PDPH EBP vs SPG.... LMNOP

[ethilo]

Hey all,
Someone just recently posted something about SPG block in PDPH and that reminded me about it.

I have heard there's loose evidence out there that says SPG is a viable alternative to EBP. I'm wondering, does anyone do these as part of their practice? What are your experiences? Is it worth incorporating?

Please share dosing/technique too.

I did it on a moderate severity PDPH on a normal BMI lady who had a 3 attempt labor epidural, converted to c section. Headache was frontal, moderate to severe, with bad photophobia.

She got immediate relief down to manageable headache pain with no photophobia after bilateral SPG using 4% lido 4mL dripped into applicator qtips over 10 minutes. We figure we'd try it while she was waiting for a head MRI ordered by the ED. The plan was to do EBP after MRI if not improved. Apparently my nighttime anesthesia partner came back to evaluate her after the MRI and ended up doing the EBP on her.

I thought it was promising But not sure if it's not a better idea to just do the EBP and get it over with rather than just delaying the inevitable.

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[sevoflurane]

Ya they don’t last that long. Nice quick trick, but you often end up needing EBP... so i go to that first as it’s definitive treatment most of the time.

 

[pgg]

I would have guessed a SPG catheter would be needed to get lasting relief from it.

 

[sevoflurane]

buahahaha.

 

[deleted162650]

I would have guessed a SPG catheter would be needed to get lasting relief from it.

Not if you use Exparel

 

[deleted59964]

Personally I reckon they’re worth a try.
we tend not to ebp till a few days later, as a proportion never need it.
spg in the mean time, repeat as necessary

 

[UscGhost]

Personally I reckon they’re worth a try.
we tend not to ebp till a few days later, as a proportion never need it.
spg in the mean time, repeat as necessary

Why leave the patient miserable for so long?

 

[Ronin786]

Why leave the patient miserable for so long?

Classical teaching is that majority are self-resolving within 72 hours, though I haven't really reviewed the literature myself. Most PDPH are going to be in tough epidurals in the first place.

 

[GassYous]

Spg block is garbage. I tried it a few times, didn't go anywhere and had to blood patch the patient anyway earning me two trips to the ed.

 

[deleted697535]

Classical teaching is that majority are self-resolving within 72 hours, though I haven't really reviewed the literature myself. Most PDPH are going to be in tough epidurals in the first place.

most prob do resolve, but we never see nor hear of them. The ones we do see, id wager are the ones that will wont resolve for weeks
Also most pdph are when junior residents or unfamiliar staff are doing them, not necessarily difficult epidurals. Honestly i havent seen a difficult epidural outside of someone with Ank spond/ RA/ laminectomy. Even BMI 70s etc... There is always few that the flavum doesnt meet midline but still

I dont do spbg unless theres contraindication for EPB (ebp pays a better code where i work, fixes it right away most often but there is a role for spgb). I had one guy with neutropenia that some imbecile rads did an LP on with a 22g. So i did q2day spgb for a week. Worked fine. He sent me a great bottle of whiskey

Id learn both techniques. They're both valuable to you and your patients

 

[woopedazz]

They're proven trash.

Conservative Mx and wait, OR, definitive Tx with EBP.

 

[deleted59964]

We generally admit people that are complaining of PDPH, they get reviewed on the acute pain round - and we generally patch on or after day 3.
Got to say I've only done a couple of SPG blocks - I have no idea from that whether they are more effective than placebo.

However, if you subscribe to the idea of conservative management until day 3, what do you have to lose by doing a SPGB ... 5 min of time for whoever is on the pain round that day.

 

[deleted697535]

They're proven trash.

Conservative Mx and wait, OR, definitive Tx with EBP.

Oh. Mind sharing study please?

 

[MirrorTodd]

Coincidentally, I'm doing my grand rounds presentation on post dural puncture headaches. Basic gist is that they work, but for short periods, so redoing is necessary, anesthesiologists suck at recognizing l3-4 interspace, and blood patches basically work, but not if you do them too soon. I would encourage attendings in academic centers to have their residents do them. Admittedly we have a good pain clinic so a lot of the staff prefer to send the pt downstairs for the blood patch.

