Page 313 Guide to Pain Management in Low-Resource Settings

Post-Dural Puncture Headache 301

to be decreased by bed rest, which could be consid- When should you perform
ered purely a symptomatic treatment. Treatment with an epidural blood patch?
nonopioid analgesics such as paracetamol (acetamino- As postdural puncture headache is self-limiting in most
phen) or other drugs such as caff eine, sumatriptan, or cases, and as EBP is not without risks (see above), it is
fl unarizine is poorly supported by scientifi c evidence. recommended only if headache is very incapacitat-
Th e same is true for fl uid “therapy.” A recent study sup- ing and it interferes with the patient’s recovery or as in
ported the use intravenous theophylline (200 mg the- the case of postpartum females, it prevents them from
ophylline in 100 mL 5% dextrose over 40 minutes). breastfeeding or bonding with their child. Being poorly
Th e only treatment that has proved to be at mobile or bedridden also increases the incidence of a
least partly eff ective is the epidural injection of blood deep vein thrombosis and fatal pulmonary emboli.
known as an “epidural blood patch” (EBP). Th e best
results from studies indicate that with the correct in- Are there any dangerous complications of
dication, a blood patch might terminate PDPH in one PDPH if unrelieved by an epidural blood patch?
out of fi ve patients. After repeated blood patching, A rare complication of an untreated PDPH is a subdural
this number might increase to more than a 90% suc- hematoma due to traction on cerebral veins. An infre-
cess rate. It is used if symptomatic treatment fails, the quent, indirect complication is a deep vein thrombosis
intensity of pain is high, and the patient is severely due to bed rest, as mentioned above.
incapacitated. Th is method is especially relevant in
postpartum females if they are unable to breastfeed or Pearls of wisdom
bond with their babies. However, there is no consent
on the optimal time of neither an EBP nor the amount • Diagnostic criteria: postural headache shortly af-
of blood that should be used. As EBP may cause even ter neuraxial puncture (spinal or accidental dural
more complications (see below) and as a PDPH is un- puncture during an epidural).
pleasant but very often self-limiting and rarely life- • Diff erential diagnoses: any other forms of head-
threatening, the indication to perform an EBP should ache (tension headache, migraine), intracranial
be made with precaution and performed by experi- hematoma and venous thrombosis, meningitis,
enced, senior staff . and in case of postpartum females, eclampsia. Al-
ways check for focal neurological defi cits, head-
How do you perform an epidural blood patch? ache independent of upright position, neck stiff -
Basically, an EBP is performed in the same way as an ness, fever, blurred vision, confusion, vomiting,
epidural anesthesia. Instead of injecting a local anes- and photophobia.
thetic drug, 10–20 mL of the patient’s blood, imme- • With a history of neuraxial puncture with typical
diately drawn, is used. You need two persons for the symptoms, no further laboratory work or radiol-
procedure itself and, if available, a third person assist- ogy examination is necessary.
ing. One person performs the epidural, often one seg- • Treatment: reclining or supine position, oral fl u-
ment below or above the former insertion site. Th e sec- ids (but not too much); consider EBP only if the
ond person draws the blood immediately after the fi rst headache severely interferes with the patient’s
person has identifi ed the epidural space under absolute daily life and an experienced team is available.
aseptic conditions (surgical skin disinfection, sterile Balance the risks of EBP and the normal sponta-
gloves, gown, mask) from an easily accessible vein and neous relief of postdural puncture headache with-
passes the syringe with the blood to the fi rst person for in 3 to 7 days.
epidural injection. • PDPH persisting for more than 1 week should be
Possible complications include all problems as- an indication for EBP.
sociated with an epidural, such as infection, hematoma,
and nerve damage, and, of course, another perforation References
of the dura and a subsequent CSF leak. Th erefore, and
[2] Sprigge JS, Harper SJ. Accidental dural puncture and post dural punc-
because the fact that PDPH has occurred might indicate ture headache in obstetric anesthesia: presentation and management: a
diffi cult puncture conditions, blood patching should be 23-year survey in a district general hospital. Anaesthesia 2008;63:36–43.
[1] Th ew M, Paech MJ. Management of postdural puncture headache in
performed only by experienced clinicians! the obstetric patient. Curr Opin Anaesthesiol 2008;21:288–92.