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ACCIDENTAL DURAL PUNCTURE: IMMEDIATE OR DELAYED BLOOD PATCH
Br. J. Anaesth. (1983), 55, 89
ACCIDENTAL DURAL PUNCTURE: IMMEDIATE OR DELAYED BLOOD PATCH F. R. CHRISTENSEN AND J. LUND
The immediate effect of extradural blood patch after accidental dural puncture in a woman in labour is described. Eztradural analgesia was performed successfully in another site shortly afterwards.
CASE REPORT The patient was 33 years of age and in labour for the first time. She was in good health and the pregnancy had been uneventful. During the first stage of labour she was in severe pain and requested extradural analgesia. An 18-gauge Tuohy needle was inserted at L 2 - 3 using a paramedian approach. The extradural space was identified with air using the loss of resistance technique. There was no evidence of dural puncture. The catheter was inserted easily through the needle 1 cm cranially, but on further insertion, the patient suddenly felt a crack in the back of her head. Five minutes after a test dose of 0.375% bupivacaine 3 ml was injected through the catheter it was confirmed that dural puncture had occurred. The catheter was removed and it was decided not to make another attempt at establishing extradural analgesia. However, 2 h later the patient began to complain of increasingly severe headache in addition to painful contractions and, anticipating FINN
REDKE
CHRISTENSEN,*
M.D.;
JEPPE
LUND,
M.D.;
Copenhagen University Hospital in Hvidovre, Department of Anaesthesia, DK-2650, Denmark. •Present address: Norrgardsgatan 7, 71100 Lindesberg, Sweden. 0007-0912/83/010089-02 $01.00
an exacerbation of these symptoms, it was decided to seal the dural hole with a blood patch and make another attempt to insert an extradural catheter. One 18-gauge Tuohy needle was inserted at L 2 - 3 , and another at L 3 - 4 (midline approach). The extradural space was identified with loss of resistance to air. There was no evidence of dural puncture. The Huber tip of the upper needle was turned cranially and the lower turned caudally, the latter because the local anaesthesic might otherwise interfere with the dural hole. Venous blood 10 ml, taken from the patient's left cubital vein, was injected through the upper needle and a catheter was inserted 2 cm through the lower one. A test dose of 0.375% bupivacaine 3 ml confirmed that no dural puncture had occurred and a further dose of 0.375% bupivacaine 3 ml was injected. Ten minutes later the patient's headache had been relieved completely and after another 10 min the pain of her contractions had been abolished. The second and third stage of labour passed without incident. She was nursed flat for 24 h and then allowed out of bed. No sign of headache or dizziness occurred and she was discharged in good health on the 5th day after delivery. DISCUSSION When establishing extradural analgesia, accidental dural puncture may occur and may cause postlumbar puncture headache. Numerous methods of treatment have been tried (Bromage, 1978), but the blood patch is well-known and is accepted as the best method if prompt relief is required (Gormley, 1960; Di Giovanni and Dunbar, 1970). Complications are minimal (Di Giovanni and Dunbar, 1970; Abouleish et al., 1975). In this patient, a blood patch was the only way to treat the increasingly severe headache. An extra © The Macmillan Press Ltd 1983
Downloaded from http://bja.oxfordjournals.org/ at Georgetown University on July 15, 2015
Accidental dural puncture may occur during identification of the extradural space; the frequency of this complication being approximately 0.5% (Bromage, 1978). The severe headache, which may occur in association with dural puncture, is relieved rapidly when 10 ml of the patient's own blood is injected into the extradural space (Gormley, 1960, Di Giovanni and Dunbar, 1970). In the following case history, a blood patch was performed soon after dural puncture because the patient was in labour and was suffering from headache of increasing severity.
BRITISH JOURNAL OF ANAESTHESIA
90
dural catheter was inserted in a lower space to relieve the pain from her contractions—an accepted procedure shortly after a dural puncture (Craft, Burton and Coakley, 1973). The patient's headache disappeared immediately after the blood patch had been carried out and there was no further pain associated with her contractions. Thus, the available evidence suggests that an extradural blood patch is effective and safe, and is the treatment of choice when a dural puncture occurs during labour.
