wet tap complications

[Gas you down]

had a lady with h/o difficult epidural placement come in for labor. previous birth, otherwise no real medical history. back was like mush, even the ligaments felt like they were giving way moreso than normal.
boom...wet tap (how embarrassing) so moved up a level and replaced.
next day. was up, walking around, taking baths, breastfeeding. no photophobia. sitting up in bed when i walked in. classic positional headache, but she says its manageable.
discharged on saturday (postpartum day 3).
called on sunday night, pt is in the ICU at another hospital due to seizures.

gotta go will finish later.

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[urge]

Puerperal Seizures After Post-Dural Puncture Headache.

SHEARER, VANCE E. MD; JHAVERI, HARISH S. MD; CUNNINGHAM, F. GARY MD

Conclusion: We propose that cerebral vasoconstriction is the mechanism for post-dural puncture headaces and seizures. Anatomic brain displacement may incite this vascospasm. This mechanism could also be the cause of cranial nerve palsies that have been described after dural puncture.

 

[Gas you down]

head CT showed cortical vein thromboses, which then underwent hemorrhagic conversion.

 

[Ipassgas]

Oh, man. That is no bueno.
Sorry to hear that. I'm not going to venture a guess as to a cause, but I'm not aware of any relationship between dual puncture, headache, and cerebral vascular thrombosis.

 

[pgg]

Thromboembolism is the #1 direct killer, beating out hemorrhage, early deaths (ectopics), hypertensive disorders, and sepsis.

I'm going to guess this patient's complication had absolutely nothing to do with the wet tap.

 

[twoliter]

I don't see a correlation between the wet tap and the cortical vein thrombosis. Though I'm a resident, so take that for what it's worth -- but at least I'm on the same side as everybody else. However, an attending did just read a case report to me a few days ago about a wet tap leading to a subdural hematoma. It's a little easier connecting those dots.

 

[Yangkower]

I wonder if she could have had an occult spina bifida resulting in the unusual feel of her back and easy wet tap? How that translates into thrombosis I'm not sure.

 

[RxBoy]

head CT showed cortical vein thromboses, which then underwent hemorrhagic conversion.

There is no direct relationship between wet tap and embolism. Pregnant pts are more prone to throwing clots.

One could make the argument that there was an indirect cause from the wet tap.
Wet tap->bed bound->stasis->embolism
But even that's a stretch.

 

[RxBoy]

There is no direct relationship between wet tap and embolism. .

So I ran a pubmed search. Interesting...

Abstract
Cerebral venous thrombosis rarely develops after lumbar puncture and spinal anesthesia with accidental dural puncture, however, occurrence of isolated cortical vein thrombosis after epidural anesthesia is extremely rare. We report three cases who developed postural headache and isolated cortical vein thrombosis after epidural anesthesia. We postulate that intracranial hypotension is the cause of compensatory venous dilatation and resultant thrombosis.

http://www.ncbi.nlm.nih.gov/pubmed/20504217

 

[urge]

Intracraneal hypotension is a plausible etiology for vein thrombosis, but implying casualty with just a few cases is quite a stretch.

 

[urge]

A few cases of CVT have been reported afterlumbar puncture (LP), suggesting a causal association. In a study by Canhao et al, LP induced a sustained decrease in mean blood flow velocity (BFV) in the straight sinus (SS), suggesting that the decrease in venous blood flow is a possible mechanism contributing to the occurrence of CVT. In the study, the investigators used transcranial Doppler ultrasonography to register the mean BFV of the SS before, during, and after LP. LP induced a decrease of 47% in mean BFV in the SS, with the mean decrease being significant immediately at the end, 30 min after, and more than 6 hours after LP.[3]

Perhaps, but there is not that much data.

 

[stonemd]

Venous thrombosis, not embolism
http://www.hindawi.com/journals/crim/2013/701264/
http://www.sciencedirect.com/science/article/pii/S0959289X08000022

 

[Gas you down]

So I ran a pubmed search. Interesting...