 

[GassYous]

Coincidentally, I'm doing my grand rounds presentation on post dural puncture headaches. Basic gist is that they work, but for short periods, so redoing is necessary, anesthesiologists suck at recognizing l3-4 interspace, and blood patches basically work, but not if you do them too soon. I would encourage attendings in academic centers to have their residents do them. Admittedly we have a good pain clinic so a lot of the staff prefer to send the pt downstairs for the blood patch.

Why would the timing matter? Its a leak and you basically patch the leak. It is a quick procedure and generates a decent number of rvus.

 

[DocVapor]

Are people forcing recent postpartums to wait 3 days before blood patch, or just those that get PDPH after the ER special barbaric LP utilizing 18ga cutting needle?

 

[ethilo]

Decreasing delay in EBP and diameter of needle causing the dural puncture are independent risk factors for failure of EBP.

Complete relief of all symptoms occurred in 377 cases (75%; 95% CI, 73–77%). In the remaining 127 (25%; 95% CI, 23–27%]) patients with incomplete relief of symptoms, 34 (7%; 95% CI, 6–8%) were considered as a failure.

Safa-Tisseront V, et al. "Effectiveness of Epidural Blood Patch in the Management of Post–Dural Puncture Headache" Anesthesiology 2001 Effectiveness of Epidural Blood Patch in the Management of Post–Dural Puncture Headache | Anesthesiology | American Society of Anesthesiologists

...Precocious EBP leading to failure is one of the reasons why people choose to wait 72 hours to perform one.

 

[MirrorTodd]

Why would the timing matter? Its a leak and you basically patch the leak. It is a quick procedure and generates a decent number of rvus.

Unfortunately, I don't have the answer to that. The science hasn't shown why, just that it's more effective to wait a bit.

 

[Hoya11]

We generally admit people that are complaining of PDPH, they get reviewed on the acute pain round - and we generally patch on or after day 3.
Got to say I've only done a couple of SPG blocks - I have no idea from that whether they are more effective than placebo.

However, if you subscribe to the idea of conservative management until day 3, what do you have to lose by doing a SPGB ... 5 min of time for whoever is on the pain round that day.

OB service calls to let you know there is a PDPH potential patient, I see the patient immediately

Typically its been less than 72hrs and I give it a day with fluids and fioricet..

The next day if they are still there and unable to be discharged by OB, then I do it.

Otherwise, typically they come in through the ER, at that point its been >72 hrs and mostly 4-5 days, and I do it right int he ER, they lay flat for an hour monitored, and go home.. admitting these people seems like overkill to me

 

[deleted59964]

OB service calls to let you know there is a PDPH potential patient, I see the patient immediately

Typically its been less than 72hrs and I give it a day with fluids and fioricet..

The next day if they are still there and unable to be discharged by OB, then I do it.

Otherwise, typically they come in through the ER, at that point its been >72 hrs and mostly 4-5 days, and I do it right int he ER, they lay flat for an hour monitored, and go home.. admitting these people seems like overkill to me

what if I said the patient doesn't get a bill?

 

[deleted59964]

Why would the timing matter? Its a leak and you basically patch the leak. It is a quick procedure and generates a decent number of rvus.

I don't think it's a direct plug of a hole, because they still work in spontaneous CSF leaks where the hole is not at the level of the patch.
maybe it sets up an inflammatory reaction - I don't know, but I think it is more complex

 

[GassYous]

I don't think it's a direct plug of a hole, because they still work in spontaneous CSF leaks where the hole is not at the level of the patch.
maybe it sets up an inflammatory reaction - I don't know, but I think it is more complex

The patch doesn't need to be at the same level and anyone experienced knows that the relief is immediate

 

[UscGhost]

Classical teaching is that majority are self-resolving within 72 hours, though I haven't really reviewed the literature myself. Most PDPH are going to be in tough epidurals in the first place.

