serial LP's & PDPH

[DOme2009]

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so i'm on medicine wards and we have a pt with cryptococcal meningitis who potentially needs daily LP's for 14 days. we marked the spot used for the first successful LP and haven't had any problems since (3 LP's total - all via same level, L4-L5). however, she has started complaining of headaches and i don't know whether it's PDPH or increased ICP (LP today had an OP>45 mmHg, so today it was increased ICP). i tried searching for serial LP's and the incidence of PDPH when alternating levels for the LP but no luck, anyone have any experience/input?

 

[Eta Carinae]

FWIW,

Cryptococal meningitis itself is independently associated with ICP(especially in the setting of AIDS), hence, could be responsible for the slightly elevated OP, as such your daily LP’s might paradoxically be therapeutic. Also she does have meningitis, and so the headache is to be expected (?)


My questions are
1.whether or not she has been experiencing headaches all along without complaining.
2. whether her headaches are positional: from what I’ve read so far, PDPH should dissipate in the supine position

For PDPH, I would have expected a lower OP (5-10 cm H2O). That being said, the rate of CSF loss could be influencing her sxs.
In addition, the incidence of PDPH is not influenced by level of puncture but by:
i. needle gauge
ii. bevel direction (parallel to longitudinal fibres of dura associated with decr. Incidence)
iii. Rate/amt of CSF depletion (onset of HA at 15-20mL loss)
iv. uncontrollables: age (r = -1 correlation with age), sex (higher incidence in females)
A Rational Approach to the cause, prevention and treatment of postdural puncture headache.
Morewood G.H. CMAJ. 1993 October 15; 149 (8): 1087-1093.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1485491/pdf/cmaj00276-0033.pdf


Isn’t daily LPs for 14 days kind of excessive? From what I’ve seen, antigen levels in CSF after 2 weeks and 10 weeks have been used in the past as markers of treatment response.
Treatment of Cryptococcal Meningitis
Larsen R. A., Zingman B. S., Saag M. S., Cloud G. A., van der Horst C.
N Engl J Med 1997; 337:1557-1558, Nov 20, 1997.
http://content.nejm.org/cgi/content/abstract/337/1/15

Disclaimer: no experience here, just literature. so please feel free to TIWAGOS.

 

[Planktonmd]

At this point I would not worry about PDPH and concentrate on treating the meningitis because even if she has PDPH I don't think you should do a blood patch now especially that you are planing on doing 11 more LPs !
Once that treatment is deemed successful and the patient continues to have positional headache (maybe in a couple of months), then this can be addressed.
In the mean time treat her headache symptomatically.

so i'm on medicine wards and we have a pt with cryptococcal meningitis who potentially needs daily LP's for 14 days. we marked the spot used for the first successful LP and haven't had any problems since (3 LP's total - all via same level, L4-L5). however, she has started complaining of headaches and i don't know whether it's PDPH or increased ICP (LP today had an OP>45 mmHg, so today it was increased ICP). i tried searching for serial LP's and the incidence of PDPH when alternating levels for the LP but no luck, anyone have any experience/input?

 

[veetz]

so i'm on medicine wards and we have a pt with cryptococcal meningitis who potentially needs daily LP's for 14 days. we marked the spot used for the first successful LP and haven't had any problems since (3 LP's total - all via same level, L4-L5). however, she has started complaining of headaches and i don't know whether it's PDPH or increased ICP (LP today had an OP>45 mmHg, so today it was increased ICP). i tried searching for serial LP's and the incidence of PDPH when alternating levels for the LP but no luck, anyone have any experience/input?

Are her headaches positional? (ie worse in upright position v. improved in supine position)

 

[DOme2009]

i was told by my upper level resident that she gets daily LP's as long as she has HA/N/V/blurry vision. at two weeks, if symptoms persist, we can ask neurosurgery to place an LP drain.

and her HAs haven't been relieved supine but they are worse upright (so positional HA but not really c/w PDPH). i guess for now, like plank said, we should just worry about treating her meningitis and we can consult acute pain for a blood patch later down the line if it's still a problem once her OP has normalized and she's gotten her 2 weeks of amphoterrible.


but is it ok to use the same site of insertion for serial LPs? i couldn't find anything in the literature that says you should avoid using the same site multiple times over a couple weeks (btw, she has no overlying skin infections, no coagulopathy, and she's fairly thin = decent landmarks. i don't mind trying a level above but with the marked spot, i have a sure thing).

 

[Bertelman]

i was told by my upper level resident that she gets daily LP's as long as she has HA/N/V/blurry vision. at two weeks, if symptoms persist, we can ask neurosurgery to place an LP drain.

and her HAs haven't been relieved supine but they are worse upright (so positional HA but not really c/w PDPH). i guess for now, like plank said, we should just worry about treating her meningitis and we can consult acute pain for a blood patch later down the line if it's still a problem once her OP has normalized and she's gotten her 2 weeks of amphoterrible.


but is it ok to use the same site of insertion for serial LPs? i couldn't find anything in the literature that says you should avoid using the same site multiple times over a couple weeks (btw, she has no overlying skin infections, no coagulopathy, and she's fairly thin = decent landmarks. i don't mind trying a level above but with the marked spot, i have a sure thing).

If she's getting 14 sticks, I don't understand how you will be able to avoid prior sites unless you march up to C6-7.

 

[pgg]

Are you using 22 gauge cutting needles like those barbarians in the ER?

 

[narcusprince]

Are you using 22 gauge cutting needles like those barbarians in the ER?

Funniest Post of the week!!

 

[tkim]

Are you using 22 gauge cutting needles like those barbarians in the ER?

We only use those if we run out of the 18s.