PERFORATION DURALE ACCIDENTELLE: EMPLATRE SANGUIN IMMEDIAT OU RETARDE RESUME
Nous decrivons l'effet immediat d'un emplatre mnguin peridural apret perforation accidentelle de la dure-mere chez une femme en travail. L'analgesie peridurale a pu etre conduite avec succes a partir d'un autre point de ponction, peu de temps apres.
VERSEHENTUCHE PUNKTION DER DURA: SOFORTIGE ODER SPATERE BLUTPROBE ZUSAMMENFASSUNG
Abouleish, E., de la Vega, S., Blendinger, I.,andTio,T. (1975). Long-term follow-up of epidural blood patch. Anesth. Analg., 54,549. Bromage, P. R. (1978). Epidural Analgesia, p.206. Philadelphia: W. B. SaundersCo. Craft, J. B., Burton, S. E., and Coakley, C. S. (1973). Prophylaxis of dural-punture headache with epidural saline. Anttth. Analg., 52,228. Di Giovanni, A. J., and Dunbar, B. S.(1970). Epidural injections of autologous blood for postlumbar-puncture headache. Anesth. Analg., 49, 268. Gonnley, J. B. (1960). Treatment of postspinal headache. Antsthesiology, 21,565.
Es wird der sofortige Effekt eines extraduralen Blutpatch nach verschentlicher Punktion der Dura bei einer Frau unter der Geburt beschrieben. Die Periduralanasthesie wurde kurz darauf an einer anderen Stelle erfolgreich durchgefiihrt.
PUNCION DURAL ACCIDENTAL: PLACAS SANGUlNEAS INMEDIATA O DEMORADA SUMARIO
Se describe el efecto inmediato de las placas sanguineas extradurales despues de una pundon dural accidental en una mujer parturiente. La analgesia extradural resulto exitosa en otro lugar poco despues de la primera.
Downloaded from http://bja.oxfordjournals.org/ at Georgetown University on July 15, 2015
REFERENCES
ACCIDENTAL DURAL PUNCTURE: IMMEDIATE OR DELAYED BLOOD PATCH F. R. CHRISTENSEN AND J. LUND
The immediate effect of extradural blood patch after accidental dural puncture in a woman in labour is described. Eztradural analgesia was performed successfully in another site shortly afterwards.
CASE REPORT The patient was 33 years of age and in labour for the first time. She was in good health and the pregnancy had been uneventful. During the first stage of labour she was in severe pain and requested extradural analgesia. An 18-gauge Tuohy needle was inserted at L 2 - 3 using a paramedian approach. The extradural space was identified with air using the loss of resistance technique. There was no evidence of dural puncture. The catheter was inserted easily through the needle 1 cm cranially, but on further insertion, the patient suddenly felt a crack in the back of her head. Five minutes after a test dose of 0.375% bupivacaine 3 ml was injected through the catheter it was confirmed that dural puncture had occurred. The catheter was removed and it was decided not to make another attempt at establishing extradural analgesia. However, 2 h later the patient began to complain of increasingly severe headache in addition to painful contractions and, anticipating FINN
REDKE
CHRISTENSEN,*
M.D.;
JEPPE
LUND,
M.D.;
Copenhagen University Hospital in Hvidovre, Department of Anaesthesia, DK-2650, Denmark. •Present address: Norrgardsgatan 7, 71100 Lindesberg, Sweden. 0007-0912/83/010089-02 $01.00
an exacerbation of these symptoms, it was decided to seal the dural hole with a blood patch and make another attempt to insert an extradural catheter. One 18-gauge Tuohy needle was inserted at L 2 - 3 , and another at L 3 - 4 (midline approach). The extradural space was identified with loss of resistance to air. There was no evidence of dural puncture. The Huber tip of the upper needle was turned cranially and the lower turned caudally, the latter because the local anaesthesic might otherwise interfere with the dural hole. Venous blood 10 ml, taken from the patient's left cubital vein, was injected through the upper needle and a catheter was inserted 2 cm through the lower one. A test dose of 0.375% bupivacaine 