Post-dural puncture headache

R. Sharma1, A. Bailey1, J. Bamber1 and D. K. Turnbull2

1 Cambridge, UK 2 Sheffield, UK

Editor—In their recent review article on post-dural puncture headache, Turnbull and Shepherd1 recommend that blood cultures should be taken whilst performing a blood patch. We disagree with this recommendation as there is little evidence to support it and it is not common practice in many units. Complications of autologous epidural blood patch (EBP) are low. The yield of positive blood cultures in apyrexial patients with no indicators of sepsis would be very small, and is likely to be much less than the number of false positives that would occur because of contaminants.2 3

A recent UK national survey found that only 46% of centres routinely performed blood cultures at the time of performing EBP.4 In those units that performed blood cultures, less than half of the respondents took further action, such as prescribing antibiotics for inpatients and informing the GP for discharged patients, if the blood culture was positive but the patient was asymptomatic. Similarly, a North American survey found that, out of 36 obstetric centres, only one routinely performed blood culture before an EBP.5 We would therefore suggest that rather than routinely performing blood cultures at the time of EBP, there should be a thorough clinical evaluation of the patient to look for evidence of sepsis and strict adherence to an aseptic technique. Information should be provided to the patient after an EBP so that medical advice is sought early if the symptoms and signs of epidural space infections occur.

In the context of obstetric practice, we also disagree with the recommendation that an intrathecal catheter should not be inserted after accidental dural puncture. If a dural puncture is recognized at the time of insertion of the Tuohy needle, it would seem reasonable to attempt to insert the catheter through the needle. This avoids additional delay in providing analgesia and also avoids the risk of a further dural puncture as a consequence of resiting the epidural. It may also reduce the risk of a high block occurring when epidural analgesia is converted to epidural anaesthesia in the presence of a dural puncture.6 Retrospective studies have shown a statistically significant reduction in the incidence of post-dural puncture headaches and the need for EBP after accidental dural puncture if an intrathecal catheter is used and left in situ.7 8 Prospective studies are needed and our unit is participating in a multicentre randomized controlled study to compare repeat epidural with intrathecal catheter placement. The neurological complication of cauda equina syndrome has been associated with spinal microcatheters and using high concentrations of hyperbaric lidocaine.9 Use of a macrocatheter and low concentrations of plain bupivacaine solutions in the obstetric unit for spinal analgesia has not been associated with major neurological complications. The risk of infection with spinal catheters is low. A large retrospective review of 603 continuous spinal anaesthetics reported only one case of aseptic meningitis.10 In contrast, there are numerous case reports of epidural abscesses and infections associated with epidural catheters. Nevertheless, use of spinal catheters also requires diligence and adherence to guidelines for their safe use, particularly on the obstetric unit.

R. Sharma

A. Bailey

J. Bamber

Cambridge, UK

Editor—In reply to the points raised by Drs Sharma, Bailey and Bamber, the taking of blood cultures at the time of the epidural blood patch is a controversial topic amongst obstetric anaesthetists.11 That it is not common amongst North American anaesthetists5 does not imply it is poor practice. The incidence of epidural abscess related to epidural blood patch is unknown. Unfortunately, this facet of care is not well studied. There is no evidence therefore, to inform clinical decision-making.12 The authors may well be correct in their assertion that it is futile, but in the absence of evidence, the clinician should exercise their own judgement.

The authors assert that it is a pragmatic approach to place an intrathecal catheter through the Tuohy needle in the case of dural puncture in the parturient. Though pragmatic, this is also a controversial issue amongst obstetric anaesthetists.13 However, the case I was making was that there is no evidence that this approach makes post-dural puncture headache less likely.

D. K. Turnbull

Sheffield, UK

References

1 Turnbull DK, Shepherd DB. Post-dural puncture headache: pathogenesis, prevention and treatment. Br J Anaesth 2003; 91: 718–29[Abstract/Free Full Text]

2 Stalnikowicz R, Block C. The yield of blood cultures in a department of emergency medicine. Eur J Emerg Med 2001; 8: 93–7[Medline]

3 Shifman RB, Strand CL, Meier FA, Howanitz PJ. Blood culture contamination: a College of American Pathologists Q-Probes study involving 640 institutions and 49 7134 specimens from adult patients. Arch Pathol Lab Med 1998; 122: 216–21[ISI][Medline]

4 Sharpe P, Asif M. Blood cultures and epidural blood patches? A national survey of clinical practice. Int J Obstet Anaesth 2002; 11: 5

5 Berger CW, Crosby CW, Grodeck W. North American survey of the management of dural puncture during labour analgesia. Can J Anaesth 1998; 45: 110–14[Abstract]

6 Cook TM. Combined spinal–epidural techniques. Anaesthesia 2000; 55: 42–64[CrossRef][ISI][Medline]

7 Samaan A, Russell IF. Management of accidental dural punctures with subarachnoid catheters. Anaesthesia 1993; 48: 451

8 Segal S, Lawrence CT, Datta S. Intrathecal catheter insertion following unintentional dural puncture reduces the requirement for epidural blood patch. Anesthesiology 1999; 90: (Part 4 Supplement) A69[CrossRef]

9 Denny NM, Selander DE. Continuous spinal anaesthesia. Anaesthesia 1998; 81: 590–7

10 Horlocker TT, McGregor DG, Matsushige DK, Chantigian RC, Schroeder DR, Besse JA. Neurological complications of 603 consecutive continuous spinal anesthetics using microcatheter and macrocatheter techniques. Anesth Analg 1997; 84: 1063–70[Abstract]

11 Anwari JA. Epidural blood patch (EBP) and septic complication. Can J Anaesth 2000; 47: 289[Free Full Text]

12 Duffy P, Crosby ET. Epidural blood patch (EBP) and septic complication (reply). Can J Anaesth 2000; 47: 289[Free Full Text]

13 Russell I. In the event of accidental dural puncture by an epidural needle in labour, the catheter should be passed into the subarachnoid space. Int J Obstet Anaesth 2002; 11: 23–5





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