Post-dural puncture headache and low platelets. What to do?

[TIVA]

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Good evening gentlemen,

I'll cut to the chase: 35 y.o. white female with acute myelogenous leukemia. Undergoes lumbar puncture by neurologists with instillation of intrathecal methotrexate as treatment. We're consulted four days later because patient has peristent headache suggestive of post-dural puncture headache (improves with lying down, aggravated by sitting up, non-thrombing in nature, diffuse across the back of the head and neck). Unfortunately, platelets are 50, 000 and dropping due to the methotrexate. No joy with caffeine and IV hydration and percocets.

All we were able to offer was this: continue current management, bed rest, please call when PLT greater than 100, 000.

Is there anything else to offer?

Personally, I don't think it's worth exposing someone to a platelet transfusion for a blood patch. I've seen patients die from platelet transfusions. And there's no evidence to indicate that platelet transfusions will prevent a spinal hematoma.

 

[The_Sensei]

Some advocate putting an abdominal binder on the patient. Not sure if it works or not. I agree with your management, however.

 

[armygas]

All we were able to offer was this: continue current management, bed rest, please call when PLT greater than 100, 000.

If it were my wife I would say, "sounds good!"

 

[rmh149]

Yup...PDPH will eventually go away.

 

[Noyac]

You could transfuse her but that would be awfully extreme.


But let me add to the problems. What if she started to complain of diplopia and tinnitus? Now how would you treat her.

 

[SleepIsGood]

Yup...PDPH will eventually go away.

Funny you mentioned this. PDPH are ridiculously hard to take care of at times. We just had a lady who is PPD #12 and still in mother baby because of PDPH. And she received a blood patch!

She's afraid as heck to get up because of the HA. Yes, the pain may go away but they take a while and just from seeing her everyday, it is not pleasant AT all.

 

[jetproppilot]

Good evening gentlemen,

I'll cut to the chase: 35 y.o. white female with acute myelogenous leukemia. Undergoes lumbar puncture by neurologists with instillation of intrathecal methotrexate as treatment. We're consulted four days later because patient has peristent headache suggestive of post-dural puncture headache (improves with lying down, aggravated by sitting up, non-thrombing in nature, diffuse across the back of the head and neck). Unfortunately, platelets are 50, 000 and dropping due to the methotrexate. No joy with caffeine and IV hydration and percocets.

All we were able to offer was this: continue current management, bed rest, please call when PLT greater than 100, 000.

Is there anything else to offer?

Personally, I don't think it's worth exposing someone to a platelet transfusion for a blood patch. I've seen patients die from platelet transfusions. And there's no evidence to indicate that platelet transfusions will prevent a spinal hematoma.

She's more than likely gonna get a platelet transfusion soon.

Just make sure your service follows her so you can do it then.

 

[VentdependenT]

You could transfuse her but that would be awfully extreme.


But let me add to the problems. What if she started to complain of diplopia and tinnitus? Now how would you treat her.

ketamine infusion for 3 days.😱

If you're getting focal symptoms then do a quick physical. Maybe its not just a PDPH after all eh? Meningitis can git ya too. Is an MRI too extreme? I don't think so.

If all is well then tough poop. The headache will subside. BTW, from what I've read, those symptoms can and do present with some PDPH's. I'd be more concerned with missing something serious however.

 

[Planktonmd]

Try Cosyntropin.

 

[CremeSickle]

The chances of transfusing platelets are high with a count on < 50K. Really, most do get one at that point.

I would give it a day, redraw the labs and if the plt didnt increase put her on plts then do the blood patch 24 hours later orso.

Otherwise, seems to me you were 100% in the right with management.

 

[BLADEMDA]

Try Cosyntropin.

Agree with Plankton. In my experience ONE patch doesn't always relieve the problem if the needle was large. Sometimes you need a second patch. Lately, about 10-15% of patients need a second patch.

In this case I would avoid a patch if at all possible. Plankton's suggestion is a good one. Several articles/case reports of Cosyntropin working well.

Anesthesiology V92 No.1 Jan 2000 Author: Carter, Bonny


Blade

 

[Calilove]

I'd suggest to just do a 2nd epidural blood patch. Epidural blood patch success rates:1st=95%, 2nd=99%... Also continue supportive management (Hydrate/ABD binder/Caffeine/Percocet/Supine). No MRI for now unless: #1 neurological status declines, #2 no resolution of symptoms after 2nd blood patch. And I agree, the headache will improve on its own!

 

[BLADEMDA]

I'd suggest to just do a 2nd epidural blood patch. Epidural blood patch success rates:1st=95%, 2nd=99%... Also continue supportive management (Hydrate/ABD binder/Caffeine/Percocet/Supine). No MRI for now unless: #1 neurological status declines, #2 no resolution of symptoms after 2nd blood patch. And I agree, the headache will improve on its own!

I don't agree on your numbers. First patch success rate more like 90%.
Second patch 95-98%. Recent data shows the First patch success rate isn't as good as many believe. My personal experience over the years bears that out. In addition, from the patient's perspective you need to be conservative on your numbers in order to explain effectively why a second patch may be needed.

Blade

 

[Noyac]

I'd suggest to just do a 2nd epidural blood patch. Epidural blood patch success rates:1st=95%, 2nd=99%... Also continue supportive management (Hydrate/ABD binder/Caffeine/Percocet/Supine). No MRI for now unless: #1 neurological status declines, #2 no resolution of symptoms after 2nd blood patch. And I agree, the headache will improve on its own!

You would do a blood patch with plts of 50K and dropping?

Wow, you must be in private practice with balls this big.