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