Cosyntropin and PDPH

[Mofeen]

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There are some old threads discussion this topic, although not directly.
Just wondering if anyone has any updates or recommendations for its use?

I have used it on 2 patients in the last 4 months. Both were obstetrical PDPH's, one from a 22G SAB and one from a dural puncture from an epidural placement.

In regards to the first patient, used it as treatment about 36 hours after the SAB because she did not want a blood patch. It worked, and she was sent home next day.

The second, patient, I used as prophylaxis post delivery with success. She was discharged 1 day later with no complaints.

Both used 1 mg in 500 mL NS over 4 hours.

Pharmacy and nursing both gave me strange looks both times. This is the only thing causing hesitation is its future use.

Sound off!

 

[Planktonmd]

There are some old threads discussion this topic, although not directly.
Just wondering if anyone has any updates or recommendations for its use?

I have used it on 2 patients in the last 4 months. Both were obstetrical PDPH's, one from a 22G SAB and one from a dural puncture from an epidural placement.

In regards to the first patient, used it as treatment about 36 hours after the SAB because she did not want a blood patch. It worked, and she was sent home next day.

The second, patient, I used as prophylaxis post delivery with success. She was discharged 1 day later with no complaints.

Both used 1 mg in 500 mL NS over 4 hours.

Pharmacy and nursing both gave me strange looks both times. This is the only thing causing hesitation is its future use.

Sound off!

I have been using it for years for both prophylaxis and treatment with very good results.
I give 0.5mg in 500cc.
There was a little study confirming it's effectiveness in prophylaxis after dural puncture but I am not aware of any new data.

 

[pgg]

What do you tell breastfeeding women? Pump/discard for 24h?

 

[BLADEMDA]

I've tried it 6 times with failure 5 out of 6. IMHO, it's not worth the money and I now proceed to Epidural blood patch as indicated.

 

[Planktonmd]

What do you tell breastfeeding women? Pump/discard for 24h?

I don't give them specific instructions.

 

[sevoflurane]

How does cosyntropin prevent or cure PDPH?
What's the mechanism?

 

[Planktonmd]

How does cosyntropin prevent or cure PDPH?
What's the mechanism?

No one knows... might be increased CSF production

 

[BuzzPhreed]

It probably is just as effective as NSAIDs and caffeine. Without the dirty looks from the pharmacist.

 

[Planktonmd]

It probably is just as effective as NSAIDs and caffeine. Without the dirty looks from the pharmacist.

No... it's way more effective than anything else and it is even effective when a blood patch fails.

 

[Gaseous Clay]

From what I've seen, it's promising but falls under that "may help" category. I also read where it should be started soon after catheter removal, about 30 minutes. I've never used it but next time I hear about a known wet tap (or I get one) I may give it a try.

 

[Gaseous Clay]

In response to Blades high failure rate, I believe it's meant more as a prevention than a treatment. If someone comes 5 days post dural puncture, blood patch is the way to go, not ACTH. But that's just an assumption on blades part.

 

[BuzzPhreed]

No... it's way more effective than anything else and it is even effective when a blood patch fails.

I gotta admit I've never tried it. Then again blood patch has always been a last resort. I think people jump on the blood patch wagon way too fast sometimes before conservative therapy has truly failed.

 

[Noyac]

I gotta admit I've never tried it. Then again blood patch has always been a last resort. I think people jump on the blood patch wagon way too fast sometimes before conservative therapy has truly failed.

I find conservative therapy just delays effective treatment which is a blood patch.
Oh, and nothing will piss a partner off more than to get called to evaluate a PDPH and you start conservative treatment for a day so that the next call guy has to come back to see the pt and do the right thing in the first place.

 

[pgg]

I gotta admit I've never tried it. Then again blood patch has always been a last resort. I think people jump on the blood patch wagon way too fast sometimes before conservative therapy has truly failed.

For the PDPHs caused by ER-special LPs I offer Maxalt. Most of them can spend a day or two lounging around supine watching TV. Even so, less than 1/2 the time they opt for the Maxalt. Most just want definitive treatment right then.

For the postpartums who got 17g Tuohy dural punctures, conservative treatment is a lot less attractive. It's hard to have a newborn and be patient with conservative treatment when every time you move you've got this severe headache. They almost always want the blood patch.

