Viral meningitis and blood patch

[Yo GabbaPentin]

21 yr old physicians kid comes in with viral meningitis, discharged yesterday. Comes in to clinic demanding a blood patch because the continued HA MUST be from the LP. I'm kind of inclined to let that whole viral meningitis thing clear up a little more and revisit this later. Thoughts?

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[SSdoc33]

21 yr old physicians kid comes in with viral meningitis, discharged yesterday. Comes in to clinic demanding a blood patch because the continued HA MUST be from the LP. I'm kind I inclined to let that whole viral meningitis thing clear up a little more and revisit this later. Thoughts?

The headache IS probably from the LP. I wouldn't do the blood patch, as there is a higher likelihood of bacterial superinfection. Risk is still very low, but I would not do the patch. Tell him to drink some red bull

 

[Yo GabbaPentin]

The headache IS probably from the LP. I wouldn't do the blood patch, as there is a higher likelihood of bacterial superinfection. Risk is still very low, but I would not do the patch. Tell him to drink some red bull

I agree that it probably is from the LP, but I'm not sure the juice is worth the squeeze regarding the blood patch. Would hate for any other crazy things that could happen to be blamed on that evil blood patch.

 

[emd123]

Why isn't the headache from the meningitis? Isn't that what got him an LP in the first place, because he went to the ER with a headache to begin with?

So he's got two reasons to have a headache:

1-PDPH and
2-viral meningitis.

Do a blood patch, and guess what, he'll still have a headache from the viral meningitis! There's no point, not to mention sticking a needle in the spine of someone with a viral infection and converting their meningitis to meningio-encephalitis.

Terrible idea.

 

[pastafan]

21 yr old physicians kid comes in with viral meningitis, discharged yesterday. Comes in to clinic demanding a blood patch because the continued HA MUST be from the LP. I'm kind of inclined to let that whole viral meningitis thing clear up a little more and revisit this later. Thoughts?

Is the headache positional? Any diplopia or nausea? Would be nice if it isn't PDPH.

 

[Jcm800]

i get this call weekly. ID will actually come in and say "clear for blood patch" patient is on anti-viral medications...

i refuse ever time. I think it is crazy talk. And yes, the headache FIRST, who is to say it still isnt from the headache.

 

[Ducttape]

i get this call weekly. ID will actually come in and say "clear for blood patch" patient is on anti-viral medications...

i refuse ever time. I think it is crazy talk. And yes, the headache FIRST, who is to say it still isnt from the headache.

thats actually a good response.

"Please confirm that the underlying process that required the initial lumbar puncture has been resolved, and the preexisting headache will not complicate the post-procedural evaluation regarding the efficacy of the elective blood patch."

 

[Doctodd]

It's gotta be a different type of headache, and has to be positional for it to be PDPH.

 

[bedrock]

It's gotta be a different type of headache, and has to be positional for it to be PDPH.

But, you have to be careful regarding the definition of "positional". Almost everyone with a generic headache will say it feels better lying down than standing up.

Inquiring about how severely the symptoms change, and how quickly, is often overlooked by most physicians outside of pain and neurology.

 

[clubdeac]

This has nothing to do with meningitis, just a blood patch question. Didn't want to start a new thread. Anyone see any problem doing a blood patch caudally through the sacral hiatus? Guys lumbar spine is sliced and diced and really no entry point at all. I tried at L1-2 but he was too hypersensitized in the area

 

[pastafan]

This has nothing to do with meningitis, just a blood patch question. Didn't want to start a new thread. Anyone see any problem doing a blood patch caudally through the sacral hiatus? Guys lumbar spine is sliced and diced and really no entry point at all. I tried at L1-2 but he was too hypersensitized in the area

Not if you use a catheter and thread as high as possible. Blood patches are almost 100% successful if a large volume, 20cc, of blood is used. I remember papers from a long time ago comparing success rate to volume utilized. If you use a small volume to distal to the insult I would think that the probability of success declines significantly.

 

[bedrock]

This has nothing to do with meningitis, just a blood patch question. Didn't want to start a new thread. Anyone see any problem doing a blood patch caudally through the sacral hiatus? Guys lumbar spine is sliced and diced and really no entry point at all. I tried at L1-2 but he was too hypersensitized in the area

You could but why not get a bit closer and just do a bilateral S1? I've done that for a patient with diffuse laminectomies and it worked.

 

[lobelsteve]

If mechanism is increased pressure in epidural space, who cares if you are close or not. For PDPH in C-spine, we still go at L2-3 with 15cc blood.

 

[Ducttape]

If mechanism is increased pressure in epidural space, who cares if you are close or not. For PDPH in C-spine, we still go at L2-3 with 15cc blood.

Anesthesia & Analgesia. 2011; 113; 6

Cousins et al.2 suggested that placement of the EBP close to the site of CSF leakage is important. The proposed mechanism is that the injected blood seals the dural defect and stops the leakage. The other theory is that the injected blood causes an epidural tamponade effect over the leakage site. It would seem sensible to target the treatment at the site of the leakage to maximize the chances of success, but there is no clear evidence to support targeted EBP, and randomized clinical trials are unlikely to be feasible given the low incidence of the condition.

CONCLUSION
Low CSF pressure headache due to spontaneous leakage has become increasingly recognized by neurologists resulting in increased referral to anesthesiologists for EBP. The availability of RC imaging clarifies the diagnosis and allows identification of the leakage site. This case series supports the view that performing EBP at the site of suspected leakage is more effective. The use of fluoroscopy to assist in identifying the spinal level can be useful especially when performing EBP at cervical or thoracic levels, and this may reduce the risk of serious complications.

 

[clubdeac]

You could but why not get a bit closer and just do a bilateral S1? I've done that for a patient with diffuse laminectomies and it worked.

Really? Did you inject through a 22g? I think that would be tough and did the patient complain of S1 radicular pain after injecting that high a volume through S1? How much did you inject per side? And thanks everyone for the insight

 

[lobelsteve]

Anesthesia & Analgesia. 2011; 113; 6

http://onlinelibrary.wiley.com/doi/10.1111/papr.12168/references
http://journals.lww.com/ejanaesthes...actions_mechanism_of_lumbar_epidural.275.aspx

Cat skinned 3 ways. I do not think the plug is the best answer, I think it is the pressure differential.

 

[Ducttape]

Or maybe not...

http://www.ncbi.nlm.nih.gov/m/pubmed/22528279/

AuthorsFichtner J, et al. Show all Journal
Neurocrit Care. 2012 Jun;16(3):444-9. doi: 10.1007/s12028-012-9702-4.

Affiliation

Lack of increase in intracranial pressure after epidural blood patch in spinal cerebrospinal fluid leak.

CONCLUSION: A shift of CSF from the spinal to the cranial compartment with a subsequent rise in ICP might not be a beneficial therapeutic mechanism of spinal epidural blood patching.

Sorry doing this from my phone so I can't capture article well...

 

[clubdeac]

Did the caudal blood patch today. Headache gone upon discharge! First time he's been headache free since his surgery in July and 3 subsequent attempts at dural repair and blood patch