Even if they self resolve after 72 hrs..I doubt very many patients would be ok waiting that long...at least the ones referred to us. They are generally quite miserable and the procedure is quite safe.

If the patient can tolerate it with mild analgesics then I wouldn't push the procedure, but pretty much every patient was extremely grateful after the patch was done.

 

[deleted59964]

Even if they self resolve after 72 hrs..I doubt very many patients would be ok waiting that long...at least the ones referred to us. They are generally quite miserable and the procedure is quite safe.

If the patient can tolerate it with mild analgesics then I wouldn't push the procedure, but pretty much every patient was extremely grateful after the patch was done.

generally it’s pretty much the same procedure that caused the problem in the first place... it is possible to cause another dural puncture

 

[pgg]

what if I said the patient doesn't get a bill?

Doesn't make it any less wasteful.

 

[UscGhost]

generally it’s pretty much the same procedure that caused the problem in the first place... it is possible to cause another dural puncture

That would be pretty uncommon. If you assume a 1% incidence...then its a 1/100 chance on the subsequent EBP attempt as well. Usually the EBP is a bit easier due to patient no longer being pregnant and moving secondary to labor pain. And even if you puncture dura during the EBP...the subsequent blood you inject will treat that as well.

I always give the option to the patient. They can wait and it might go away in the next 3-7 days...or i can do the EBP and there is a 90-95% chance of resolution immediately. They always choose the immediate relief. The important part is that they get to choose..
Forcing them to wait 72 hrs seems unnecessary with little benefit.

 

[woopedazz]

That would be pretty uncommon. If you assume a 1% incidence...then its a 1/100 chance on the subsequent EBP attempt as well. Usually the EBP is a bit easier due to patient no longer being pregnant and moving secondary to labor pain. And even if you puncture dura during the EBP...the subsequent blood you inject will treat that as well.

I always give the option to the patient. They can wait and it might go away in the next 3-7 days...or i can do the EBP and there is a 90-95% chance of resolution immediately. They always choose the immediate relief. The important part is that they get to choose..
Forcing them to wait 72 hrs seems unnecessary with little benefit.

There is a higher failure rate if performed within 48-72 hours of the insult.

Weighing up the risk of repeat instrumentation; and the knowledge it is more likely to recur, thus potentially requiring a repeat patch ... vs waiting for what will most likely resolve spont... i rarely patch prior to 72hr

 

[UscGhost]

There is a higher failure rate if performed within 48-72 hours of the insult.

Weighing up the risk of repeat instrumentation; and the knowledge it is more likely to recur, thus potentially requiring a repeat patch ... vs waiting for what will most likely resolve spont... i rarely patch prior to 72hr

I am not aware of any literature that suggests waiting 72 hrs. If the headache pops up within the first 24 hrs..its more likely that its a severe CSF leak or a patient predisposed to being more sensitive. In that scenario..its more likely to fail regardless. Even then..EBP is considered the gold standard.

Forcing someone to wait an additional 48 hrs in misery is tough to swallow. If it's a mild headache..then they probably won't be calling you anyways and if the patient responds to mild analgesics..then by all means go that route.

But given that only 60% resolve within 4 days..and some can last as long as 14 days. I find it hard to sell a patient on the plan to delay care hoping that it resolves and let them be miserable in the meantime. If its a mild headache..patients won't want it to begin with.

In my practice, waiting that long would be looked at as dumping the procedure on someone else.

 

[deleted59964]

Doesn't make it any less wasteful.

yeah - it does, as long as there is a bed and staff available - the real cost to the system is small.
and as above there is some evidence of improved efficacy 3 days down the track.

 

[deleted59964]

I always give the option to the patient. They can wait and it might go away in the next 3-7 days...or i can do the EBP and there is a 90-95% chance of resolution immediately. They always choose the immediate relief. The important part is that they get to choose..
Forcing them to wait 72 hrs seems unnecessary with little benefit.

yeah - I reckon how you sell it affects what they choose.

