Anesthesia Significant Events Review / Post Dural Puncture Headache (PDPHA)

1. Anesthesia Significant Events Review / Post Dural Puncture Headache (PDPHA) Dr. Bruce Baker

2. Significant Event Review • #1 01-4586 BBS Pt is a neonate who was being poorly resuscitated by Peds- unable to intubate- when CRNA arrived and intubated patient. • . • #2 02-9106 LH 13 month old baby with history of open heart surgery x 3, being seen for pneumonia who suffered respiratory failure in ER. On intubation patient suffered brief cardiac arrest which resolved with chest compressions and adenosine? Pt transferred to NMCSD PICU. • #3 01-8545 AMT Pt is a 7 mo old baby who was in respiratory arrest and required intubation in the ER after probable abuse. • Outcome: No long term adverse effects noted or expected from anesthetic care. • Lessons/improvement: Case reviewed, no problems noted, no action required.

3. Significant Events Review • #4 20-2085 LGM Pt is a 22 yo male with prolonged tourniquet/ operative time on an ACL repair who had opposite leg numbness and tingling after procedure. In phone conversation 16 Oct, pt still with some numbness slowly resolving (now down to two toes) and with pain/ swelling from calf to foot. Pt advised to be reevaluated for calf swelling to r/o DVT. • #5 30-6658 MEC Pt is a 22 yo female who underwent total colectomy via GETA/CLE who did well intraoperatively and post-operatively until POD#3 after CLE pulled. Pt developed BLE weakness and swelling. MRI revealed no epidural hematoma, and swelling and weakness resolved over the next two days. • Outcome: No long term adverse effects noted or expected from anesthetic care. • Lessons/improvement: Case reviewed, no problems noted, no action required.

4. Significant Events Review • #6 30-5893 JFA Pt is a 35 yo female for Mini-Lap Tubal which was attempted by SAB, converted to GETA for failed block. • . • #7 30-8964 CT Pt is a 23 yo female 5’5 107 kg who had two failed CLE attempts then given ITN x2 for labor and delivery. • #8 20-0444 ST Pt is a 31 yo female s/p recent TAB and extreme tolerance to sedation who underwent Colonoscopy requiring rescue sedation by anesthesia. Pt required large amounts of analgesia post –procedure requiring admission to PACU and to 4N. • Outcome: No long term adverse effects noted or expected from anesthetic care. • Lessons/improvement: Case reviewed, no problems noted, no action required.

5. Significant Events Review • #9 20-2757 NJJ Pt is a 19 yo male who underwent a L femoral nailing via GA/ CLE. Pt was treated for 24 hours with antibiotics for a tonsillitis, which delayed the start of the case for one day. Pt did well during the procedure and was doing well in the PACU until he was noted to have a sudden desaturation in the PACU. Pt had received a CLE in the PACU postoperatively but there does not seem to be any relation to the CLE and no reason perioperatively to have had a reason to develop NPPE. Pt brought up pink tinged, frothy sputum after the desaturation episode. CXR revealed B infiltrates. Pt was admitted to PACU and over 24 hours after the procedure was still having desaturations on 6l/min O2, even though CXR showed some improvement. Main speculation is R/O Fat embolus. • #10 20-1447 BJG Pt is a 21 yo male who had a R thigh compartment syndrome relieved by fasciotomy, taken back to the OR that same night for bleeding. Underwent re-exploration via GA/ LMA. • Outcome: No long term adverse effects noted or expected from anesthetic care. • Lessons/improvement: Case reviewed, no problems noted, no action required.

6. Significant Events Review • #11 30-8122 YMH Pt is a 62 yo female ASA 3 for CAD, NIDDM, HTN, COPD who underwent 51/2 hour Low anterior resection via GETA/ CLE. Pt was stable throughout case but had some hypotension with the epidural. Pt’s HCT was low 20’s at the end of case and provider wanted to transfuse the patient but the surgeons were reluctant. Pt was transported to ICU, noted to be moaning and given 10 cc of Marcaine 0.25% via CLE. Approximately twenty minutes later patient went into cardiac arrest with EKG showing 30 BPM, but pt pulseless. Code Blue called, patient reintubated and Epi and Atropine given, then patient started on Dopamine and later Levofed. Pt returned to SR and had pressures slowly stabilize over the next couple of hours, and pt did receive the units of blood. • Outcome: Post-operative cardiac arrest without MI, possibly due to sympathectomy in the face of a Beta-Blocked patient. Patient recovered and is doing well postoperatively • Lessons/improvement: Case reviewed. Full discussion with surgeons and anesthesia providers to follow.

