications called selective serotonin receptor agonists. It works by narrowing blood vessels in the brain, stopping pain signals from being sent to the brain, and stopping the release of certain natural substances that cause pain, nausea, and other symptoms of migraine. Rizatriptan does not prevent migraine attacks.

How should this medicine be used?

Rizatriptan comes as a tablet and an orally disintegrating tablet to take by mouth. It should be taken at the first sign of a migraine headache. If you are at risk for heart disease and you have never taken rizatriptan before, you may need to take the first dose in your doctor's office. Usually only one dose is needed. If pain is not relieved with the first dose, your doctor may prescribe a second dose to be taken 2 hours after the first dose. Do not take more than 30 mg of rizatriptan in any 24-hour period. If you are also taking propranolol (Inderal), you should not take more than 15 mg of rizatriptan in any 24-hour period. Follow the directions on the package or prescription label carefully, and ask your doctor or pharmacist to explain any part you do not understand. Take rizatriptan exactly as directed. Do not take more or less of it or take it more often than directed by the package label or prescribed by your doctor.
The orally disintegrating tablet should not be removed from the package until just before it is taken. The packet should be opened with dry hands, and the orally disintegrating tablet should be placed on the tongue, where it will dissolve and be swallowed with saliva.
 
Do you mind elaborating on your regimen? Do you add caffeine tablets to the mix?

I am giving 0.5 mg in 500 cc NS over a couple of hours.
No caffeine but I give some Dizepam PO for 1-2 days since most of these patients have a component of anxiety and muscle spasm.
There was a study published recently from Egypt that susupport the use of Cosyntropin for prophylaxis after a dural puncture.
There are a few case reports also for successful treatment after failed blood patch.
 
I do all my blood patches prone with the c-arm. Patients don't have to sit up and make their headaches worse. Plus it makes the procedure a chip shot for the obese pt who was a difficult epidural in the first place. I give a couple mg of midazolam too.
 
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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 use those statements once I suspect that it's not a PDPH.
 
I do all my blood patches prone with the c-arm. Patients don't have to sit up and make their headaches worse. Plus it makes the procedure a chip shot for the obese pt who was a difficult epidural in the first place. I give a couple mg of midazolam too.

The problem isn't the Epidural blood patch, it is getting the blood.
 
Perhaps, we should rethink our approach to PDPH:

First line should be Cosyntropin and caffeine/Maxalt. Then, if the headache isn't improved/mild proceed to Epidural Blood Patch.

Currently, many practices are just doing a Blood patch right away after the patient complains of a postural headache.

Is it time to re-evaluate that approach?


❖ Cosyntropin also reduced the need for epidural blood patch from 30% to 11%.
 
Prone? Sterile? Sure.:rolleyes:

You act like its impossible. Patients can still supinate their arm if they're prone. Right now, stick your arms out in front of you, bend the elbows at 90 degrees like they would likely be if prone, now supinate your lower arms... lookie at that, access to the radial aspect of the wrist! I've done this twice in that past 6 months. Its not the easiest, but its definitely possible, and likely easier that trying to get enough blood from a peripheral IV in a 400lbs fatty.
 
POD, Are you using the newer drugs to get the same effect as Caffeine tablets without the side-effects? Is that why you chose MAXALT?

I imagine POD is using REMERON because this drug has been shown to help reduce Migraine H/A with a good side-effect profile.

Dosage for PDPH? 3 days worth?

The theory behind the triptans (Imitrex/ Maxalt) is the same as the theory behind caffeine is the same as the theory behind Remeron.

Loss of CSF results in a reflexive vasodilation of cerebral vessels which results in a headache. Caffeine/ Triptans/ Remeron have vasoconstrictive actions that offset this vasodilation, thus improving the headache. My goal is to reduce their symptomatology while giving their bodies a chance to heal on their own (which most of them will do). I want a drug that can be taken at home by the patient to relieve the symptoms over the course of a few days while they heal. Maxalt ODT fits the bill, but I am somewhat uncomfortable with repeated dosing over the course of 3-5 days. Remeron on the other hand is very safe over that time span. I would go 15 mg qhs over 3-5 days.