Abstract
Cerebral venous thrombosis rarely develops after lumbar puncture and spinal anesthesia with accidental dural puncture, however, occurrence of isolated cortical vein thrombosis after epidural anesthesia is extremely rare. We report three cases who developed postural headache and isolated cortical vein thrombosis after epidural anesthesia. We postulate that intracranial hypotension is the cause of compensatory venous dilatation and resultant thrombosis.

http://www.ncbi.nlm.nih.gov/pubmed/20504217

yeah I saw that one and a few more like it...small studies. personally, I don't need any more convincing, I think the wet tap resulted in the thrombosis. rare but it happens.
I've never had this cerebral vein thrombosis before, and the one time I get a wet tap it occurs 48 hrs later.
that made me pause to rethink sending a patient home after wet tap, even if they were doing well.

 

[Noyac]

Not an expert here but it sure seems plausible to me that the decreased intracranial pressure along with the somewhat hypercoagulable state of a postpartum pt could lead to this.

That's it, I never doing another labor epidural ( after 10pm ).

 

[narcusprince]

I would like to take a crack at this. Was this patient worked up for collagen vascular disease. I have seen something familiar to this. I suspected the patient had Ehlers Danlos syndrome, lax ligaments hyper flexibility, thrombosis. Sounds collagen vascular.

 

[smb4]

I would like to take a crack at this. Was this patient worked up for collagen vascular disease. I have seen something familiar to this. I suspected the patient had Ehlers Danlos syndrome, lax ligaments hyper flexibility, thrombosis. Sounds collagen vascular.

Excellent point and along these lines do you think anything else could be done differently to avoid such outcome? i.e. knowing previously difficult h/o epidural should other anesthetic options be used?
Just trying to learn from the best

 

[Noyac]

You wit til they hit 7-8 cm and pop a spinal in them and dose it like a CSE. That's taking a chance tho.
Just as you did, I probably would have taken the challenge head on.

But I was trained to inject 10cc sterile saline from the epidural tray intrathecally when a wet tap occurs. It cuts down the PDPH rates tremendously.

 

[neuroride]

What's the theory on injecting 10cc of normal saline intrathecally?

 

[Noyac]

What's the theory on injecting 10cc of normal saline intrathecally?

You need a theory? 😉

 

[Noyac]

Here's the study I was involved with:

http://www.ncbi.nlm.nih.gov/pubmed/11464346

 

[deleted59964]

lots of conflicting results, and small studies (understandably) ...
http://bja.oxfordjournals.org/content/105/3/255.full.pdf+html

Place I was at left intrathecal catheters in place for 24 hours ... I worry about the risk of medication administration error.

 

[Noyac]

Jobsfan, your avatar confuses me. Wtf?

 

[deleted59964]

she's an awesome Australian athlete.

 

[pgg]

Intracraneal hypotension is a plausible etiology for vein thrombosis, but implying casualty with just a few cases is quite a stretch.

I agree it's a stretch but I'd go even further. Cerebral vasodilation by definition slows flow, that tube radius math thing, but that's not really the same thing as stasis. Slow flow isn't no flow.

Vasodilation doesn't cause clots in normal people, else stroke would be a common complication of migraine headaches.

She was pregnant, that's all the reason se needs to have a thrombotic complication. I have a hard time wrapping my head around the wet tap causing an intravascular clot. The lawyers' hired gun expert witness will have no trouble making up a connection though.

 

[narcusprince]

So, posting some numbers regarding pdph injecting 10 ml of saline through the tuohy intrathecally decreased the incidence from 62% to 32%. Continuous epidural infusions have also been used however per the literature the symptoms resumed onced the infusion was discontinued. The question here is do you prophylactically blood patch the patient? And what patient related risk factors in young healthy pregnant patients do we need to use as a trigger for prophylactic blood patch. If the patient has had a h/o of headache in the past? I would prophylactically patch a patient with previous h/o of pdph with documented wet tap, in whom I wet tapped, h/o seizure disorder as with a documeted wet tap I would patch. This is an area of our practice that needs to be developed.

 

[Noyac]

Personally I wouldn't prophylactically place a EBP. I believe the effectiveness of this is diminished. I wait for them to develop symptoms.