1) The study investigated the effect of administering cosyntropin after accidental dural puncture on the incidence of post-dural puncture headache and need for epidural blood patch. 2) 95 women who experienced accidental dural puncture during epidural analgesia for childbirth were included in the study. 3) The results showed a significant reduction in the incidence of post-dural puncture headache and need for epidural blood patch with cosyntropin administration, but it did not influence the duration or severity of headaches in those who still developed headaches.

1. Cosyntropin for Prophylaxis against Postdural Puncture Headache after Accidental Dural Puncture Department of Anesthesiology, Faculty of Medicine, Ain Shams University, Cairo, Egypt Anesthesiology :August 2010 Sheeba Hakak.

2. Aim of Study Investigate the effect of administration of cosyntropin after accidental dural puncture (ADP) on the incidence of post-dural puncture headache (PDPH) and the need for therapeutic epidural blood patch (EBP). A secondary aim was to study the effect of this intervention on the severity of PDPH and the need for repeat EBP.

3. Background Incidence of inadvertent dural tap at attempted epidural placement in obstetric patients is 0.4–6%. 75–86% of the incidents are complicated by postdural puncture headache . Associated with a significant increase in the hospital length of stay. Role of prophylactic administration cosyntrophin on PDPH is unclear.

4. Cosyntrophin in PDPH Precise mechanism of action not known. ACTH stimulates aldosterone release. Increased CSF production. ACTCH interaction with opioid receptors. Specific dose .Not known.

5. Material and Method 95 parturients, who had epidural analgesia for normal vaginal delivery and who suffered an inadvertent dural tap, were included in this study. Exclusion criteria were contraindication to steroid or ACTH therapy ( e.g., hypertension or diabetes mellitus), preeclampsia, or contraindication to EBP (e.g., fever or leukocytosis).

6. Technique of Epidural block Anaesthesiologist. 16 or 18 g Needle. Sitting or lying down. Loss of resistance to saline. Median or paramedian approach. Site of block. Dural Tap……… Withdraw needle and try epidural at other space. Catheter threaded 3 cm into the epidural space and tested with 3 ml of 2% lidocaine with 1:200,000 epinephrine. Loading dose of 8–15 ml of 0.125% bupivacaine and 50 μg of fentanyl . Infusion of 0.125% bupivacaine with fentanyl 2 μg/ml at a rate of 8–15 ml/h.

7. Diagnosis of post dural puncture headache Headache within 5 days after dural puncture, which worsened within 15 min of sitting or standing, and improved within 15 min after lying, with at least one of the following criteria: neck stiffness, tinnitus, hypacusia, photophobia, or nausea. Patients who did not develop PDPH for 48 h after ADP and who were ambulating normally were discharged from the hospital with the instruction to come back for reassessment if they experience any headache.

8. Management of acute dural puncture Patient admitted to hospital for 48 hrs. Patient to report headache and encouraged to ambulate ,take plenty of fluids and stool softners prescribed. Headache inquired every 8hrs.

9. Management of post dural puncture headache Conservative management for 48hrs. Fluids/NSAIDS/ Mepireden. Epidural blood patch. Redo epidural blood patch if no improvement within 24 hrs of blood patch. Patients followed up for 14 days post blood patch.

10. Results

17. Conclusion Significant reduction in the incidence of PDPH and the need for EBP. Significant prolongation of the time from ADP to occurrence of PDPH. No influence either the duration or the severity of the headache. In patients who developed PDPH, prophylactic administration of cosyntropin did not seem to influence the need of either EBP or repatching.