Pneumocephalus after Blood Patch

[docnyc]

Hi everyone,

My wife is a neurologist and was consulted this weekend on a patient that had a blood patch after having spinal headache on labor and delivery (LOR to air). The anesthesiology team did a blood patch and her headache did not improve, therefore they waited another day and did a repeat blood patch and the patient started to develop severe headache, and neurology was consulted. She requested a Head CT for further info.

Head CT showed pneumocephalus. Was wondering if anyone has any recs on the best treatment for this. I have personally never had this happen to anyone in my practice and from what I saw in the literature it appears to be conservative care with a few case studies showing slight improvement of headache with 100% O2 therapy for 24 hrs.

Thanks.

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[lobelsteve]

Had a fellow do this a few years back on a CESI.
Hydrate, O2, symtpomatic treatment (opiates, tylenol, NSAID, sedatives)

Our patient was managed at home without O2. Treat like PDPH.

 

[docnyc]

Thanks Steve, how long did pt have HA for?

 

[lobelsteve]

Thanks Steve, how long did pt have HA for?

4 days. I believe the fellow was responsible for calling the patient every day to make sure they were doing OK. And no, it was not AMPA.

 

[Tenesma]

pneumocephalograms used to be a diagnostic modality --- just wait... it will get better

 

[Ligament]

Ditto what Tenesma said.

 

[Jcm800]

had patient with this after CSE for TKA...callled me because he was having "post-operative pain" but he was complaining of a headache.
work comp, young. I thought it was bull****. Turned out to be a rip-roaring pneumocephalous on MRI, and he got better in 2 days...

 

[Aether2000]

It will resolve spontaneously. However, the cause of the pneumocephalus will not...the ***** that uses air to demonstrate loss of resistance to find the epidural space. Contact the chief of the department and report this substandard care. In this day and age, saline or saline/air is the standard of care with the saline only injected. Pneumocephalus is caused by a subarachnoid injection of air, can cause seizures and other serious complications, and should not be tolerated. It is completely 100% unnecessary and avoidable.

 

[SSdoc33]

It will resolve spontaneously. However, the cause of the pneumocephalus will not...the ***** that uses air to demonstrate loss of resistance to find the epidural space. Contact the chief of the department and report this substandard care. In this day and age, saline or saline/air is the standard of care with the saline only injected. Pneumocephalus is caused by a subarachnoid injection of air, can cause seizures and other serious complications, and should not be tolerated. It is completely 100% unnecessary and avoidable.

100% agreed. plus, air is compressible, while water is not. ive always found a much cleaner LOR with saline alone -- dont see a reason to ever use air

 

[nvrsumr]

It will resolve spontaneously. However, the cause of the pneumocephalus will not...the ***** that uses air to demonstrate loss of resistance to find the epidural space. Contact the chief of the department and report this substandard care. In this day and age, saline or saline/air is the standard of care with the saline only injected. Pneumocephalus is caused by a subarachnoid injection of air, can cause seizures and other serious complications, and should not be tolerated. It is completely 100% unnecessary and avoidable.

Do you use saline LOR in your stim trials?

 

[Arch Guillotti]

It will resolve spontaneously. However, the cause of the pneumocephalus will not...the ***** that uses air to demonstrate loss of resistance to find the epidural space. Contact the chief of the department and report this substandard care. In this day and age, saline or saline/air is the standard of care with the saline only injected. Pneumocephalus is caused by a subarachnoid injection of air, can cause seizures and other serious complications, and should not be tolerated. It is completely 100% unnecessary and avoidable.

Anesthesiologist here.

What are you basing your "standard of care" assertion here on?

 

[Tenesma]

i agree that LOR to air is risky --- and yet a lot of anesthesiologists are so dependent on that feel with air and a glass syringe, that they can't figure what to do with a plastic syringe and saline...

after just one case of pneumocephalus as a resident with air in they syringe, i haven't used air (except for a little bubble of air in the saline syringe) since...

