1. Obstetric Epidural Audit – Accidental Dural Puncture, Incidence and Management
Michael Hicks – Registrar
Gosford Hospital 2013
RAP Meeting August 6th 2013

2. Accidental Dural Puncture - Introduction
Inadvertent puncture of the dura mater, in anaesthetic practice, usually following attempted insertion of an epidural catheter
Can be recognised immediately (CSF through needle or catheter, or inferred from rapid onset of block/dense motor block) or unrecognised at the time of insertion
The nature of the obstetric patient group may lead to greater apparent ADP rates: → younger, healthier population , earlier mobilisation (? less opportunity for spontaneous sealing)
“Acceptable” rates of dural puncture? Wide range of data in the literature (more later)
Complications are numerous – most commonly PDPH in 50-80%1-2, nausea, vomiting, photophobia, meningism, hyperacusis/tinnitus, cranial nerve palsies (diplopia), subural haemorrhage

3. Accidental Dural Puncture - Introduction
Once a dural puncture has occurred, there is no firm consensus on what constitutes optimal management
Many strategies
For prophylaxis after recognised ADP: intrathecal techniques such as intrathecal catheter (ITC), ± intrathecal saline or prophylactic epidural blood patch/saline patch, various pharmacotherapies
For management of PDPH: bed rest ± other position, hydration, simple analgesia + adjuvants (e.g. caffeine), opioids, epidural saline, epidural blood patch

4. Accidental Dural Puncture - Introduction
The evidence:
Prevention Cochrane reviews have been published for:
Posture and Fluids 3 with head down vs. horizontal, prone vs supine, bed rest vs. early mobilisation, and IV fluids vs. standard oral intake reviewed
Drug therapy 4 with epidural and spinal morphine, spinal fentanyl, PO caffeine, PR indomethacin, IV cosyntropin (synthetic ACTH), aminophylline and dexamethasone
In summary – there was no evidence to support bed rest or aggressive hydration to prevent PDPH.
The only drugs found to be effective in prevention of PDPH of any severity were epidural morphine, and IV cosyntropin (only 1 trial) and aminophylline . PO caffeine associated with ↑ insomnia (!)

5. Accidental Dural Puncture - Introduction
A Cochrane protocol has been written for Epidural Catheter Replacement vs. Intrathecal Catheter in recognised ADP 5(but no review yet conducted)
A very large prospective case series from (n=17,158, of which 16,193 were CSE!) found a small reduction in PDPH rate when ITC was left in situ vs. ECR (52% from 61%) but it was not statistically significant (n=55 recognised ADP)
ITC also had saline 2mL/hr
Same study published a meta analysis (n=599) of ITC vs. ECR and found a significant reduction in both PDPH and EDBP after ITC was inserted – PDPH from 66% down to 51%, which was similar, but statistically significant (p<0.001)

6. Accidental Dural Puncture - Introduction
Reasons suggested were: - inadequately powered study ? Intrathecal saline impaired inflammation and repair inferior to administration of analgesia only
Despite 2 small promising trials, a later meta-analysis1 found no significant difference when ITC was used for >24 hours, based mainly on a 2007 study7 of 334 patients with ADP (60 ITCs) vs no treatment or prophylactic epidural blood patch
As with most interventions in this area, more research needed!
However, there are other reasons to leave an ITC in situ if ADP occurs, namely high quality, titratable analgesia or anaesthesia if LSCS is required (notwithstanding risks of ITC)

7. Accidental Dural Puncture - Introduction
Management
Cochrane review of Epidural Blood Patch (EDBP) for prevention and treatment of PDPH8
In prevention, prophylactic EDBP was better than no treatment, conservative treatment and epidural saline, it was not superior to sham procedure - overall, authors did not recommend it as numbers too small
The authors advocated EDBP as treatment for established PDPH, but did advocate more trials. The also noted increased backache vs. conservative treatment

8. From Choi et al,

9. Going forward – guideline for management of ADP/PDPH
The main points are: - if sub-arachnoid catheter is recognised, leave in situ for 24 hours (and if recognised with needle, advance 2-3cm in space - compliance with this was reasonable, 2 intrathecal catheters were not inserted that might otherwise have been - as previously noted 3/7 were pulled out early (8,17,21 hours)
EDBP to be considered after 48 hours of conservative management, if warranted by ongoing symptoms – evidence suggests greater failure rates if EDBP is performed earlier than this (consensus, not unanimous view)

10. Going forward – guideline for management of ADP/PDPH
Other prophylactic measures – talking points: The use of caffeine, though mentioned in our protocol (and Australian therapeutic guidelines), is sporadic at GDH in the event of ADP (charted for 2/21 patients!)
It is not supported by strong evidence (transient effect) and has side effects - should we remove it from our protocol?
Should we consider the use of epidural morphine (where possible) and cosyntropin, which were both backed by Cochrane review? (albeit with limited data)

11. References
Apfel et.al. Prevention of postdural puncture headache after accidental dural puncture: a quantitative systematic review. British Journal of Anaesthesia 2010; 105 (3): 255–63
Paech M, Banks S, Gurrin L. An audit of accidental dural puncture during epidural insertion of a Tuohy needle in obstetric patients. Int J Obstet Anesth 2001; 10: 162–7
Arevalo-Rodriguez I, et. al. Posture and fluids for preventing post-dural puncture headache. Cochrane Database of Systematic Reviews 2013, Issue 7
Basurto Ona X et. al. Drug therapy for preventing post-dural puncture headache. Cochrane Database of Systematic Reviews 2013, Issue 2
Newman MJ, Cyna AM, Middleton P. Epidural catheter replacement and intrathecal catheter techniques for preventing post-dural puncture headache following an inadvertent dural puncture in labour. Cochrane Database of Systematic Reviews 2010, Issue 1
M. Van de Velde et. al. Ten years of experience with accidental dural puncture and post-dural puncture headache in a tertiary obstetric anaesthesia department. International Journal of Obstetric Anesthesia (2009) 17, 329–335
Kaul B, Sines D, Vallejo MC, Derenzo J, Waters J. A five year experience with post dural puncture headaches. Anesthesiology 2007:A1762
Boonmak P, Boonmak S. Epidural blood patching for preventing and treating post-dural puncture headache. Cochrane Database of Systematic Reviews 2010, Issue 1
Choi P T, Galinski S E, Takeuchi L, Lucas S, Tamayo C, Jadad A R. PDPH is a common complication of neuraxial blockade in parturients: a meta-analysis of obstetrical studies. Can J Anesth 2003; 50: 460–9
Gleeson C M, Reynolds F. Accidental dural puncture rates in UK obstetric practice. Int J Obstet Anesth 1998; 7: 242–8