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    2882survey bg 2882survey bg Presentation Transcript

    • SURVEY OF TURKISH PRACTICE EVALUATING THE MANAGEMENT OF POSTDURAL PUNCTURE HEADACHE IN THE OBSTETRIC POPU L ATION Berrin Günaydın, MD, PhD Department of Anesthesiology Gazi University Faculty of Medicine ANKARA-TURKEY
    • GAZI UNIVERSITY FACULTY OF MEDICINE
    •  
    • Background
      • S urveys and meta-analysis concerning the management of PDPH in the obstetric population have been published
        • Choi et al. Examining the evidence in anaesthesia literature: a survey and evaluation of obstetrical Postdural puncture headache reports. Can. J. Anesth., 49 , 49–56, 2002.
        • Baraz and Collis . The management of accidental dural puncture during labour epidural analgesia: a survey of UK practice. Anaesthesia, 60 , 673-679, 2005.
    • Aim
      • Primarily to determine the current practice in the management of PDPH in a small sample reflecting roughly the commonly preferred approaches
      • S econdly to provide awareness of the responders with this particular entity
    • Methods
      • Q uestionnaire including 24 questions similar to Baraz and Collis’s were given to the participants
      • Participants were asked to submit their surveys either to the surveyors or send it via e-mail to the contact person later
      • Microsoft Excel® software was used for data analysis
      • Results were presented as n and/or %
    • Questionnaire
    • Results
      • 78 out of 111 surveys returned
      • (R esponse rate was 70% )
      • The responders consisted of
        • 21 (26.92%) residents
        • 25 (32.05%) fellows
        • 21 (26.92%) academic staff
        • 11 (14.10%) did not identify any degree
    • Results
      • Rate of audit ing inadvertent dural puncture during labour or cesarean was 35%
      • H aving written guidelines for the management of accidental dural puncture
        • Yes: 10%
        • N: 64%
        • U nder the process of writing : 4%
        • No reply : 22%
      50% stated that it was necessary at the end of the survey
    • Prophylactic measures to prevent PDPH following recognized accidental dural puncture
      • During delivery
      • No thing ( 19.2% )
      • Others (80.8%)*
        • Leave spinal catheter for 24 h
        • Avoid pushing
        • Variable
        • Limit 2nd stage
      • After delivery *
      • F luid intake and/or p aracetamol/NSAID/codeine (59 -81 %)
      • Blood injection before catheter removal (10%)
      • Epidural c rystalloid infusion before catheter removal (19%)
      • Prophylactic blood patch within 24 h of delivery (12%)
      • Variable (15%)
      * one or more of the options have been chosen
    • Results - During delivery
      • When accidental dural puncture during epidural insertion was recognized
        • epidural catheter was left in situ to use as a spinal catheter (36%)
      • Kuczkowski K.M., Decreasing the incidence of post-dural puncture headache: an update. Acta Anaesthesiol. Scand., 49, 594, 2005.
        • or
        • e pidural catheter was re-sited at a different level (64%)
      • Gunaydin and Karaca . Prevention strategy for PDPH. Acta Anaesth. Belg., 57, 163-165, 2006.
    • Possible reasons for using an epidural catheter as an intrathecal catheter
      • No recommendation (62%)
      • Possible reasons according to preferance order (38%)*
        • Allow immediate analgesia for labour
        • Avoid another dural puncture
        • Reduce the incidence and/or severity of PDPH
        • Only in difficult cases ( e.g. obesity & multiple attempts )
      • Kuczkowski K.M., Post-dural puncture headache in the obstetric patient: an old problem. New solutions. Minerva Anestesiol., 70, 823-830, 2004.
      • Kuczkowski and Benumof . Decrease in the incidence of post-dural puncture headache: maintaining CSF pressure. Acta Anaesthesiol. Scand., 47, 98-100, 2003.
      * one or more of the options have been chosen
    • Results - After delivery Non-invasive methods for PDPH treatment
      • In addition to the encouragement of fluid intake and/or p aracetamol/NSAID/codeine
        • Caffeine (oral/iv)
        • Theophylline (oral)
        • IV hydrocortisone
        • IM ACTH
        • SC sumatriptin
        • Strong opioids
    • Ambulation after delivery following accidental dural puncture
      • A s early as possible : 7%
      • Bed rest : 6 h (3%) , 12 h (15%) or 24 h (36%)
      • No idea : 49%
    • Methods routinely used for PDPH treatment
      • 1st option is the c onservative treatment
      • Blood patch was mostly preferred after failed conservative treatment
      • Blood patch as soon as PDPH diagnosed is less preferred
      • D ifferent measures can be selected
        • History ( Gormley 1960, DiGiovanni & Dunbar 1970 )
        • Mechanism of action
          • Plug theory
          • C lot is formed by injecting  1 5 -20 m l autologous blood in the epidural space to provid e adherence to the dura mater and directly patch es the hole
          • Pressure patch hypothesis
          • V olume of blood injected into epidural space increases CSF pressure leading to reduction in the traction of the pain sensitive brain structures
      Epidural Blood Patch ( EBP )
    • EBP
      • Contraindications
      • Infection on the back
      • Sepsis
      • Coagulopathy
      • Raised white cell count
      • Prexia
      • Patient refusal
      • Timing
      • B eyond 24 h after dural puncture
      • R ecumbent positioning
      • For 2 h after patching may improve the efficacy
    • EBP
      • C omplication rate is rare
      • ~ 35% backache
      • S uccess rate is ~ 94% (70-98%)
        • 90% initial relief
        • 61-75% persistent relief
      • Repeat EBP has a similar success rate
      • R everse compl i cations of dural pu n cture
    • Treatment
      • I t is recommended not to delay EBP more than 24 h after the diagnosis of severe PDPH
    • EBP
      • Mostly performed in the recovery room
      • Sometimes in the labour ward
      • Rarely in the patient’s room
      • Generally performed with the help of a resident or a staff member
      • Rarely performed by one person
      Gunaydin et al. Acta Anaesthesiol Belg 2008
    • EBP
      • Intravenous access before EBP (69%)
      • ECG (58%)
      • Blood pressure (65%) and
      • Pulse oxymeter (63%) were performed by the majority of the responders
      Gunaydin et al. Acta Anaesthesiol Belg 2008
    • Advices at discharge after a successfull EBP
      • Discharge
        • After EBP 1 (4%), 2 (15%) or 3-6 hours (44%)
      • Follow-up
        • Before full mobilization 2 (47%) or 4 hours (23%) of bed rest
        • Increase fluid intake
        • Keep intervention side clean
        • Contact whenever headache reoccurs and report fever, weakness or numbness
      Gunaydin et al. Acta Anaesthesiol Belg 2008
    • After an unsuccessfull EBP
      • Rate of never considering another EBP (36%)
      • Rate of repeating EBP (37%)
      • No recommendation (27%)
      • If two EBPs were unsuccessfull, further investigations were considered (63%)
      Gunaydin et al. Acta Anaesthesiol Belg 2008
    • Conclusion
      • According to the present survey, re-siting epidural catheter at a different intervertebral space or using epidural catheter as an intrathecal catheter was preferred for the prevention of PDPH in case of recognized accidental dural puncture
      • N on - i n vasive methods consisting of encouragement of fluid intake and drugs were routinely used for the treatment of PDPH
    • Conclusion
      • Although these results showed the current practice of this small sample, in order to follow the change in these strategies and to catch almost a standard approach for the prevention and management of PDPH , further surveys including most of the centers are required.
    • Thank you