Post Dural Puncture Headache--clinical scenario.

[sevo85288]

30 y/o healthy pt with scoliosis had labor epidural with dural punture with 17G touy. Had PDPH 3 days out treated with blood patch. (19ml) Headache free for two days, headache returns. Had 2nd blood patch, (16 ml, back pain) headache free for 1 day, headache returns. Now I will send her to neurologist for eval and possible CT guided blood patch ??? Any other ideas???

I know the literature says that 99% of headaches will naturally go away by 30 days.....but any ideas why the blood patches are failing....and what else should I be considering...The headache is postural, has assoc. photophobia and visual changes.....classic. Any advice is appreciated. (ps. she is currently on fiorcet, fluids, etc..)

SEVO

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[toughlife]

30 y/o healthy pt with scoliosis had labor epidural with dural punture with 17G touy. Had PDPH 3 days out treated with blood patch. (19ml) Headache free for two days, headache returns. Had 2nd blood patch, (16 ml, back pain) headache free for 1 day, headache returns. Now I will send her to neurologist for eval and possible CT guided blood patch ??? Any other ideas???

I know the literature says that 99% of headaches will naturally go away by 30 days.....but any ideas why the blood patches are failing....and what else should I be considering...The headache is postural, has assoc. photophobia and visual changes.....classic. Any advice is appreciated. (ps. she is currently on fiorcet, fluids, etc..)

SEVO

Why not caffeine IV to begin with before the blood patch? Also, when doing the epidural did you use air or saline for LOR? If you used air, don't forget to rule out the possibility of pneumocephalus with head CT.

 

[Mman]

tried cosyntropin yet?

 

[refmem]

Low probability, but may consider cerebral venous sinus thrombosis (since pregnant and hypercoag) or posterior reversible encephalopathy syndrome (if any history of pre-eclampsia with the pregnancy). If you spat on your needle consider arachnoiditis. Im sure the screaming baby isn't helping either. Ten dollars for the neuro consult. Can't wait to do gas next year.

 

[Planktonmd]

Bed rest, hydration and time!

 

[Noyac]

Why not caffeine IV to begin with before the blood patch? Also, when doing the epidural did you use air or saline for LOR? If you used air, don't forget to rule out the possibility of pneumocephalus with head CT.

I find caffeine to be of little use. How about you?

 

[Planktonmd]

I had some success with Sumatriptan (Imitrix) in the past although the data is not too impressive.

 

[Gern Blansten]

Once she gets an effective blood patch, instruct her that she should not lift anything heavier than a milk carton for ~1 week or it could return(hard to comply with a new baby at home). I agree with the further testing to rule out more ominous problems. I too have heard of sumatriptan's occasional effectiveness though it is not support in the literature. In a refractory case, I believe I would try it. Like Noyac, I usually go straight to patch and skip the caffeine. It rarely is completely effective and seems to only delay definitive therapy.

 

[The_Sensei]

I find caffeine to be of little use. How about you?

Worthless and for the lazy who do not want to do an EBP.

 

[toughlife]

I find caffeine to be of little use. How about you?

I've seen it work with patients on the floor. Issue is that I've had to repeat the infusion as the relief is not permanent with only one dose.


This particular patient already had blood patches with no resolution. So why not give caffeine a try?

I'd like to know what the head CT showed.

 

[sevo85288]

I am waiting to see what the neurologist finds. I am willing to consider consyntropin, many anecdotal reports of effectiveness and minimally invasive. Anyone have first hand experience with cosyntropin. I was thinking of giving 500 mcg (7ug/kg) in one litre of normal saline over 6 hrs....I'll let you guys know how things turn out.

 

[Mman]

Cosyntropin can be of some effectiveness, though not nearly as good as the EBP in my experience. I've seen a few people, though, that had fairly severe PDPH have significant relief after a 500 mcg infusion. And it is noninvasive which patients tend to agree to much more easily than another epidural procedure.