Dr. Apurb Sharma
MD in Anesthesiology.Head, Department of Anesthesiology and critical
care, Nepal Mediciti.
Emailapurbsharma1976@gmail.comphone no. +977 9841221467
https://orcid.org/0000-0002-1655-5997
All authors: Department of Anesthesia, Pain Management, and Critical
Care
Nepal Mediciti, Sainbu, Lalitpur, Nepal
*Corresponding Author
Running title:
The management of Post-Dural Puncture Headache; a prospect from a low
and middle-income country.
Post-Dural Puncture Headache (PDPH) is a recognized and treatable
complication following an intentional or accidental dural puncture. In
our institutional audit, the incidence of PDPH in the obstetric
population following spinal anesthesia and epidural labor analgesia is
13% and 3%, respectively. Among those patients, 98.62% of cases
recovered with physical and pharmacological management, and 1.38% of
patients required the epidural blood patch (EBP). The worldwide
incidence of PDPH after intentional dural puncture and accidental dural
puncture (ADP) varies from 0.1 to 36% and 80-86%, respectively.[1]
The epidural blood patch is the definitive treatment for PDPH with an
approximately 98% success rate. [2] This is a sterile procedure,
requiring two providers, where one withdraws autologous blood, and the
other injects it into the epidural space.
Dr. James Gormley in 1960, a general surgeon in Berwick, Pennsylvania,
first introduced the epidural blood patch. Dr. Gormley injected 2-3 ml
of autologous blood into the epidural space.[3] Dr. Anthony
DiGiovanni, an anesthesiologist, in San Antonio, Texas popularized the
technique of injecting 10 ml of autologous blood instead of 2-3
ml.[4] In 1980, Crawford JS reported that the earlier practice of
6-10 ml blood as the epidural blood patch did not produce satisfactory
results. While the subsequent increase in volume up to 20 ml resulted
in an improved outcome.[5] The volume needed for the patch is
recommended as 20 ml in the recent practices.[6]
There is extensive data available worldwide on the incidence,
prevention, and management of PDPH. On the contrary, there are only a
few publications on PDPH from low and middle income
country.[7][8][9]
We believe that post-dural puncture headache and its management have
been overlooked in our and many low and middle-income countries. PDPH is
obnoxious to the patient. It will increase the hospital stay and add a
financial burden to the patient. The patient will have an unpleasant
experience for the rest of their life as well. Unless we do not treat
the patient diagnosed as PDPH on time, they can develop postpartum
complications that can be fatal, e.g., seizures, cerebral venous
thrombosis, subdural hematoma from traction on dural veins,
hypopituitarism, syringomyelia, herniation, coma, and even
death.[10] Inappropriately managed PDPH increases the workload to
the anesthesiologist and delays admission-discharge turnaround time.
Why do we have a lack of candor on the management of PDPH and practicing
EBP? The reasons are multifold for the problem. First, the attending
surgeon and anesthesiologist do not realize the PDPH as the problem.
Second, the patients are unaware that there are options for the
treatment of PDPH. Third, workload and shortage of workforce restrict
anesthesiologists to work outside the operative room, and fourth,
standard operating protocols (SOP) are not well established in our part
of the world. We should take into some general measures to address the
chasm. We design a system approach to the management of PDPH (figure 1).
We should increase awareness of PDPH among the service providers, e.g.
Anesthesiologists, obstetricians, surgeons, nurses, and hospital
managers. The patients should be counseled beforehand. We should develop
a workflow distribution plan and inclusion of a pain link nurse in the
acute pain management program. The acute pain management program should
include a clinical pathway for the management of complications as PDPH.
Each institute should identify processes and outcome indicators for
tracing the effectiveness of the program. Finally, we should develop a
nationwide anesthesia outcome registry.
We took the facts into the consideration and initiated an Acute Pain
Management System (APMS). The system includes a director, educator, pain
physician, pain link nurse, anesthesia nurse, and ward nurse. Each
individual bears the defined responsibilities according to organograms
and SOPs. In addition to ensemble modal anesthesia practice, we ensure
proper postoperative follow-up of our patients, so we could timely
detect and manage complications of anesthesia. We have defined an
operating pathway for the management of PDPH.(figure 2)
In our institute, we follow all patients on the first postoperative day
who have received anesthesia. If any signs and symptoms suggestive of
complications of anesthesia prevailed, we turn on the pathway for the
respective complications. Similarly, if a patient develops a headache
post neuraxial anesthesia or analgesia, we activate the PDPH pathway. As
stated in the clinical pathway, the pain link nurse will attend the call
immediately and will inform the anesthesiologist on duty. If clinical
features correlate with the diagnosis of PDPH, the anesthesiologist
counsels the patient about different options available to treat it. The
anesthesiologist will start conservative and pharmacological management.