7. PDPHA • Accidental dural puncture is one of the most common complications of epidural analgesia. In one study, 86% of women who had a PDPH after epidural would not receive an epidural again. • Headache is the third most common reason for lawsuit after epidural (15%). • While not completely preventable, there are several techniques which can alter the risk and impact of this event.

8. PDPHA Pathophysiology • First PDPHA was described in 1898 by August Bier after he was injected with cocaine by his assistant. • There is approximately 150 cc of CSF in the CNS, 75cc in the spinal space and 75cc supra-spinally. • CSF production 0.3-0.4 ml/minute- if leak is greater…

9. It has been postulated that CSF leakage and brain “sag” on the meninges is the cause for PDPHA but this “sag” has not been shown by MRI. There is less volume of CSF present – compensated with either increased blood or brain tissue - hypothesis is that cerebral vasodilation occurs in response to the decreased intracranial volume, and that this results in the headache. Monro-Kellie Doctrine Brain + CSF + Blood ------------ Total Intracranial volume Traction on Cranial Nerves results from increased CBF and thus brain volume PDPHA Pathophysiology

10. Accidental Dural Puncture: Frequency • High Number of Blocks- (>60 year or 10/mo) - 1.3% Wet Tap • Low Number of Blocks- (< 60/yr or <10/mo) – 4.4% Wet Tap 3. Sleep deprivation impairs technical skills- wet taps occur most often in the early morning hours after long hours of working.

11. PDPHA Duration PDPHA- 72% of headaches resolve spontaneously within 7 days but there have been case reports of headaches which have lasted greater than 6 months to one year.

12. Symptoms of PDPHA- • Headache- usually frontal (CN V) or occipital areas, usually bilateral, may involve neck and shoulders • Usually develops within 3 days of dural puncture (bigger the needle, sooner the onset, in general)- 65% develop within first 24 hours, 92% within first 48 hours • Postural component • Neck Stiffness

13. PDPHA- Symptoms • Nausea, vomiting (interference with circulation of endolymph in semicircular canal) • Hearing alteration at low frequencies - CN VIII (10 + decibels loss in 30-93% of patients, depending on needle size.) • Visual disturbances (14%) - 95% of cases with visual disturbances are from CN VI palsy

14. Differential Diagnoses • Non-specific headache • Migraine • Hypertension • Brain tumor • Subdural/ subarachnoid hemorrhage • Cortical vein thrombosis • Sinusitis • Meningitis • Pneumocephalus

15. PDPHA- Incidence by needle type and size- (Choi et al) Quincke 16 ga – 18% Quincke 20 ga – 16% Quincke 22 ga – 10% Quincke 24 ga – 6% Quincke 27 ga – 1.5% Pencil Point 22 ga – 1.6% Pencil Point 24 ga – 2% Tuohy 18 ga – 52.5%

16. PDPHA Risk Factors- • Young age (but not too young, rarely before 10 years of age) - incidence decreases with each decade of life. • Women- in some studies, higher incidence • Quincke type needle • Perpendicular insertion – parallel insertion either splits fibers or has “tin-lid” appearance (more likely to make a difference with smaller bore and pencil point needles than with Tuohy needles.) • Larger-bore needles • Pushing during second stage

17. Decreasing Incidence of PDPHA 1. Loss of resistance with saline is associated with a lower incidence of wet taps but only if performed with continuous pressure technique. • Loss of resistance with air is associated with a higher incidence of headache from injection of air intrathecally. This headache is self-limited. 3. Parallel needle direction to dural fibers can decrease incidence of headache after accidental wet tap- in some studies by as much as 50%. 4. With pencil-point needles, replacing the stylet before withdrawal of the needle is associated with a lower incidence of headache 5. Paramedian approach has also been suggested to decrease incidence of headache due to the oblique angle going through dural fibers.

18. Treatment After Dural Puncture 1. Pt is aware that it is an iatrogenic problem 2. Bed rest is not useful 3. It is postulated that leaving a catheter in place in the dural tear will act as a barrier to CSF leakage and also incite an inflammatory reaction that can seal the hole.

