cefalea postpunción parturienta 2007
TRANSCRIPT
-
8/3/2019 cefalea postpuncin parturienta 2007
1/3
Obstetrics
ANAestHesiA AND iNteNsiVe cAre MeDiciNe 8:8 309 2007 elv Ld. All gh vd.
Post-dral ptrada i t partritMhl Hndk
Gay M sok
Abstrat
th oun o po-dual punu hadah (PDPH) a adn-
al dual punu n h o pan a dlang ondon.
claal PDPH poual n nau and may aoad wh phoo-
phoa, nk n, and naua and vomng. PDPH a dagno o
xluon and mu dnguhd om oh au o popaum
hadah. Vaou pvnav mau hav nludd hadng o an
nahal ah va a tuohy ndl, njon o nahal aln
a h m o punu and pophyla pdual lood pah (ebP).Managmn opon am o al h dual punu , onol al
vaodlaaon and o csF volum. convav amn nlud
, hydaon and h ppon o mpl analga, u h ma-
u do no han h oluon o h hadah, no do hy du
h qumn o pdual lood pahng. Phamaologal amn
nlud al vaoono uh a an, umapan, and
adnoooop homon, whh hough o na csF podu-
on. th dug do no pvn h nd o ebP u may gv ymp-
oma l. ebP h gold andad o PDPH amn, u h
da aou whn hould don and how muh lood o nj.
th pa a mo un o dlay ebP o 2448 hou and nj
appoxmaly 20 ml o lood, u o op njng h pan xp-
n akah. Long-m omplaon o ebP a a and h noonandaon o uqun pdual analga.
Kywords adnal dual punu; anah hnqu; ompla-
on; pdual lood pah; po-dual punu hadahPost-dural puncture headache (PDPH) is the most requent com-
plication o central neuraxial blockade. It is a debilitating con-
dition, especially in the parturient, but prompt diagnosis and
management can treat it and prevent rare but serious sequelae.
Symptoms ad diaosisNormally PDPH is experienced in the rontal or occipital regions and
develops 2448 hours ater dural puncture. It is postural in nature,
worsening when changing position rom supine to sitting and by
Michele Hendricks, FRCA, is Specialist Registrar in anaesthesia at
Queen Charlottes and Chelsea Hospital, London.
Gary M Stocks, FRCA, is Consultant anaesthetist at Queen Charlottes
and Chelsea Hospital, London. He qualifed at St Georges Hospital,
London, and trained in anaesthesia in London. His specialist interest
is obstetric anaesthesia.
coughing or straining. It may be associated with nausea, vomiting,
neck and shoulder stiness, hearing alteration, and visual distur-
bances, such as photophobia. Rare presentations include cranial
nerve palsy, convulsions and subdural haemorrhage.
Other common and serious causes o postpartum headache
(Table 1) should be considered beore a denitive diagnosis o
PDPH is made.
Patopysioloy
The cause o PDPH is not known, but the loss o CSF through the
dural tear causes cranial hypotension. This may result in head-
ache by the ollowing mechanisms:
traction on the intracranial structures that are pain sensitive
reduced CSF volume, causing compensatory cerebral
vasodilatation
sudden loss o CSF, which activates adenosine receptors,
causing cerebral vasodilatation.
Iid
Because o the obstetric patients youth and gender,1 the inci-
dence o PDPH ater accidental dural puncture with a 1618GTuohy needle is as high as 75%. Choice o spinal needle is also
an important determinant o PDPH incidence. The use o 27G
pencil-point Whitacre needles can reduce PDPH rates to as low
as 0.37% in non-obstetric patients.2
Prvtio
Intrathecal placement of the epidural catheter via a Tuohy
needle: in a retrospective study o 115 patients with accidental
dural puncture, the incidence o PDPH was signicantly reduced
in those who had an intrathecal catheter compared with those
who had an epidural resited. The reduction in PDPH rate was
greatest in the group that had an intrathecal catheter let in place
or 24 hours (Figure 1).3 Theoretically, the catheter blocks thedural hole, preventing urther CSF loss, and generates an infam-
matory response, which acilitates rapid closure o the hole once
the catheter is removed.
