Blood Patch?

[Pharmado]

Alright, I had an OB pt yesterday that a colleague put an epidural in. She has a long history of spinal issues (repaired tethered cord, repaired scoliosis fused from T4-L4). First attempt his epidural did nothing. Second attempt he thought was successful, but produced profound analgesia and was obviously intrathecal. This is a sound and experienced individual placing the epidural. Now she's got a horrible spinal HA. She's also a chronic pain nightmare. I can't reasonably say that doing a blood patch wouldn't do more harm than good. Personally, I don't really want anything to do with sticking a needle into her, but I do want to help. Any thoughts on what to do with her? The usual fluids and caffeine aren't helping. Maybe a blood patch under fluoro or US? Not sure that's much safer either. Thoughts?

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[sevo00]

sphenopalatine ganglion block?

 

[vector2]

Alright, I had an OB pt yesterday that a colleague put an epidural in. She has a long history of spinal issues (repaired tethered cord, repaired scoliosis fused from T4-L4). First attempt his epidural did nothing. Second attempt he thought was successful, but produced profound analgesia and was obviously intrathecal. This is a sound and experienced individual placing the epidural. Now she's got a horrible spinal HA. She's also a chronic pain nightmare. I can't reasonably say that doing a blood patch wouldn't do more harm than good. Personally, I don't really want anything to do with sticking a needle into her, but I do want to help. Any thoughts on what to do with her? The usual fluids and caffeine aren't helping. Maybe a blood patch under fluoro or US? Not sure that's much safer either. Thoughts?

Dude wtf, epidural scarring/obliteration is significant and usually severe after major multiple level spine surgeries like that. I wouldnt have tried an epidural on that pt and I certainly wouldnt try a blood patch.

 

[deleted131481]

Agree would not try a blood patch here, good chance you make it worse with another Dural puncture. I'll generally only try above or below the fusion - if t4-l4 I would just avoid.

Try SPG as mentioned above.

 

[AdmiralChz]

Has anyone here actually done a SPG? I’ve read about it, but I can’t see myself doing it unless you just do a cotton-tipped applicator - going at someone’s nose with a large needle might scare the spinal headache right out if them.

I have a colleague that frequently attempts epidurals in patients like this - typically with less than 25-50% success. I personally almost certainly wouldn’t try and let them know that up front - Nubain, fentanyl or nothing for this patient and I’ll preferably leave that decision up to OB. I guess if you are one of those places with nitrous they might be a reasonable option. Labor analgesia is not an absolute requirement, despite what L&D nurses will tell you.

 

[sevo00]

Has anyone here actually done a SPG? I’ve read about it, but I can’t see myself doing it unless you just do a cotton-tipped applicator - going at someone’s nose with a large needle might scare the spinal headache right out if them.

I have a colleague that frequently attempts epidurals in patients like this - typically with less than 25-50% success. I personally almost certainly wouldn’t try and let them know that up front - Nubain, fentanyl or nothing for this patient and I’ll preferably leave that decision up to OB. I guess if you are one of those places with nitrous they might be a reasonable option. Labor analgesia is not an absolute requirement, despite what L&D nurses will tell you.

I have done SPG Block twice. Seems to have worked.

 

[deleted162650]

Neostigmine/Atropine

 

[deleted875186]

Maybe discuss trying an L5-S1 blood patch, but if the first and second epidural attempt didn’t get any good ligament I probably would not.

ACTH, analgesia, sphenopalentine block with a couple qtips.

anyone think a single shot spinal for labor analgesia at late first stage would be a good option?

 

[dannyboy1]

if you can get in the best option would be intrathecal catheter for labor analgesia, then leave it in for 24 hours to prevent PDPH. would not even attempt epidural in this patient because even if you get it at L5 - S1 interspace there is probably no epidural space above for the local to spread...

 

[lane]

Consult IR

 

[deleted697535]

Ive done about 25 spg for pdph. success rate is about 50-60% id say. It can be repeated q8 hours. Cotton tip applicator of course.

I 100% would not touch her back either for the primary epidural or for a patch. Id probaly do a spinal for C.S for her but thats neither here nor there

So yes id do spg plus multimodal and set the bar low for her expectations

SPG does work. I had one lady who had a deviated septum from a basketball injury. SPG worked 100% on half of her head! I couldnt get the applicator to the back of the nares on the deviated side

 

[Modanq]

Addition of Neostigmine and Atropine to Conventional Management of Postdural Puncture Headache: A Randomized Controlled Trial - PubMed

Neostigmine/atropine was effective in treating PDPH after only 2 doses. Neostigmine can pass the choroid plexus but not the blood-brain barrier. The central effects of both drugs influence both cerebrospinal fluid secretion and cerebral vascular tone, which are the primary pathophysiological...

www.ncbi.nlm.nih.gov

Not OB oriented but a recent article came to my mind. Haven't read the editorials. Hope it helps.