The side effect profile is somewhat problematic however. It has been described to me as a super doobie. Remeron is a potent anti-histamine and results in marked sedation at a 15 mg dose. I am told that it is less prominent at the 30 mg dose because of the increased NA and 5HT effects. Patients experience a profound craving for carbohydrates (MUNCHIES). I have heard of patients eating sugar right out of the bag.

I have been watching the Cosyntropin closely. My only problem is that I have to bring a patient into the hospital to administer it. My goal is to be able to have them be able to treat their symptoms at home. If Cosyntropin proves to be a "1-shot cure" then I will likely start using it.

Neither Cosyntropin nor Remeron are particularly good options for diabetics so I will likely go with my caffeine/ Maxalt regimen for them.


I use those statements once I suspect that it's not a PDPH.

I always suspect that it is not a PDPH. Too many other reasons to have a headache after delivery. I figure if it is a real PDPH then that statement probably won't bother them.

- pod
 
You act like its impossible. Patients can still supinate their arm if they're prone. Right now, stick your arms out in front of you, bend the elbows at 90 degrees like they would likely be if prone, now supinate your lower arms... lookie at that, access to the radial aspect of the wrist! I've done this twice in that past 6 months. Its not the easiest, but its definitely possible, and likely easier that trying to get enough blood from a peripheral IV in a 400lbs fatty.


I've put dozens of arterial lines during my career in the prone position. That's much tougher to do than a stick. Of Course, I know it can be done.
But, easier that sitting a 400lb. patient up? No. You may need Fluoro and expensive equipment to do a Blood Patch but all I need is a good Tuohy needle and a motivated patient. I have both when a patient has a severe PDPH who needs a blood patch.

FWIW, Morbidly obese patients are less likely to get a PDPH and when they do they usually don't last as long as a standard/IBW patient. That said, I've patched a few 400 pounders and they aren't the easiest; again, the hardest part is getting the blood.
 
The theory behind the triptans (Imitrex/ Maxalt) is the same as the theory behind caffeine is the same as the theory behind Remeron.

Loss of CSF results in a reflexive vasodilation of cerebral vessels which results in a headache. Caffeine/ Triptans/ Remeron have vasoconstrictive actions that offset this vasodilation, thus improving the headache. My goal is to reduce their symptomatology while giving their bodies a chance to heal on their own (which most of them will do). I want a drug that can be taken at home by the patient to relieve the symptoms over the course of a few days while they heal. Maxalt ODT fits the bill, but I am somewhat uncomfortable with repeated dosing over the course of 3-5 days. Remeron on the other hand is very safe over that time span. I would go 15 mg qhs over 3-5 days.

The side effect profile is somewhat problematic however. It has been described to me as a super doobie. Remeron is a potent anti-histamine and results in marked sedation at a 15 mg dose. I am told that it is less prominent at the 30 mg dose because of the increased NA and 5HT effects. Patients experience a profound craving for carbohydrates (MUNCHIES). I have heard of patients eating sugar right out of the bag.

I have been watching the Cosyntropin closely. My only problem is that I have to bring a patient into the hospital to administer it. My goal is to be able to have them be able to treat their symptoms at home. If Cosyntropin proves to be a "1-shot cure" then I will likely start using it.

Neither Cosyntropin nor Remeron are particularly good options for diabetics so I will likely go with my caffeine/ Maxalt regimen for them.




I always suspect that it is not a PDPH. Too many other reasons to have a headache after delivery. I figure if it is a real PDPH then that statement probably won't bother them.

- pod

POD,

As usual a great post. I appreciate the response. But, we differ on our philosophy here. My goal isn't to be their Neurologist; I'm there to the solve the problem.

I'll offer them one of two options:

1. Blood Patch- that's the most effective treatment. If they have a severe postural H/A after a Epidural/Spinal I will recommend that approach. If they hesitate or want to try something more conservative I offer (plan to start with my next patient) option 2.

2. Option 2- I'll explain there is a medication which might work to reduce the H/A. I'll say it works 1/3-1/2 of the time in reducing the H/A enough that their own body will heal the hole/leak over time. I'll give the Cosyntropin prior to discharge (1.0 mg) and prescribe THREE Days of Maxalt or Remeron. THREE DAYS. If after three days the H/A is still bothersome I'll recommend they reconsider Option 1.