Top-ups via an intrathecal catheter must be administered by
an anaesthetist. An intrathecal catheter increases the risk o acci-
dental injection o substances into the subarachnoid space.
Injection of intrathecal saline: in a non-randomized study o
54 patients, Charlsley and Abram4 compared the eects o an
injection o 10 ml normal saline into the intrathecal space at the
Diffrtial diaosis of postpartm ada
Non-p
Po-dual punu hadah
Mnng/nphal
Mgan
Pgnany-ndud hypnon (p-lampa)
coal vn homo
cal umou
inaanal/uaahnod hamohag
sudual hamaoma
Tabl 1
-
8/3/2019 cefalea postpuncin parturienta 2007
2/3
Obstetrics
ANAestHesiA AND iNteNsiVe cAre MeDiciNe 8:8 310 2007 elv Ld. All gh vd.
time o dural puncture with a control group. They demonstrated
a signicant reduction in the incidence o PDPH (62% versus
25%). The authors speculated that the injection o normal saline
limits the loss o CSF volume and prevents adenosine-receptor
activation, thereby reducing cerebral vasodilatation.
Prophylactic epidural blood patch (EBP) is the injection o
autologous blood into the epidural space soon ater accidental
dural puncture, but beore development o headache. Trials havereported conficting outcomes rom this procedure. It is not com-
mon practice because a delayed, therapeutic EBP may be more
eective. Furthermore, during prophylactic EBP a patient who
may not go on to experience PDPH is exposed to a second pro-
cedure with the associated risks.
Tratmt
Most treatment options relieve the symptoms o PDPH by
attempting to:
replace lost CSF
minimize cerebral vasodilatation
seal the dural puncture site.
Conservative treatment: symptoms o PDPH are controlled, in
the expectation that the hole in the dura will seal spontaneously.
Patients are advised to bed rest, maintain hydration and to take
simple analgesics, such as paracetamol and non-steroidal anti-
infammatory drugs. Vandam and Dripps5 showed that in more
than 10,000 spinal anaesthetics PDPH resolves when let untreated
(Figure 2). Within 7 days, 72% o the patients recovered, and by
6 months 87% had recovered.5 When a dural puncture is made
by a small-bore spinal needle, conservative treatment is more
likely to work. However, when a dural puncture is made with a
large-bore needle in the obstetric population, symptoms may be
severe and conservative treatment is oten ineective.
Pharmacological treatment
Adrenocorticotropic hormone may increase CSF production,
and it has been used in the treatment o PDPH. However, a small,
randomized controlled trial ailed to demonstrate a reduction
in pain scores or EBP rates in patients receiving intramuscular
synacthen 1 mg, compared with saline placebo.6
Caffeine is a cerebral vasoconstrictor and has been used in
the treatment o PDPH, with doses o 300500 mg twice daily.
Caeine diminishes the severity o the PDPH but its eect is
transient. Studies relating to the use o caeine in this condition
have ailed to group patients according to the size o the needlepuncturing the dura, and so the benets o caeine are dicult
to assess.
Sumatriptan is a serotonin-receptor agonist, and is also a
cerebral vasoconstrictor. It is widely used or the treatment o
migraine. Findings rom case reports suggest it may be eective
when given as a subcutaneous injection, but randomized con-
trolled trials have not shown benets rom using this agent.
Epidural saline and dextran: many units in the UK used crystal-
loid or dextran 40 inusions via the epidural catheter to prevent
PDPH. Theoretically, fuid creates a mass eect, similar to that
o blood, and raises epidural pressure, thus reducing CSF leakage
and resolving the headache. However, recent reviews have con-cluded that this method is not an eective treatment or PDPH.
Epidural blood patch
Effectiveness EBP is still regarded as the gold standard treat-
ment or PDPH, with success rates o up to 75%.7 A proportion
o patients will require a second EBP beore complete resolution
o symptoms occurs.
Mechanism of action EBP seems to work in two ways. First,
immediate pain relie is achieved through a tamponade eect,
which raises intracranial pressure. Second, the injected blood
seals the dural puncture, preventing urther CSF leakage.8 Nor-
mal CSF production soon replenishes the lost CSF.