 

[AdmiralChz]

We used to use ACTH for PDPH in residency. Personally never saw it work once and had a near-100% rate of requiring a blood patch. The single article (at the time) showing marginal efficacy was sort of laughable.

 

[Gaseous Clay]

Ive done about 25 spg for pdph. success rate is about 50-60% id say. It can be repeated q8 hours. Cotton tip applicator of course.

I 100% would not touch her back either for the primary epidural or for a patch. Id probaly do a spinal for C.S for her but thats neither here nor there

So yes id do spg plus multimodal and set the bar low for her expectations

SPG does work. I had one lady who had a deviated septum from a basketball injury. SPG worked 100% on half of her head! I couldnt get the applicator to the back of the nares on the deviated side

About 25? Are you the OB guru at a large academic center doing over 5000 deliveries a year (being serious, not sarcastic)? Otherwise that’s a lot of wet tapping going on where you are unless that’s over 10+ years and again, you’re the go to guy for that.

 

[caligas]

She may not have a lumbar epidural space to patch.

 

[dhb]

anyone think a single shot spinal for labor analgesia at late first stage would be a good option?

Would

 

[deleted697535]

I'm not ob guru but yes to the rest. 8 years now. 11k deliveries

 

[caligas]

She may not have a lumbar epidural space to patch.

This.
Question is what and how much.

 

[AdmiralChz]

anyone think a single shot spinal for labor analgesia at late first stage would be a good option?

What do you do when it wears off? For a G1 patient first stage will almost certainly last longer than a spinal will.

if you can get in the best option would be intrathecal catheter for labor analgesia, then leave it in for 24 hours to prevent PDPH. would not even attempt epidural in this patient because even if you get it at L5 - S1 interspace there is probably no epidural space above for the local to spread...

The newer data not out of Miami shows that threading intrathecal catheters and leaving in for X amount of time doesn’t have much protective effect against PDPH.

I absolutely hate intrathecal catheters on L&D. Pain control can be very temperamental (either totally numb with zero pain or no effect and excruciating) and frustrating for patients. I have also seen at least 3 specific instances where the L&D staff did not program the epidural pump correctly (and once in residency where a new pump was needed, and the resident programmed the new pump in epidural settings). I have heard of several near-misses as well - a lot of danger for a frustrating, minimally-helpful option that will likely still buy you a PDPH on the backend. I refuse to allow them when I am covering the floor unless delivery is imminent or some other situation where a delay could be detrimental.

 

[deleted697535]

What do you do when it wears off? For a G1 patient first stage will almost certainly last longer than a spinal will.



The newer data not out of Miami shows that threading intrathecal catheters and leaving in for X amount of time doesn’t have much protective effect against PDPH.

I absolutely hate intrathecal catheters on L&D. Pain control can be very temperamental (either totally numb with zero pain or no effect and excruciating) and frustrating for patients. I have also seen at least 3 specific instances where the L&D staff did not program the epidural pump correctly (and once in residency where a new pump was needed, and the resident programmed the new pump in epidural settings). I have heard of several near-misses as well - a lot of danger for a frustrating, minimally-helpful option that will likely still buy you a PDPH on the backend. I refuse to allow them when I am covering the floor unless delivery is imminent or some other situation where a delay could be detrimental.

Amen!!!
I totally agree. A spinal catheter on L&D is like a giant red nuclear button just waiting for a resident to come along and press it. Theyre so dangerous. I hate them and could never understand how leaving a catheter in there reduced the risk of PDPH. OB have no clue what they are, nurses barely understand. Shift changeover all info on them is lost

I cant believe how blaise some residents are. They've taken to a fad of doing CSEs out on L&D recently. All have different mixes and very decidedly unsterile practices. Its nuts. Making spinal catheters a normal thing would only add to this

 

[CubsDynasty]

Regarding initial placement: likely obliterated or scarred epidural space if surgery down to L4 so would offer remi/fentanyl PCA or IT catheter (you'd need to convince me, and it would have to be a high risk patient bad airway/TOLAC) and after some imaging if I saw the patient as a consult.

As said before: analgesia, cosyntropin (anecdotally this has worked wonders when ordered prophylactically for known wet taps (residents)), and SPG with qtips. Sometimes you have to repeat the SPG (I've done it up to 3 times for one patient) but it's a benign procedure. Refer to have EBP performed under fluoroscopy.