3. I always tell my patients that the First Blood patch only solves the problem 75-80% of the time. Hence, 20-25% of patients may need to return for a second blood patch. I'm considering adding Cosyntropin IV (0.5 mg) for patients who return seeking a second patch. My success rate after a second patch is 95-98% so I'm on the fence whether to add anything to my routine.

4. The question still arises whether we all should be adding Cosyntropin with our FIRST BLOOD PATCH because the success rate is only 75-80%.
Perhaps, the addition of Cosyntropin would push those numbers to 95% which would save quite a few patients a return visit to the hospital for a second patch.

It's tough to practice Evidence based medicine when we have insufficient/inadequate evidence.
 
I've put dozens of arterial lines during my career in the prone position. That's much tougher to do than a stick. Of Course, I know it can be done.
But, easier that sitting a 400lb. patient up? No. You may need Fluoro and expensive equipment to do a Blood Patch but all I need is a good Tuohy needle and a motivated patient. I have both when a patient has a severe PDPH who needs a blood patch.

FWIW, Morbidly obese patients are less likely to get a PDPH and when they do they usually don't last as long as a standard/IBW patient. That said, I've patched a few 400 pounders and they aren't the easiest; again, the hardest part is getting the blood.

I never said I had to have flouro to do a blood patch, I said its easier for the patients, and that makes it better for me. What I've never done is a radial stick for blood in a blood patch. If you have to do an arterial stick for a blood draw, I guess you should force your patient with a postural headache to sit up. Whatever, I was just posting my preference, which was the point of this thread, not trying to start an argument.
 
POD,

What's your cocktail for RX of PDPH (non invasive)?


Question for you everyone on here. What's your protocol for PDPH?

I primarily do Pain Management, and have seen a flux of consults for blood patches. I'm in a private practice setting and have been to mutliple academic centers in the past and have not seen this before.

Usual if it's a patient s/p labor epidural that has PDPH, the anesthesiologist does the blood patch. I've never seen a consult to pain management for fluro guidance. It's one thing if the patient is very obese, but even then, in my aneshtesia training, we would always do the blood patch, not turf to pain management.
 
Question for you everyone on here. What's your protocol for PDPH?

I primarily do Pain Management, and have seen a flux of consults for blood patches. I'm in a private practice setting and have been to mutliple academic centers in the past and have not seen this before.

Usual if it's a patient s/p labor epidural that has PDPH, the anesthesiologist does the blood patch. I've never seen a consult to pain management for fluro guidance. It's one thing if the patient is very obese, but even then, in my aneshtesia training, we would always do the blood patch, not turf to pain management.

We (as a group) always lived by the "you poke it, you own it" doctrine and did our own EBPs.
 
Question for you everyone on here. What's your protocol for PDPH?

I primarily do Pain Management, and have seen a flux of consults for blood patches. I'm in a private practice setting and have been to mutliple academic centers in the past and have not seen this before.

Usual if it's a patient s/p labor epidural that has PDPH, the anesthesiologist does the blood patch. I've never seen a consult to pain management for fluro guidance. It's one thing if the patient is very obese, but even then, in my aneshtesia training, we would always do the blood patch, not turf to pain management.

It depends on your community. If procedure done peri-op by Anes, they typically patch it.
But if done by radiology for myelogram or Neuro for LP- they can send them all over to you for a quick and much more cost-effective fix in the office fluoro suite rather than in the hospital setting. And it is good for your marketing. You help their patients get relief for overall less health dollars and help the other docs out by caring for their patients. Win/Win.
 
I never said I had to have flouro to do a blood patch, I said its easier for the patients, and that makes it better for me. What I've never done is a radial stick for blood in a blood patch. If you have to do an arterial stick for a blood draw, I guess you should force your patient with a postural headache to sit up. Whatever, I was just posting my preference, which was the point of this thread, not trying to start an argument.

Not looking to start something with anybody either. Blood patch technique is like taping the goddamned tube in... everybody has their own way of tweaking it/doing it and other ways are sub-par. Some do them sitting up, some lateral, some with fluoro. It doesn't matter.

