- Email: [email protected]
Quantifying and personalizing blood patch risk
Correspondence
Declaration of interest All interests are declared on the BJA website.
References 1. Kozek-Langenecker S, Fries D, Spahn DR, Zacharowski K III. Fibrinogen concentrate: clinical reality and cautious Cochrane recommendation. Br J Anaesth 2014; 112: 784–7 2. Wikkelsø A, Lunde J, Johansen M, et al. Fibrinogen concentrate in bleeding patients. Cochrane Database Syst Rev 2013; 8: CD008864 3. Wikkelsø AJ, Edwards M, Afshari A, et al. Pre-emptive treatment with fibrinogen concentrate for postpartum haemorrhage: randomized controlled trial. Br J Anaesth 2015; 114: 623–33 4. Samama CM. Fibrinogen concentrates and major bleeding in post partum haemorrhage? Don’t miss the most relevant population! Br J Anaesth 2015; 114: 548–50 doi:10.1093/bja/aev094
Quantifying and personalizing blood patch risk I. Delroy-Buelles* and R. Green Bournemouth, UK *E-mail: [email protected]
Editor—Providing consent for neuraxial procedures involves explanation and understanding of risk and benefit, and for the former we have increasing evidence.1 Consenting guidance from the The Association of Anaesthetists of Great Britain and Ireland mentions particularly disclosing information that would be important to the individual patient.2 The frequency of postdural puncture headache (PDPH) may be quoted as a percentage depending on procedure, patient, and clinician factors. But what does this number mean for the patient and can we clarify this particular risk any further? More specifically, what is their chance of requiring intervention for a PDPH? We decided to review data from our institution to reflect the risk of requiring an intervention for PDPH more accurately. We calculated epidural blood patch rates after neuraxial procedures (spinal, epidural, or lumbar puncture) at our district general hospital. We obtained the number of spinal and epidural procedures performed and the number of blood patches between April 2010 and March 2013. The number of diagnostic lumbar punctures was obtained from the cerebrospinal fluid samples sent to the laboratory in the same time period. In total, 7185 spinal and 997 epidural procedures were performed in theatre and 830 lumbar punctures on the wards in this time period. Seventeen epidural blood patches were performed, eight after a spinal procedure, giving around a one in 1000 risk, and six after lumbar puncture, giving around a one in 100 risk. Three patches were performed after epidurals, giving around a one in 300 risk, two of which were documented dural
taps. All patches performed were successful, data from one were missing, and three patches were repeated before success. Five of the lumbar puncture cases showed evidence of multiple attempts, though much of the documentation was poor and data were missing. Data collection for this project was simple and easy to do. Through education and review of the equipment used, we are now looking to reduce our patch rate after lumbar puncture. When consenting for neuraxial technique, we quote the risk of PDPH and can now add in the risk of requiring intervention (i.e. a blood patch) for this. We believe this gives more meaningful outcome information to patients to inform them better of the risk and consequences of PDPH in our hospital.
Declaration of interest None declared.
References 1. Cook TM, Counsell D, Wildsmith JAW; on behalf of the RCOA Third National Audit Project. Major complications of central neuraxial block: report on the Third National Audit Project of the Royal College of Anaesthetists. Br J Anaesth 2009; 102: 179–90 2. The Association of Anaesthetists of Great Britain and Ireland. Consent for Anaesthesia. London, revised edition 2006. doi:10.1093/bja/aev092
Downloaded from http://bja.oxfordjournals.org/ at Dalhousie University on May 18, 2015
integrity of the research and raises more suspicion about any published material. Therefore, given the current environment under which we operate, contrary to the implications of Bormann and colleagues in their letter, COPE remains a highly respected, well-regarded body to guide researchers and publishers in maintaining the highest possible standards of publication ethics, and the BJA is fully committed to the COPE guidelines. Having said that, the research community, authors, and editors should all be mindful of making continuous improvements in these standards, wherever the room for improvement exists, in order to maintain the scientific validity of published material. Finally, it is important that none of us should patronize our readers and underestimate their intelligence or their ability to exercise their own independent professional judgement. Depending upon how transparent the funders, researchers/ authors, editors and journals have been during the whole journey of conducting research or publishing a paper, readers will exercise their own considered discretion on the integrity of the process and will come to their own conclusions about the published material.
| 857
Declaration of interest All interests are declared on the BJA website.