19. Treatment After Dural Puncture Ayad- • 115 parturients with accidental puncture randomized into three groups: resite the epidural catheter, intrathecal catheter removed after delivery, intrathecal catheter left in place x 24 hours. • The incidence of PDPH was: 91.1% in the resite group 51.4% in the immediate group 6.2% in the delayed group

20. Treatment After Dural Puncture • Cohen et al- • Three groups going to C-Section were identified: • Group I (n = 15) patients had a dural puncture on the first attempt at epidural block, but successful epidural block on a repeated attempt; • 33% incidence of PDPHA • Group II (n = 17) patients had a dural puncture with immediate conversion to continuous spinal anesthesia with catheterization lasting only for the duration of caesarean delivery; • 47% incidence of PDPHA • Group III (n = 13) patients had an immediate conversion to spinal anesthesia and received post-caesarean section continuous intrathecal patient-controlled analgesia consisting of fentanyl 5 micrograms.ml-1 with bupivacaine 0.25 mg.ml-1 and epinephrine 2 micrograms.ml-1 with catheterization lasting > 24 h. • 0% incidence of PDPHA

21. Treatment After Dural Puncture • Injection/ infusion of intrathecal Normal Saline- decreased incidence but not statistically significant in a couple of studies. Headache returns after infusion stopped. Dextran has also been used but has not been shown to have long-term efficacy. 2. At least one small study showed a 66% success rate with acupuncture treatment 3. Gelatin powder (Gelfoam) and fibrin glue have both been used as epidural patches for postdural puncture headaches. They may be effective, but are significantly more difficult to administer.

22. Conservative methods for treating PDPHA- • Analgesics • Bedrest • IV hydration • Caffeine benzoate 500mg temporizing measure but does not change overall severity of headache at 24 hours, and not without risk (i.e. grand mal seizure) - One study showed 85% success rate, but studied 22ga Quincke needle, not Tuohy, not in just parturients, and 60% resolved with no treatment in the study. • Sumatriptan- potent vasoconstrictor and has been shown to decrease headache associated with small dural puncture, but not with CLE PDPHA • Methergine has been reported to decrease severity and incidence of PDPHA

23. Epidural Blood Patch- • 15-20 cc of patient’s own blood injected into epidural space (or until patient develops back or leg pain). No studies to prove efficacy of volume. • 75% complete relief, 18% partial relief so overall 93% effective depending upon when it is performed- better success after 24-72 hours. • By one study 71% failure rate if done sooner than 24 hours. Better if performed after at least 48 hours – recurrence rate of HA 59% vs. 11%. (Some question of bias as the more severe a headache, the earlier it is likely to be performed.)

24. PDPHA Recurrence/ Repeat EPB • Patient should be counseled that the headache may return, but probably will be less severe. Force fluids/ caffeinated beverages of unproven efficacy. • In some studies, as high as 50% recurrence of HA, of which 31% may require second blood patch. A relative few 7% could require a third patch. • Bed rest for 2 hours after patch associated with less recurrence. • No Valsalva/ heavy lifting for 48 hours associated with less recurrence.

25. Epidural Blood Patch- • No studies showing how much to force fluids in conjunction with an epidural blood patch. • Back pain common- about 35% of patients • Prophylactic epidural blood patch – 34 cases of success reported in the literature, but no established study showing any improvement in need for EBP, although there is a decrease in PDPHA duration. Best reserved for those parturients who already have a headache at delivery.

26. Complications of Epidural Blood Patch • Remarkably safe • Contraindications • Septicemia • Local infection of the back • Active neurologic disease • No report of infectious meningitis after Epidural Blood Patch

27. Special Situations • Post-laminectomy Patients and CLE- literature review not helpful- best opinion is to attempt at a space not included in the laminectomy, if possible. If you get a wet tap then pass catheter and use as an ITN catheter. ? Decreased incidence of PDPHA? 2. Obesity- ? Decreased incidence of PDPHA 3. Patients who have history of PDPHA and especially accidental wet tap are associated with an increased risk the next time they have a procedure.

28. Conclusions • PDPHA is not 100% preventable but you can mitigate the effects of a wet tap. • Consider: • 1.Continuous pressure vs intermittent pressure for LOR • 2. Saline vs air for LOR • 3. Paramedian approach • 4. Parallel needle position • 5. Replacing stylet prior to removal of needle in SAB

29. Conclusions If you get a wet tap consider: • Leaving catheter in 24 hours and using as intrathecal • Leaving catheter in 24 hours and moving to new space • Infusing Saline or Dextran into space for 24 hours • Prophylactic blood patch • Conservative vs Aggressive (EBP) treatment- probably optimal to wait 24-48 hours after initial puncture but then aggressive approach may get patient out of hospital sooner.