The management includes adequate hydration, caffeinated drinks, bed
rest, abdominal binder, and analgesics such as a combination of
paracetamol and codeine, and NSAIDs. If symptoms are not relieved within
the next twenty-four hours, then the patient is counseled for
Sphenopalatine Ganglion Block (SPB) or EBP according to the clinical
features of the patient. The SPB is a minimally invasive procedure with
a success rate of approximately 69% in treating PDPH.[xi] The EBP
is the definitive management of PDPH with an approximately 98% success
rate if done after 48 hours. (ii) In our experience, this has been true
and rewarding.
Going back to Zemba, we have to start planning right during the
pre-anesthesia checkup (PAC). The attending anesthesiologists should be
aware of possible complications and counsel and assure the patient that
those complications are treatable. We should develop the mechanism to
follow-up patients and diagnose complications and treat them
accordingly. We could educate the nurse as pain link nurses, allow them
to follow up with the patients, and consult with the anesthesiologist as
per need. Furthermore, each hospital and individual department should
define the clinical indicators to measure process and outcome, and we
should implicate the process nationwide so that we could establish a
multi-center coordination and data collection system. Anesthesia Outcome
Registry can play a vital role to follow the complications of anesthesia
as data is the record of our work, and we can utilize the data for the
analysis as well. The process will serve to coalesce all that happened
into one connected whole, which will give on to improve the quality of
the healthcare system and patient safety.
We realize the need for a system, led by the anesthesiologists, which
should define the process of the identification of anesthesia
complications and their treatment in the view of overlooked management
of PDPH despite the EBP being the gold-standard treatment worldwide.
REFERENCE
- Darvish B, Gupta A, Alahuhta S, Dahl V, Helbo-Hansen S, Thorsteinsson
A, Irestedt L, Dahlgren G. Management of accidental dural puncture and
post-dural puncture headache after labour: a Nordic survey. Acta
Anaesthesiol Scand. 2011 Jan;55(1):46-53. doi:
10.1111/j.1399-6576.2010.02335.x. Epub 2010 Oct 29. PMID: 21039355.
- Tubben RE, Jain S, Murphy PB. Epidural Blood Patch. 2020 Jul 6. In:
StatPearls [Internet]. Treasure Island (FL): StatPearls
Publishing; 2020 Jan–. PMID: 29493961.
- Gormley, J.B. Treatment of Post Spinal Headache. Anesthesiology. 1960;
21, 565-566.
- DiGiovanni AJ, Dunbar BS. Epidural injections of autologous blood for
postlumbar-puncture headache. Anesth Analg. 1970 Mar-Apr;49(2):268-71.
PMID: 5534630.
- Crawford JS. Experiences with epidural blood patch. Anaesthesia. 1980
May;35(5):513-515. DOI: 10.1111/j.1365-2044.1980.tb03834.x.
- Peach MJ, Doherty DA, Christmas T, Wong CA; Epidural Blood Patch Trial
Group. The volume of blood for epidural blood patch in obstetrics: a
randomized, blinded clinical trial. Anesth Analg. 2011
Jul;113(1):126-33. doi: 10.1213/ANE.0b013e318218204d. Epub 2011 May
19. PMID: 21596867.
- Acharya, S., B. Parajuli, and D. Aryal. Benign Intracranial
Hypotension Caused by Spontaneous Cervical Cerebrospinal Fluid Leak
Treated With Cervical Epidural Blood Patch: A Case Report.Journal of Society of Anesthesiologists of Nepal (JSAN0 . 2016;
Mar. 3 (1) 47-49. doi:10.3126/jsan.v3i1.14644.
- Tabedar S, Maharjan SK, Shrestha BR, Shrestha BM. A comparison of 25
gauge Quincke spinal needle with 26 gauge Eldor spinal needle for the
elective Caesarian sections: insertion characteristics and
complications. Kathmandu Univ Med J (KUMJ). 2003 Oct-Dec;1(4):263-6.
PMID: 16388267.
- K C HB , Pahari T . Effect of Posture on Post Lumbar Puncture Headache
after Spinal Anesthesia: A Prospective Randomized Study. Kathmandu
Univ Med J (KUMJ). 2017 Oct.-Dec.;15(60):324-328. PMID: 30580350.
- Plewa MC, McAllister RK. Postdural Puncture Headache (PDPH). 2020 Aug
23. In: StatPearls [Internet]. Treasure Island (FL): StatPearls
Publishing; 2020 Jan–. PMID: 28613675.