If I say, "well we could do the same procedure that caused your headache in the first place - but instead of local anaesthetic I get some of your blood and inject that instead - then it could help. Of course if we wait, your headache may well go away by itself, and if we do the blood injection there is a risk of making another hole and making more of your spinal fluid leak. oh and if we wait and then do the blood injection, it works better anyway ..." then I reckon they'll be less keen.

 

[UscGhost]

yeah - I reckon how you sell it affects what they choose.

If I say, "well we could do the same procedure that caused your headache in the first place - but instead of local anaesthetic I get some of your blood and inject that instead - then it could help. Of course if we wait, your headache may well go away by itself, and if we do the blood injection there is a risk of making another hole and making more of your spinal fluid leak. oh and if we wait and then do the blood injection, it works better anyway ..." then I reckon they'll be less keen.

Yup. You can definitely sell it either way depending on how you phrase it. Always better to under-promise and over-deliver.

Usually these patients don't present to us until 24-72 hrs post procedure anyways. So most of the hypotethetical benefit of delay has been accomplished. The chance of two dural punctures in the same patient is likely quite rare and given the number of EBP performed in the average career, you are unlikely to encounter many of those..if any.

In my experience..usually the patients that deferred were not that symptomatic. The ones that wanted it were usually pretty incapacitated and extremely grateful afterwards. So there is a bit of self selection as well.

 

[deleted59964]

Yup. You can definitely sell it either way depending on how you phrase it. Always better to under-promise and over-deliver.

Usually these patients don't present to us until 24-72 hrs post procedure anyways. So most of the hypotethetical benefit of delay has been accomplished. The chance of two dural punctures in the same patient is likely quite rare and given the number of EBP performed in the average career, you are unlikely to encounter many of those..if any.

In my experience..usually the patients that deferred were not that symptomatic. The ones that wanted it were usually pretty incapacitated and extremely grateful afterwards. So there is a bit of self selection as well.

prospectively that's true most people quote 1/100 dural puncture (though my rate is less)
1/100 X 1/100

but the chance once you've already got your first 1/100 is still 1/100 on the repeat

 

[deleted59964]

OK - I'm being argumentative now - I'm just going to stop.
this is all small print stuff.

 

[Arch Guillotti]

That would be pretty uncommon. If you assume a 1% incidence...then its a 1/100 chance on the subsequent EBP attempt as well. Usually the EBP is a bit easier due to patient no longer being pregnant and moving secondary to labor pain. And even if you puncture dura during the EBP...the subsequent blood you inject will treat that as well.

If you wet tap during a blood patch, you would inject the blood anyway? Fortunately, blood patches are pretty rare but if I wet tapped I don't know that I would inject blood right after. My guess is that this happens so rarely there is no "standard".

 

[Arch Guillotti]

We generally admit people that are complaining of PDPH

This seems nuts to me.

 

[UscGhost]

prospectively that's true most people quote 1/100 dural puncture (though my rate is less)
1/100 X 1/100

but the chance once you've already got your first 1/100 is still 1/100 on the repeat

The main point would be why delay an EBP for 99/100 patients simply to avoid the possible chances of a wet tap on 1 patient. Those other 99 patients end up going to the ED for pain control..incapacitated at home or even kept in the hospital. That's a significant utilization of resources for minimal gain.

 

[UscGhost]

If you wet tap during a blood patch, you would inject the blood anyway? Fortunately, blood patches are pretty rare but if I wet tapped I don't know that I would inject blood right after. My guess is that this happens so rarely there is no "standard".

Not sure i would inject blood immediately after a wet tap. I think general guidance is to remove the needle and attempt at a different level. I would wager a wet tap during a ebp is quite rare so I wouldnt delay care for patients for that reason.

 

[MirrorTodd]

The main point would be why delay an EBP for 99/100 patients simply to avoid the possible chances of a wet tap on 1 patient. Those other 99 patients end up going to the ED for pain control..incapacitated at home or even kept in the hospital. That's a significant utilization of resources for minimal gain.

Pretty sure that's the standard for American medicine.