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cefalea postpunción parturienta 2007

cefalea postpunción parturienta 2007

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Published by: Sergio Alberto Esquivel Méndez on Dec 24, 2011
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ANAestHesiA AND iNteNsiVe cAre MeDiciNe 8:8
© 2007 elv Ld. All gh vd.
Post-dral ptrada i t partrit 
Mhl HndkGay M sok
th oun o po-dual punu hadah (PDPH) a adn-al dual punu n h o pan  a dlang ondon.claal PDPH  poual n nau and may  aoad wh phoo-phoa, nk n, and naua and vomng. PDPH  a dagno o xluon and mu  dnguhd om oh au o popaumhadah. Vaou pvnav mau hav nludd hadng o annahal ah va a tuohy ndl, njon o nahal alna h m o punu and pophyla pdual lood pah (ebP).Managmn opon am o al h dual punu , onol alvaodlaaon and o csF volum. convav amn nlud, hydaon and h ppon o mpl analga, u h ma-u do no han h oluon o h hadah, no do hy duh qumn o pdual lood pahng. Phamaologal amnnlud al vaoono uh a an, umapan, andadnoooop homon, whh  hough o na csF podu-on. th dug do no pvn h nd o ebP u may gv ymp-oma l. ebP  h gold andad o PDPH amn, u h da aou whn  hould  don and how muh lood o nj.th pa a mo un  o dlay ebP o 24–48 hou and njappoxmaly 20 ml o lood, u o op njng  h pan xp-n akah. Long-m omplaon o ebP a a and h  noonandaon o uqun pdual analga.
adnal dual punu; anah hnqu; ompla-on; pdual lood pah; po-dual punu hadah
Post-dural puncture headache (PDPH) is the most requent com-plication o central neuraxial blockade. It is a debilitating con-dition, especially in the parturient, but prompt diagnosis andmanagement can treat it and prevent rare but serious sequelae.
Symptoms ad diaosis
Normally PDPH is experienced in the rontal or occipital regions anddevelops 24–48 hours ater dural puncture. It is postural in nature,worsening when changing position rom supine to sitting and by
Michele Hendricks,
 , is Specialist Registrar in anaesthesia at Queen Charlotte’s and Chelsea Hospital, London.
Gary M Stocks,
 , is Consultant anaesthetist at Queen Charlotte’sand Chelsea Hospital, London. He qualifed at St George’s Hospital,London, and trained in anaesthesia in London. His specialist interest is obstetric anaesthesia.
coughing or straining. It may be associated with nausea, vomiting,neck and shoulder stiness, hearing alteration, and visual distur-bances, such as photophobia. Rare presentations include cranialnerve palsy, convulsions and subdural haemorrhage.Other common and serious causes o postpartum headache(Table 1) should be considered beore a denitive diagnosis o PDPH is made.
The cause o PDPH is not known, but the loss o CSF through thedural tear causes cranial hypotension. This may result in head-ache by the ollowing mechanisms:traction on the intracranial structures that are pain sensitivereduced CSF volume, causing compensatory cerebralvasodilatationsudden loss o CSF, which activates adenosine receptors,causing cerebral vasodilatation.
Because o the obstetric patients’ youth and gender,
the inci-dence o PDPH ater accidental dural puncture with a 16–18GTuohy needle is as high as 75%. Choice o spinal needle is alsoan important determinant o PDPH incidence. The use o 27Gpencil-point Whitacre needles can reduce PDPH rates to as lowas 0.37% in non-obstetric patients.
Intrathecal placement of the epidural catheter via a Tuohyneedle:
in a retrospective study o 115 patients with accidentaldural puncture, the incidence o PDPH was signicantly reducedin those who had an intrathecal catheter compared with thosewho had an epidural resited. The reduction in PDPH rate wasgreatest in the group that had an intrathecal catheter let in placeor 24 hours (Figure 1).
Theoretically, the catheter blocks thedural hole, preventing urther CSF loss, and generates an infam-matory response, which acilitates rapid closure o the hole oncethe catheter is removed.‘Top-ups’ via an intrathecal catheter must be administered byan anaesthetist. An intrathecal catheter increases the risk o acci-dental injection o substances into the subarachnoid space.
Injection of intrathecal saline:
in a non-randomized study o 54 patients, Charlsley and Abram
compared the eects o aninjection o 10 ml normal saline into the intrathecal space at the
Diffrtial diaosis of postpartm ada