Oh, and nothing will piss a partner off more than to get called to evaluate a PDPH and you start conservative treatment for a day so that the next call guy has to come back to see the pt and do the right thing in the first place.

That too.

 

[BLADEMDA]

Sorry Gentlemen. But, until a real Academic centers shows this crap works I'm done with it. Cosyntropin is expensive and failed to avoid my doing a Blood Patch 5/6 times in which I used it.

They either get conservative therapy or a blood patch.

 

[Planktonmd]

Sorry Gentlemen. But, until a real Academic centers shows this crap works I'm done with it. Cosyntropin is expensive and failed to avoid my doing a Blood Patch 5/6 times in which I used it.

They either get conservative therapy or a blood patch.

No one said you should use this "crap" or discredited your extensive personal experience with your sample number of 6!
As for "real" centers... you ,very frequently, copy and paste "crap" from weird obscure sources as long as they fit your excentric (crazy) opinions... we always let you slide with it... so... chill

 

[BLADEMDA]

No one said you should use this "crap" or discredited your extensive personal experience with your sample number of 6!
As for "real" centers... you ,very frequently, copy and paste "crap" from weird obscure sources as long as they fit your excentric (crazy) opinions... we always let you slide with it... so... chill

I don't care if anyone uses Cosyntropin for PDPH. But, it is very expensive and the mixed results suggest it may not be cost effective. So, I recommend you check the cost of this stuff and think hard before spending the money on an unproven method of treating PDPH. I stand by my statement that this stuff is expensive, ineffective crap until proven otherwise by a study in the USA, Canada or UK.

From your posts I clearly see why the AMC has issues with you. Your opinions aren't based on any solid evidence or good clinical data. Instead, you like to argue because you enjoy it.

 

[Planktonmd]

I don't care if anyone uses Cosyntropin for PDPH. But, it is very expensive and the mixed results suggest it may not be cost effective. So, I recommend you check the cost of this stuff and think hard before spending the money on an unproven method of treating PDPH. I stand by my statement that this stuff is expensive, ineffective crap until proven otherwise by a study in the USA, Canada or UK.

From your posts I clearly see why the AMC has issues with you. Your opinions aren't based on any solid evidence or good clinical data. Instead, you like to argue because you enjoy it.

You know that I always thought you were crazy... it's not a secret and it's not new... so why are you getting upset now?
Crazy people like you need a reality check every time their craziness gets too annoying, and that's precisely what I enjoy doing.
For the longest time I believed that you must be a nurse pretending to be a physician based on your concrete thinking and the lack of logic and based on the diarrhea of copied and pasted Google searches that you inflict on us constantly.

 

[MaximusD]

Dayyum!

That's all I've got...

 

[sleepallday]

I don't care if anyone uses Cosyntropin for PDPH. But, it is very expensive and the mixed results suggest it may not be cost effective. So, I recommend you check the cost of this stuff and think hard before spending the money on an unproven method of treating PDPH. I stand by my statement that this stuff is expensive, ineffective crap until proven otherwise by a study in the USA, Canada or UK.

From your posts I clearly see why the AMC has issues with you. Your opinions aren't based on any solid evidence or good clinical data. Instead, you like to argue because you enjoy it.

Just curious. Why are you only willing to look at studies from the USA, Canada, or UK? There is a decent amount of anesthesia literature coming out of Germany, Japan, and India just to name a few other countries.

 

[BLADEMDA]

Just curious. Why are you only willing to look at studies from the USA, Canada, or UK? There is a decent amount of anesthesia literature coming out of Germany, Japan, and India just to name a few other countries.

Because Cosyntropin doesn't work and I want a solid academic center to prove otherwise. This stuff can cost as much as $1,000 per dose and that isn't the actual patient charge. For that kind of money I expect better than 1/6 success rate. The other 5 required blood patches anyway so why spend the $1,000++ on nothing?

 

[Noyac]

You know what, when Blade agreed with me on the ECG thread I thought he was a nurse as well.

Edit: I had a emoticon or whatever they are called there at the end of that statement but for some reason it doesn't show. I guess everyone will just have to guess what it was and what I meant.

 

[Planktonmd]

Because Cosyntropin doesn't work and I want a solid academic center to prove otherwise. This stuff can cost as much as $1,000 per dose and that isn't the actual patient charge. For that kind of money I expect better than 1/6 success rate. The other 5 required blood patches anyway so why spend the $1,000++ on nothing?