Re SPG: I know people overseas who have even just put patients in the sniffing position and poured/sprayed lidocaine and let it pool and sit. Heard it works pretty well and it can be performed by husbands at home as well if it persists. Again, that's not in 'Merica.

 

[Consigliere]

Do nothing. Headache will eventually go away.

 

[deleted697535]

Do nothing. Headache will eventually go away.

I think that's a bit harsh on the poor girl plus probably not great for her baby. She'll be flat on her back for up to 10 days...

 

[Tramadeezy]

You could do a caudal (with or without ultrasound). Run a catheter until you hit resistance (which will likely be at fusion level) pull back and inject until headache symptoms go away...

 

[deleted162650]

You could do a caudal (with or without ultrasound). Run a catheter until you hit resistance (which will likely be at fusion level) pull back and inject until headache symptoms go away...

How do you expect the blood to patch the hole if it stops at the scar tissue and the hole is higher than that?

 

[urge]

sphenopalatine ganglion block?

This

 

[urge]

Re SPG: I know people overseas who have even just put patients in the sniffing position and poured/sprayed lidocaine and let it pool and sit. Heard it works pretty well and it can be performed by husbands at home as well if it persists. Again, that's not in 'Merica.

This.
2ml lido 4%/2ml ropi 0.5% each nares drop at a time, stop when she starts swallowing local. Let it pool in trendelenberg for 30 min.

You can thank the guy from Rutgers if it works.

 

[Bryan O’Blivion]

Addition of Neostigmine and Atropine to Conventional Management of Postdural Puncture Headache: A Randomized Controlled Trial - PubMed

Neostigmine/atropine was effective in treating PDPH after only 2 doses. Neostigmine can pass the choroid plexus but not the blood-brain barrier. The central effects of both drugs influence both cerebrospinal fluid secretion and cerebral vascular tone, which are the primary pathophysiological...

www.ncbi.nlm.nih.gov

Not OB oriented but a recent article came to my mind. Haven't read the editorials. Hope it helps.

Results in impressive flatulence, but underwhelming reduction in pain. Doesn’t aid the patient’s dignity or sense of satisfaction with current events. In fact, no one present is happy about it. Would not recommend.

 

[deleted162650]

Results in impressive flatulence, but underwhelming reduction in pain. Doesn’t aid the patient’s dignity or sense of satisfaction with current events. In fact, no one present is happy about it. Would not recommend.

Disagree. We’ve tried it 4 times at my shop. Worked 3/4. 0/4 had impressive flatulence. I think your patient was just looking for a scapegoat after busting ass.

 

[Consigliere]

I think that's a bit harsh on the poor girl plus probably not great for her baby. She'll be flat on her back for up to 10 days...

As opposed to possibly being in a wheelchair for the rest of her life as a result of a ham fisted attempt to "help" the "poor girl?" Primum non nocere, my friend. Given her history, I would avoid a needle in her back at all costs. But what do I know? I've only been doing this for 25 years with nary a malpractice case.

 

[sevoflurane]

SGB don’t last that long. If it works, she is going to want one twice a day. Agree with Consigliere. She isn’t going to die w/o an intervention.

 

[Tramadeezy]

How do you expect the blood to patch the hole if it stops at the scar tissue and the hole is higher than that?

Thought being that the blood would increase subarachnoid pressure and normalize csf pressures. Ive seen several headaches from cervical wet taps cured with lumbar blood patches

 

[Modanq]

Results in impressive flatulence, but underwhelming reduction in pain. Doesn’t aid the patient’s dignity or sense of satisfaction with current events. In fact, no one present is happy about it. Would not recommend.

Lol. Totally forgot about the aromatic aspect of neostig. And I have used it on many occasion for an Ogilvis's in the unit while the nurses moan and complain!

 

[sevoflurane]

...wrong thread

 

[sevoflurane]

.

 

[Bryan O’Blivion]

Disagree. We’ve tried it 4 times at my shop. Worked 3/4. 0/4 had impressive flatulence. I think your patient was just looking for a scapegoat after busting ass.

Well, admittedly, n of 1, but pretty discouraging. Seriously, it actually worked 3 times? I had to blood patch the one time I tried it. I even gave it about 6 hours, but aside from the initial eruption, no discernible effect.

 

[deleted697535]

As opposed to possibly being in a wheelchair for the rest of her life as a result of a ham fisted attempt to "help" the "poor girl?" Primum non nocere, my friend. Given her history, I would avoid a needle in her back at all costs. But what do I know? I've only been doing this for 25 years with nary a malpractice case.

Why not spg. If you read my earlier post I 100% agree I'd not touch her back except for a single shot spinal.