 

[Aether2000]

Always use saline...have for over a decade, and most anesthesiologists are finally converting to saline. It is simply indefensible when doing a labor epidural to use air solely for the convenience of the physician, when exactly the same result is achieved with saline but without the risk of air embolism to the brain or air injected causing a radiculopathy. Air has been reported in the heart from an interlaminar epidural placement.
As for SCS, yes I use saline, but I recognize that some may question the dispersive capacity of the saline with respect to electric charge. Then it comes down to volume of saline injected and the location of the needle tip compared to the catheter electrodes. I use maximally 1 cc saline. If you enter the epidural space using saline with a 14 ga needle, there is simply no question you are in the epidural space, esp. given the use of fluoroscopy. The 1cc of saline cannot rise to the level of the electrodes, therefore there would be no dispersion of charge. Also given the time frame from catheter advancement to testing, there is a sufficiently rapid redistribution within the epidural space that charge dispersion should not come into play. But for those that typically use 4-10cc saline, then yes, you will probably have a diminished on-the-table trial testing accuracy. But one could make a case for the use of air (or sterile water) for epidural needle tip placement if the alternative would be to use large amounts of saline injected.
I use pulse oximetry. Not because I need it, but because it is a simple addition used for patient safety, that doesn't cause any harm to the patient. Not using it is substandard care, even for those of us trained prior to pulse oximetry when we had to recognize signs of hypoxia. I use saline because it adds to patient safety without detracting from that safety. Yes, I know saline costs 40 cents, but that would not break my bank to improve safety 🙂

 

[Jcm800]

i quit the air bubble thing...i never understood using air, especially in a glass syringe, it seeps out. saline in the platic syringe is so much more definitive, (thank you SDN board)

for SCS i use water for that reason 1-2 cc. Never had an issue. I have had an issue with dispersion with a wet tap...

Always use saline...have for over a decade, and most anesthesiologists are finally converting to saline. It is simply indefensible when doing a labor epidural to use air solely for the convenience of the physician, when exactly the same result is achieved with saline but without the risk of air embolism to the brain or air injected causing a radiculopathy. Air has been reported in the heart from an interlaminar epidural placement.
As for SCS, yes I use saline, but I recognize that some may question the dispersive capacity of the saline with respect to electric charge. Then it comes down to volume of saline injected and the location of the needle tip compared to the catheter electrodes. I use maximally 1 cc saline. If you enter the epidural space using saline with a 14 ga needle, there is simply no question you are in the epidural space, esp. given the use of fluoroscopy. The 1cc of saline cannot rise to the level of the electrodes, therefore there would be no dispersion of charge. Also given the time frame from catheter advancement to testing, there is a sufficiently rapid redistribution within the epidural space that charge dispersion should not come into play. But for those that typically use 4-10cc saline, then yes, you will probably have a diminished on-the-table trial testing accuracy. But one could make a case for the use of air (or sterile water) for epidural needle tip placement if the alternative would be to use large amounts of saline injected.
I use pulse oximetry. Not because I need it, but because it is a simple addition used for patient safety, that doesn't cause any harm to the patient. Not using it is substandard care, even for those of us trained prior to pulse oximetry when we had to recognize signs of hypoxia. I use saline because it adds to patient safety without detracting from that safety. Yes, I know saline costs 40 cents, but that would not break my bank to improve safety 🙂

 

[axm397]

Do you use saline LOR in your stim trials?

I use sterile water for SCS trials, saline for interlaminar ESIs

 

[ctts]

Are you using saline in a regular plastic syringe or in a plastic LOR syringe? I've been using plastic LOR syringe with air...

 

[Jcm800]

Are you using saline in a regular plastic syringe or in a plastic LOR syringe? I've been using plastic LOR syringe with air...

im a convert to regular cheapo terumo 5 cc syringe