References 1. Kozek-Langenecker S, Fries D, Spahn DR, Zacharowski K III. Fibrinogen concentrate: clinical reality and cautious Cochrane recommendation. Br J Anaesth 2014; 112: 784–7 2. Wikkelsø A, Lunde J, Johansen M, et al. Fibrinogen concentrate in bleeding patients. Cochrane Database Syst Rev 2013; 8: CD008864 3. Wikkelsø AJ, Edwards M, Afshari A, et al. Pre-emptive treatment with fibrinogen concentrate for postpartum haemorrhage: randomized controlled trial. Br J Anaesth 2015; 114: 623–33 4. Samama CM. Fibrinogen concentrates and major bleeding in post partum haemorrhage? Don’t miss the most relevant population! Br J Anaesth 2015; 114: 548–50 doi:10.1093/bja/aev094
Quantifying and personalizing blood patch risk I. Delroy-Buelles* and R. Green Bournemouth, UK *E-mail: [email protected]
Editor—Providing consent for neuraxial procedures involves explanation and understanding of risk and benefit, and for the former we have increasing evidence.1 Consenting guidance from the The Association of Anaesthetists of Great Britain and Ireland mentions particularly disclosing information that would be important to the individual patient.2 The frequency of postdural puncture headache (PDPH) may be quoted as a percentage depending on procedure, patient, and clinician factors. But what does this number mean for the patient and can we clarify this particular risk any further? More specifically, what is their chance of requiring intervention for a PDPH? We decided to review data from our institution to reflect the risk of requiring an intervention for PDPH more accurately. We calculated epidural blood patch rates after neuraxial procedures (spinal, epidural, or lumbar puncture) at our district general hospital. We obtained the number of spinal and epidural procedures performed and the number of blood patches between April 2010 and March 2013. The number of diagnostic lumbar punctures was obtained from the cerebrospinal fluid samples sent to the laboratory in the same time period. In total, 7185 spinal and 997 epidural procedures were performed in theatre and 830 lumbar punctures on the wards in this time period. Seventeen epidural blood patches were performed, eight after a spinal procedure, giving around a one in 1000 risk, and six after lumbar puncture, giving around a one in 100 risk. Three patches were performed after epidurals, giving around a one in 300 risk, two of which were documented dural
taps. All patches performed were successful, data from one were missing, and three patches were repeated before success. Five of the lumbar puncture cases showed evidence of multiple attempts, though much of the documentation was poor and data were missing. Data collection for this project was simple and easy to do. Through education and review of the equipment used, we are now looking to reduce our patch rate after lumbar puncture. When consenting for neuraxial technique, we quote the risk of PDPH and can now add in the risk of requiring intervention (i.e. a blood patch) for this. We believe this gives more meaningful outcome information to patients to inform them better of the risk and consequences of PDPH in our hospital.
Declaration of interest None declared.
References 1. Cook TM, Counsell D, Wildsmith JAW; on behalf of the RCOA Third National Audit Project. Major complications of central neuraxial block: report on the Third National Audit Project of the Royal College of Anaesthetists. Br J Anaesth 2009; 102: 179–90 2. The Association of Anaesthetists of Great Britain and Ireland. Consent for Anaesthesia. London, revised edition 2006. doi:10.1093/bja/aev092
Downloaded from http://bja.oxfordjournals.org/ at Dalhousie University on May 18, 2015
integrity of the research and raises more suspicion about any published material. Therefore, given the current environment under which we operate, contrary to the implications of Bormann and colleagues in their letter, COPE remains a highly respected, well-regarded body to guide researchers and publishers in maintaining the highest possible standards of publication ethics, and the BJA is fully committed to the COPE guidelines. Having said that, the research community, authors, and editors should all be mindful of making continuous improvements in these standards, wherever the room for improvement exists, in order to maintain the scientific validity of published material. Finally, it is important that none of us should patronize our readers and underestimate their intelligence or their ability to exercise their own independent professional judgement. Depending upon how transparent the funders, researchers/ authors, editors and journals have been during the whole journey of conducting research or publishing a paper, readers will exercise their own considered discretion on the integrity of the process and will come to their own conclusions about the published material.
| 857