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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