Threading an intrathecal catheter reduces therequirement for epidural blood patch
0
Resitedepidural
Intrathecalcatheter
Intrathecal catheter(24 hours)
Proportionofpatientsreq
uiring
epiduralbloodpatch(%)
60
50
40
30
20
10
70
80
100
Fir 1
The proportion of 10,098 non-obstetric patients whorecovered from PDPH when left untreated
PDPH, post-dural puncture headache
12 days
34 days
57 days
814 days
36 weeks
36 months
712 months
Proportion of patients (%)
35302520151050
Fir 2
-
8/3/2019 cefalea postpuncin parturienta 2007
3/3
Obstetrics
ANAestHesiA AND iNteNsiVe cAre MeDiciNe 8:8 311 2007 elv Ld. All gh vd.
Timing o EBP is under debate. In the largest series o
504 patients, perorming EBP early was identied as a risk ac-
tor or ailure.9 In practice, most obstetric anaesthetists wait
2448 hours beore perorming an EBP i the headache persists.
Social and individual circumstances also dictate when an EBP
should optimally be perormed.
Volume of blood Craword10 observed a 96% success rate
with 20 ml o blood, and this volume is used by many anaesthe-tists. Some inject more than 20 ml until the patient eels a sensa-
tion o pressure or pain in their back, buttocks or legs. However,
there is anecdotal evidence o cauda equina syndrome when
more than 20 ml is injected.
Blood cultures traditional teaching advises that blood cul-
tures should be taken at the time o EBP to detect and treat any
inection that arises. In many units this is no longer routinely
practised because the yield rom blood cultures in an apyrexial
patient with no signs o sepsis is very small.
Complications short-term complications include backache
or a eeling o pressure in the back, buttocks or legs. Long-term
complications are rare, but include aseptic meningitis, arach-
noiditis, lumbovertebral syndrome, radicular pain, bradycardia,ever and seizures. EBP is not a contraindication to subsequent
epidural analgesia.
ReFeRenceS
1 Flaan H, rod s, Vamm J, al. Podual punu hadah:
a ompaon wn 26 and 29 gaug ndl n young pan.
Anaesthesia 1989; 44: 1479.
2 sanann U, rauoma P, Luula H, al. compaon o 27 gaug
Wha and Qunk pnal ndl wh p o podual
punu hadah and non-dual punu hadah.
Acta Anaesthesiol Scand2004; 48: 4749.
3 Ayad s, Dman Y, Naouz sN, tzla Je. suaahnod ah
plamn a w ap o analga n laou: nfun on h
k o hadah n o pan. Reg Anesth Pain Med2003;
28: 51215.
4 chally MM, Aam se. th njon o nahal nomal aln
du h vy o podual punu hadah. Reg Anesth
Pain Med2001; 26: 3015.
5 Vandam LD, Dpp rD. Long-m ollow-up o pan whovd 10,098 pnal anah.JAMA 1956; 161: 58691.
6 rukldg MWM, Yn sM, Pah MJ. synahn dpo o h
amn o podual punu hadah.Anaesthesia 2004; 59:
13841.
7 sudlow c, Walow c. epdual lood pahng o pvnng and
ang po-dual punu hadah. Cochrane Database
Syst Rev2001; 2: cD001791.
8 Vakhaa sb, thoma Ps, ronaum Ae, al. Magn onan
magng o opnal fud lak and amponad o lood
pah n podual punu hadah.Anesth Analg 1997; 84:
58590.
9 saa-ton V, thomann F, Malan P, al. evn o
pdual lood pah n h managmn o podual punuhadah.Anesthesiology2001; 95: 3349.
10 cawod Js. expn wh pdual lood pah.Anaesthesia
1980; 35: 51315.
FuRTheR ReADIng
Gla r. Podual punu hadah. Curr opin anaesthesiol 2006;
19: 24953.
tunull DK, shphd Db. Po dual punu hadah:
pahogn, pvnon and amn. Br J Anaesth 2003; 91:
71829.