Clinical Update 2010: Epidural Blood Patch - SOAP

1 Clinical Update 2010 : Epidural Blood PatchMichael J. Paech, FANZCA, DMProfessor and Chair of Obstetric AnaesthesiaThe School of Medicine and Pharmacology, The University of Western Australia, Perth, Western AustraliaObjective: After this presentation participants will 1. Understand the place of Epidural Blood Patch as a therapy for headache2. Be able to obtain informed consent from obstetric patients with post-dural puncture headache3. Have a framework for the successful conduct of an Epidural Blood patchSummary: The results of expectant, symptom management of post-dural puncture headache are disappointing and Epidural Blood Patch (EBP) is effec-tive.

2 Anecdotal reports suggest it is effective for postural headache due to cerebrospinal fl uid leak in spontaneous intracranial hypotension. The effi cacy of EBP appears lower in the obstetric population, possibly related to gender, age or pregnancy/postpartum differences. In my opinion prophylactic EBP is not with a fi rm diagnosis of post-dural puncture headache should be advised of the benefi ts and risks of EBP and alternative treatments. Expectant management delays discharge but it appears that delaying EBP up to 48 hours improves success rates. Although 95% of patients obtain short-term relief of symptoms and complete relief usually persists if headache resulted from a small, non-cutting spinal needle, after unintentional dural puncture only 35-70% remain headache-free after several days and up to 40% of these patients request a second main adverse effects of EBP are vertebral pain during injection of Blood and post-procedural back pain (moderate in up to a third, lasting up to 5 days).

3 Repeat dural puncture and subarachnoid injection of Blood are concerns. Quantifying serious complications is not possible, but subdural hema-toma, cranial nerve palsy, seizures, radicular back pain and infection or arachnoiditis appear to be very conduct of EBP varies considerably, largely due to poor levels of evidence for specifi c practices. Expert opinion and best evidence supports perform-ing the procedure in a sterile fashion at or near the original intervertebral space, with the patient positioned laterally. The optimum volume after unin-tentional dural puncture appears to be 20 ml and ideally the patient should remain supine for 2 hours after the procedure.

4 Repeat EBP should only be undertaken after patient review and if the diagnosis is in any doubt, other pathologies must be Points:1. Epidural Blood Patch is the most effective therapy for post-dural puncture or low intracranial pressure-type Epidural Blood Patch completely relieves post-dural puncture headache in up to 95% of cases resulting from a spinal technique but less than half of those resulting from Epidural Awaiting spontaneous resolution of headache delays hospital discharge but EBP should preferably be delayed 24-48 hours after the onset of The EBP procedure requires sterility, avoidance of repeat dural puncture and injection of 20 ml of Blood , unless the volume is restricted by back pain5.

5 Other pathologies must be excluded if the headache is atypical or other features indicate that investigation is References:1. Seebacher J, Ribeiro V, LeGuillou L, Lacomblez L, Henry M, Thorman F, Youl B, Bensimon G, Darbois Y, Bousser MG: Epidural Blood Patch in the treatment of post dural puncture headache: A double blind study. Headache 1989; 29:630-22. Sandesc D, Lupei MI, Sirbu C, Plavat C, Bedreag O, Vernic C. Conventional treatment or Epidural Blood Patch for the treatment of different etiologies of post dural puncture headache. Acta Anaesthesiol Belg 2005;56:265-93. van Kooten F, Oedit R, Bakker SLM, Dippel DWJ: Epidural Blood Patch in postdural puncture headache: a randomised, observer-blind, controlled Clinical trial.

6 J Neurol Neurosurg Psychiatry 2008; 79:553-84. Taivainen T, Pitkanen M, Tuominen M, Rosenberg PH: Effi cacy of Epidural Blood Patch for post-dural headache. Acta Anaesthesiol Scand 1993; 37:702-55. Scavone BM, Wong CA, Sullivan JT, Yaghmour E, Sherwani SS, McCarthy RJ. Effi cacy of a prophylactic Blood Patch in preventing post dural punc-ture headache in parturients after inadvertent dural puncture. Anesthesiology 2004; 101:1422-76. Vilming ST, Kloster R, Sandvik L: When should an Epidural Blood Patch be performed in postlumbar puncture headache? A theoretical approach based on a cohort of 79 patients.

7 Cephalalgia 2005; 25:523-77. Paech M: Epidural Blood Patch myths and legends. Can J Anesth 2005; 52:6 Annual Meeting Supplement Harrington BE, Schmitt AM. Meningeal (postdural) puncture headache, unintentional dural puncture, and the Epidural Blood Patch . Reg Anesth Pain Med 2009; 34:430-79. Paech MJ, Doherty DA, Christmas T, Wong CA and the Epidural Blood Patch Trial Group. The volume of Blood for Epidural Blood Patch in obstetrics: A randomized, blinded Clinical trial (abstract). SOAP abstracts 2010