Non-pPo-dual punu hadahMnng/nphalMganPgnany-ndud hypnon (p-lampa)coal vn homocal umouinaanal/uaahnod hamohagsudual hamaoma
Tabl 1
ANAestHesiA AND iNteNsiVe cAre MeDiciNe 8:8
© 2007 elv Ld. All gh vd.
time o dural puncture with a control group. They demonstrateda signicant reduction in the incidence o PDPH (62% versus25%). The authors speculated that the injection o normal salinelimits the loss o CSF volume and prevents adenosine-receptoractivation, thereby reducing cerebral vasodilatation.
Prophylactic epidural blood patch
(EBP) is the injection o autologous blood into the epidural space soon ater accidentaldural puncture, but beore development o headache. Trials havereported conficting outcomes rom this procedure. It is not com-mon practice because a delayed, therapeutic EBP may be moreeective. Furthermore, during prophylactic EBP a patient whomay not go on to experience PDPH is exposed to a second pro-cedure with the associated risks.
Most treatment options relieve the symptoms o PDPH byattempting to:replace lost CSFminimize cerebral vasodilatationseal the dural puncture site.
Conservative treatment:
symptoms o PDPH are controlled, inthe expectation that the hole in the dura will seal spontaneously.Patients are advised to bed rest, maintain hydration and to takesimple analgesics, such as paracetamol and non-steroidal anti-infammatory drugs. Vandam and Dripps
showed that in morethan 10,000 spinal anaesthetics PDPH resolves when let untreated(Figure 2). Within 7 days, 72% o the patients recovered, and by6 months 87% had recovered.
When a dural puncture is madeby a small-bore spinal needle, conservative treatment is morelikely to work. However, when a dural puncture is made with alarge-bore needle in the obstetric population, symptoms may besevere and conservative treatment is oten ineective.
Pharmacological treatment
 Adrenocorticotropic hormone
may increase CSF production,and it has been used in the treatment o PDPH. However, a small,randomized controlled trial ailed to demonstrate a reductionin pain scores or EBP rates in patients receiving intramuscularsynacthen 1 mg, compared with saline placebo.
is a cerebral vasoconstrictor and has been used inthe treatment o PDPH, with doses o 300–500 mg twice daily.Caeine diminishes the severity o the PDPH but its eect istransient. Studies relating to the use o caeine in this conditionhave ailed to group patients according to the size o the needlepuncturing the dura, and so the benets o caeine are dicultto assess.
is a serotonin-receptor agonist, and is also acerebral vasoconstrictor. It is widely used or the treatment o migraine. Findings rom case reports suggest it may be eectivewhen given as a subcutaneous injection, but randomized con-trolled trials have not shown benets rom using this agent.
Epidural saline and dextran:
many units in the UK used crystal-loid or dextran 40 inusions via the epidural catheter to preventPDPH. Theoretically, fuid creates a ‘mass’ eect, similar to thato blood, and raises epidural pressure, thus reducing CSF leakageand resolving the headache. However, recent reviews have con-cluded that this method is not an eective treatment or PDPH.
Epidural blood patch
– EBP is still regarded as the gold standard treat-ment or PDPH, with success rates o up to 75%.
A proportiono patients will require a second EBP beore complete resolutiono symptoms occurs.
 Mechanism of action
– EBP seems to work in two ways. First,immediate pain relie is achieved through a tamponade eect,which raises intracranial pressure. Second, the injected bloodseals the dural puncture, preventing urther CSF leakage.
Nor-mal CSF production soon replenishes the lost CSF.
Threading an intrathecal catheter reduces therequirement for epidural blood patch
ResitedepiduralIntrathecalcatheterIntrathecal catheter(24 hours)
    P   r   o   p   o   r   t    i   o   n   o    f   p   a   t    i   e   n   t   s   r   e   q   u    i   r    i   n   g   e   p    i    d   u   r   a    l    b    l   o   o    d   p   a   t   c    h    (    %    )
Fir 1
The proportion of 10,098 non-obstetric patients whorecovered from PDPH when left untreated
PDPH, post-dural puncture headache
1–2 days3–4 days5–7 days8–14 days3–6 weeks3–6 months7–12 months
Proportion of patients (%)
Fir 2

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