3 ml confirmed that no dural puncture had occurred and a further dose of 0.375% bupivacaine 3 ml was injected. Ten minutes later the patient's headache had been relieved completely and after another 10 min the pain of her contractions had been abolished. The second and third stage of labour passed without incident. She was nursed flat for 24 h and then allowed out of bed. No sign of headache or dizziness occurred and she was discharged in good health on the 5th day after delivery. DISCUSSION When establishing extradural analgesia, accidental dural puncture may occur and may cause postlumbar puncture headache. Numerous methods of treatment have been tried (Bromage, 1978), but the blood patch is well-known and is accepted as the best method if prompt relief is required (Gormley, 1960; Di Giovanni and Dunbar, 1970). Complications are minimal (Di Giovanni and Dunbar, 1970; Abouleish et al., 1975). In this patient, a blood patch was the only way to treat the increasingly severe headache. An extra © The Macmillan Press Ltd 1983
Downloaded from http://bja.oxfordjournals.org/ at Georgetown University on July 15, 2015
Accidental dural puncture may occur during identification of the extradural space; the frequency of this complication being approximately 0.5% (Bromage, 1978). The severe headache, which may occur in association with dural puncture, is relieved rapidly when 10 ml of the patient's own blood is injected into the extradural space (Gormley, 1960, Di Giovanni and Dunbar, 1970). In the following case history, a blood patch was performed soon after dural puncture because the patient was in labour and was suffering from headache of increasing severity.
BRITISH JOURNAL OF ANAESTHESIA
90
dural catheter was inserted in a lower space to relieve the pain from her contractions—an accepted procedure shortly after a dural puncture (Craft, Burton and Coakley, 1973). The patient's headache disappeared immediately after the blood patch had been carried out and there was no further pain associated with her contractions. Thus, the available evidence suggests that an extradural blood patch is effective and safe, and is the treatment of choice when a dural puncture occurs during labour.
PERFORATION DURALE ACCIDENTELLE: EMPLATRE SANGUIN IMMEDIAT OU RETARDE RESUME
Nous decrivons l'effet immediat d'un emplatre mnguin peridural apret perforation accidentelle de la dure-mere chez une femme en travail. L'analgesie peridurale a pu etre conduite avec succes a partir d'un autre point de ponction, peu de temps apres.
VERSEHENTUCHE PUNKTION DER DURA: SOFORTIGE ODER SPATERE BLUTPROBE ZUSAMMENFASSUNG
Abouleish, E., de la Vega, S., Blendinger, I.,andTio,T. (1975). Long-term follow-up of epidural blood patch. Anesth. Analg., 54,549. Bromage, P. R. (1978). Epidural Analgesia, p.206. Philadelphia: W. B. SaundersCo. Craft, J. B., Burton, S. E., and Coakley, C. S. (1973). Prophylaxis of dural-punture headache with epidural saline. Anttth. Analg., 52,228. Di Giovanni, A. J., and Dunbar, B. S.(1970). Epidural injections of autologous blood for postlumbar-puncture headache. Anesth. Analg., 49, 268. Gonnley, J. B. (1960). Treatment of postspinal headache. Antsthesiology, 21,565.
Es wird der sofortige Effekt eines extraduralen Blutpatch nach verschentlicher Punktion der Dura bei einer Frau unter der Geburt beschrieben. Die Periduralanasthesie wurde kurz darauf an einer anderen Stelle erfolgreich durchgefiihrt.
PUNCION DURAL ACCIDENTAL: PLACAS SANGUlNEAS INMEDIATA O DEMORADA SUMARIO
Se describe el efecto inmediato de las placas sanguineas extradurales despues de una pundon dural accidental en una mujer parturiente. La analgesia extradural resulto exitosa en otro lugar poco despues de la primera.
Downloaded from http://bja.oxfordjournals.org/ at Georgetown University on July 15, 2015
REFERENCES