Cosyntropin is generic and costs a few dollars. Don't make stuff up!

 

[BuzzPhreed]

As of 2009, the average wholesale price of cosyntropin was $120 per 0.25 mg vial.

http://www.ptcommunity.com/ptjournal/fulltext/34/5/PTJ3405250.pdf

For the longest time I believed that you must be a nurse pretending to be a physician based on your concrete thinking and the lack of logic and based on the diarrhea of copied and pasted Google searches that you inflict on us constantly.

You know what, when Blade agreed with me on the ECG thread I thought he was a nurse as well.

That would make his the greatest effort of underground double-agent trolling in the history of this or maybe any forum.

 

[BuzzPhreed]

I find conservative therapy just delays effective treatment which is a blood patch.
Oh, and nothing will piss a partner off more than to get called to evaluate a PDPH and you start conservative treatment for a day so that the next call guy has to come back to see the pt and do the right thing in the first place.

I generally agree with you. But it depends on the situation. I had a 400+ pound parturient not that long ago that I intentionally put a spinal catheter in. I grabbed the 15 cm Tuohy (aka harpoon) and entered the intrathecal space at 13+ cm. I put the catheter in to make sure that if the c-section took longer than planned I would have a way to re-dose her. I sure as hell didn't want to have to tube her.

POD1 I went back and pulled the catheter. She had a nuchal headache by ythe end of POD1 when she got out of bed. I decided to wait and watch her and give conservative Rx. She wasn't going home yet anyway. By POD4 no more headache. She would've been a nightmare to try to bloodpatch.

So, yes I agree with you if someone comes from home after a neurologist stuck a 22g Quincke in their back five days ago and they are complaining of headache. But each situation is different and a lot of blood patches I've seen especially in post c/s patients could probably have waited another day or two. Most of them get better without our help.

 

[Noyac]

Next time you pull that catheter try injecting 10cc NS (sterile of course) in it before pulling it. I don't know why it works but it does, at least as good as Cosyntropin and cost nothin.

 

[Planktonmd]

Next time you pull that catheter try injecting 10cc NS (sterile of course) in it before pulling it. I don't know why it works but it does, at least as good as Cosyntropin and cost nothin.

Cosyntropin does work.
I have used it more than 100 times over the past few years with impressive results, probably around 50% success.
There is no conservative therapy that works as well.

 

[Noyac]

Cosyntropin does work.
I have used it more than 100 times over the past few years with impressive results, probably around 50% success.
There is no conservative therapy that works as well.

That is a hell of a lot.
Are these PDPHs from radiology/ER?

 

[Planktonmd]

That is a hell of a lot.
Are these PDPHs from radiology/ER?

A mixture but mainly S/P labor epidurals by our esteemed midlevel colleagues.

 

[BuzzPhreed]

I have used it more than 100 times over the past few years with impressive results, probably around 50% success.

A mixture but mainly S/P labor epidurals by our esteemed midlevel colleagues.

Dude. WTF? Maybe you should stop letting your "esteemed midlevel colleagues" put in labor epidurals? Just a thought.

Since being fully in PP for me in 2008 I've done probably a handful (or a few more) of blood patches. It's not a common procedure in my practice. Most resulted from radiologists/neurologists/ER docs following spinal tap.

Cosyntropin is expensive. It's not $1000 per dose. But, not just a "few bucks" either.

 

[Planktonmd]

Dude. WTF? Maybe you should stop letting your "esteemed midlevel colleagues" put in labor epidurals? Just a thought.

Not my choice!

 

[jope]

Not sure why anyone is slamming Blade. As a resident, I've found his contributions to be some of the most solid on this board since the majority is backed up by evidence while you guys are exchanging anecdotes.

 

[Planktonmd]

Not sure why anyone is slamming Blade. As a resident, I've found his contributions to be some of the most solid on this board since the majority is backed up by evidence while you guys are exchanging anecdotes.

There is nothing wrong in exchanging anecdotes!
Evidence based medicine is definitely the gold standard but studies and articles are available to everyone with an internet connection.
On the other hand, the personal experiences and observations of individual physicians (anecdotes) are not always easily attainable and having a forum where they are shared freely is a huge privilege.
There are certain pearls and "anecdotes" that you don't find in the books and the articles... trust me!