I am a fan of the art stick for blood in the morbidly obese. Don't care if pt sitting up/prone/lateral. Give it a try some time.
 
POD,

As usual a great post. I appreciate the response. But, we differ on our philosophy here. My goal isn't to be their Neurologist; I'm there to the solve the problem.

I'll offer them one of two options:

1. Blood Patch- that's the most effective treatment. If they have a severe postural H/A after a Epidural/Spinal I will recommend that approach. If they hesitate or want to try something more conservative I offer (plan to start with my next patient) option 2.

2. Option 2- I'll explain there is a medication which might work to reduce the H/A. I'll say it works 1/3-1/2 of the time in reducing the H/A enough that their own body will heal the hole/leak over time. I'll give the Cosyntropin prior to discharge (1.0 mg) and prescribe THREE Days of Maxalt or Remeron. THREE DAYS. If after three days the H/A is still bothersome I'll recommend they reconsider Option 1.

3. I always tell my patients that the First Blood patch only solves the problem 75-80% of the time. Hence, 20-25% of patients may need to return for a second blood patch. I'm considering adding Cosyntropin IV (0.5 mg) for patients who return seeking a second patch. My success rate after a second patch is 95-98% so I'm on the fence whether to add anything to my routine.

4. The question still arises whether we all should be adding Cosyntropin with our FIRST BLOOD PATCH because the success rate is only 75-80%.
Perhaps, the addition of Cosyntropin would push those numbers to 95% which would save quite a few patients a return visit to the hospital for a second patch.

It's tough to practice Evidence based medicine when we have insufficient/inadequate evidence.

Cosyntropin is expensive. Very expensive for a 1.0 mg dose (? close to $1,000).
So far my results with it are poor. I'm not impressed for the cost vs benefit of this treatment and have almost completely abandoned it these days as an option.
 
Perhaps, we should rethink our approach to PDPH:

First line should be Cosyntropin and caffeine/Maxalt. Then, if the headache isn't improved/mild proceed to Epidural Blood Patch.

Currently, many practices are just doing a Blood patch right away after the patient complains of a postural headache.


Is it time to re-evaluate that approach?


❖ Cosyntropin also reduced the need for epidural blood patch from 30% to 11%.

Not for the obstetric population/wet tap with a big tuohy.
Not for the young fit patient who had diagnostic LP or myelogram with a big Quincke.

Straight to EBP for the above. Assuming no confounding issues/contraindications.
 
With a labor epidural, why not leave the catheter after delivery and blood patch through it if needed the next day?
 
Not for the obstetric population/wet tap with a big tuohy.
Not for the young fit patient who had diagnostic LP or myelogram with a big Quincke.

Straight to EBP for the above. Assuming no confounding issues/contraindications.

My anecdotal evidence agrees with your post. Cosyntropin failed in every young patient who got a headache. Every single one. At $1,000 a pop it's a waste of money and resources. Straight to blood patch is my approach these days unless contraindicated.
I prefer to blood patch 24 hours (give or take a few hours) after the wet tap/dural puncture.
 
How do people in private practice do phlebotomy for blood patches? Do you always have an assistant who is drawing blood or do you draw blood yourself and then do bp or access epidural space and then draw blood? Obviously phlebotomy and accessing the space can both potentially be time consuming procedures and having a capable assistant is ideal. Just curious how it is done in the real world.
 
How do people in private practice do phlebotomy for blood patches? Do you always have an assistant who is drawing blood or do you draw blood yourself and then do bp or access epidural space and then draw blood? Obviously phlebotomy and accessing the space can both potentially be time consuming procedures and having a capable assistant is ideal. Just curious how it is done in the real world.

Random nurse to draw blood. They are better at putting IVs in than I had in residency too. Some need minimal coaching on sterile technique though.

I get the patient in lateral position, then we race to our respective targets, normally ending with them putting an IV in at the same time I get in epidural space. I then hand them the syringe from the tray and they draw off.
 
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I place a fresh 20 gauge in a large AC vein and then I go around and make the epidural puncture. I've been stung a couple of times with the helper nurse screwing around trying to get an Iv or drawing blood off the back of pts hand and me sitting with my needle tip in the epidural space.
 
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