Idk why anyone would do an epidural on her in the first place. Do ye guys have a Remi pca option as backup or is it very hospital dependent

 

[Aether2000]

I have performed SPG blocks x 50 using the sphenopalatine fissure approach to reach the pterygopalatine fossa for chronic pain- these are at times difficult and require fluoroscopy. The cotton tip method is much easier. For home use SPG block, I dispensed 0.25% bupivacaine to be given 1ml Q8-12 delivered via sheathed 25ga needle inserted horizontally into the nares with a hole bored in the end of the sheath (using 18ga needle).

I agree another needle stick at the same level is likely to result in another dural puncture. Using a caudal epidural needle placement under fluoroscopy with advancement of a Brevicath or other stiff wire wound catheter would be my first approach with a secondary approach above the level of the fusion but using contrast to assure adequate spread before blood injection. If this were insufficient, then a transforaminal approach advancing an Epimed blunt needle into the lateral epidural space for the blood patch would be my next choice.

 

[ScarfTheVerb]

Anyone ever done a spinal with just opioids for a laboring scoli? I’ve thought about it but never pulled the trigger. Not sure how effective it would be.

 

[deleted875186]

Anyone ever done a spinal with just opioids for a laboring scoli? I’ve thought about it but never pulled the trigger. Not sure how effective it would be.

Why would you do just opioid? I would do a low dose spinal similar to a CSE technique.

 

[Angus Avagadro]

I know it's Old School, but doesnt anyone use IV Caffeine anymore? Agree, she wont die with a dural puncture headache, but I've had decent results with caffeine and analgesics.

 

[deleted162650]

I know it's Old School, but doesnt anyone use IV Caffeine anymore? Agree, she wont die with a dural puncture headache, but I've had decent results with caffeine and analgesics.

A) it’s been proven ineffective

B) it’s no longer being manufactured

 

[Aether2000]

It is being manufactured and we have it in stock in multiple hospitals. I ordered IV caffeine yesterday for a caffeine withdrawal headache.

 

[deleted162650]

It is being manufactured and we have it in stock in multiple hospitals. I ordered IV caffeine yesterday for a caffeine withdrawal headache.

Good to know. I haven't asked for it in a while cuz' pharmacy told me it was outta production.

 

[epidural man]

Flood her with fluids. People think 500ml bolus will do the trick....more like 3L.

SGP - take a 20 gauge IV catheter and slide that into each nares and squirt (really squirt it - it needs to spray back there) 0.25% bupivacaine - maybe 1/2ml each side. Super safe. doesn't hurt (tickles....)

Cosyntropin - doesn't hurt. May help. I've seen it work several times.

Try caffeine.

 

[Pharmado]

Thankfully her HA only lasted around 24 hours and resolved with fluids and caffeine (not IV since we don’t have that). I talked with her pain doc who said that the HA should be self limiting because she has no real epidural space for the CSF to leak into.

 

[10KHertz]

Like I recommended in the pain thread S/p a cervical ESI dural puncture. Get more data...
A T1 weighted lumbar and brain MRI can now provide more information regarding a true dural puncture (cerebral menigeal traction signs/enhancement,etc.).

MRI (T1 weighted) with gadolinium contrast, however, reveals changes that can make a difference in the diagnosis of PDPH. This particular type of MRI rules out more serious conditions, such as subdural hematoma and intracranial masses. The two key findings using T1-weighted contrast MRI are meningeal enhancement and descent or sagging of the brain. Diffuse meningeal enhancement is seen on the MRI. “The meninges … light up with gadolinium,”

If there are true finding continue conservative care, try an abdominal binder, and plan a patch with IR or a good pain interventionalist ...

 

[Angus Avagadro]

Like I recommended in the pain thread S/p a cervical ESI dural puncture. Get more data...
A T1 weighted lumbar and brain MRI can now provide more information regarding a true dural puncture (cerebral menigeal traction signs/enhancement,etc.).

MRI (T1 weighted) with gadolinium contrast, however, reveals changes that can make a difference in the diagnosis of PDPH. This particular type of MRI rules out more serious conditions, such as subdural hematoma and intracranial masses. The two key findings using T1-weighted contrast MRI are meningeal enhancement and descent or sagging of the brain. Diffuse meningeal enhancement is seen on the MRI. “The meninges … light up with gadolinium,”

If there are true finding continue conservative care, try an abdominal binder, and plan a patch with IR or a good pain interventionalist ...

Not sure I would order an MRI or and IR consult in a self limiting condition. Obviously, if symptoms persisted, ok. IR person could end up with another dural puncture, as epidural space might be obliterated from prior surgery, hence the original puncture. Then what? Gadolinium appears to accumulate in the brain, noticed in MS patients with multiple scans. Although it's considered benign, it would give me pause to order it in a PDPH unless it wasnt resolving or worsening.