|
|
|
|
Purpose
|
To ensure appropriate and safe management of women with a Post Dural Puncture Headache (PDPH).
|
Definition of Terms
|
Post Dural Puncture Headache (PDPH)
|
Usually presents as a severe, dull and non-throbbing headache.
|
It is usually fronto-occipital and is aggravated when the woman sits up or strains (e.g. when coughing) and diminishes when the woman is lying flat.
|
It may or may not be accompanied with nausea and / or vomiting, anorexia, visual disturbances (photophobia, blurred vision), audio disturbances (tinnitus) and / or neck stiffness.
|
Dura / dural
|
Refers to the outer meningeal layer of the spinal cord.
|
Accidental Dural Puncture (ADP)
|
Inadvertent placement of the epidural needle, catheter or both through the dura, thereby creating a hole. This is not to be confused with spinal anaesthesia where inserting the spinal needle through the dural layer is intended as part of the procedure.
|
Epidural Blood Patch
|
Procedure undertaken for the treatment of a PDPH.
|
Acute Pain Service (APS)
|
The Acute Pain Service (APS) is a specialised service, offered as a division of the Department of Anaesthesia. The APS is co-ordinated by a clinical nurse consultant with the support of an anaesthetic registrar and consultant on a daily basis. The role of the APS includes the daily review of all women receiving analgesic therapy as well as the review of women following spinal / epidural anaesthesia to assess for complications.
|
Assessment / Investigations
|
Following epidural / spinal anaesthesia, all headaches which are not relieved with simple analgesia should be referred to the APS (Monday-Friday in-hours) or to the anaesthetic registrar covering the hospital (contacted via the Women's switchboard).
|
Assessment involves determining the nature of the headache and should include the following:
|
|
|
- severity (? interference with daily activities)
|
- postural element (i.e. Is the headache worse when sitting up / standing?)
|
- visual / audio disturbances
|
- analgesia given and if there has been some relief
|
|
A full neurological assessment should also be performed by the anaesthetic registrar at the initial review.
|
 |
Management
|
Recognised dural puncture at time of epidural insertion.
|
Guidelines for Anaesthetists:
|
- If needle puncture, thread catheter into subarachnoid space.
|
- If catheter puncture, leave catheter in CSF.
|
- Ensure that the catheter / filter is clearly labelled as 'subarachnoid'.
|
OR
|
- Alternatively, attempt to re-site the catheter at another space. If this is difficult, there is uncertainty with correct placement or another puncture occurs, contact the anaesthetic consultant in charge.
|
- Note: In the presence of an ADP, epidural boluses must be given by the anaesthetic registrar.
|
- The PCEA or continuous infusion techniques should not be utilised as there is an increased risk for total spinal block.
|
- The woman must be informed of the ADP and a management plan discussed with her. This management plan must be documented in the progress notes.
|
|
Presentation and Management of a PDPH
|
- Around 30-70% of patients with a known dural puncture will develop a PDPH.
|
- Otherwise, women will present with a PDPH when an accidental dural puncture has occurred during epidural insertion.
|
- Although rarer, a PDPH has occurred in women following spinal anaesthesia.
|
|
For women where a PDPH has been identified, the following steps should be taken:
|
0-24 hours following dural puncture
|
Encourage fluid intake
|
Ensures that the rate of CSF production is adequate. It is thought that improvements in the ratio of CSF production to CSF leak will improve the outcome. Dehydration can result in a decrease in CSF production. Conversely, in the presence of adequate hydration, there is no evidence to suggest that overhydration will increase the production of CSF any further.
|
Bedrest
|
Lying in the flat supine position is advised to lessen the severity of symptoms. If the headache is mild and does not interfere with daily activities, then bed rest is not necessary.
|
Analgesia
|
Mild PDPH
|
- paracetamol 4-6 hourly and a NSAID such as voltaren (unless contraindicated)
|
Moderate - Severe PDPH
|
- treat as with mild PDPH (above) plus an opioid (e.g. oxycodone and/or tramadol)
|
- SC, IV or PR routes should be considered in the presence of nausea and vomiting.
|
|
A 'PDPH Record' form (MR43004) must be completed by the anaesthetic registrar or a member of the APS team for patient follow-up by the APS (if not already completed).
|
24-48 hours following dural puncture
|
Women with a mild PDPH, which does not interfere with daily activities, then the above management should be continued.
|
Where the PDPH is moderate-severe and is interfering with daily activities, an epidural blood patch should be considered and discussed with the women.
|
An epidural blood patch should not be performed within the first 24 hours following dural puncture.
|
The anaesthetic consultant in charge should be notified when an epidural blood patch is considered.
|
Once completed, the details of the blood patch should be documented in the specified area on the 'PDPH Record' form (MR43004) and in the progress notes of the woman's medical record.
|
Please refer to the Women's procedure: Epidural Blood Patch.
|
General Considerations
|
The anaesthetic consultant is to be notified of women with a known or suspected ADP or PDPH during daytime hours.
|
The Post-Dural Puncture Headache Record (MR/43004) must be completed in the following instances:
|
 | | - at the time of a known dural puncture regardless of whether a headache develops
- at the time of identifying a possible post dural puncture headache.
|
|
|
|
This form allows continuity of patient care as it enables collation of information regarding management of the post dural puncture headache onto one form. The form will then be kept in the woman's medical record for reference for future admissions. A photocopy of the form will be kept in the Acute Pain Service office for discharge follow-up and QA purposes.
|
Women with a known ADP or PDPH should be reviewed daily by the APS (or by the anaesthetic registrar out of hours).
|
An epidural blood patch should be performed on women with a known ADP, who have typical symptoms of a PDPH of moderate to severe intensity and is associated with limitation of activity unless it is otherwise contraindicated (refer to procedure on epidural blood patch for contraindications).
|
Women who are referred or are picked up by the pain round who have had a regional anaesthetic without a known ADP but have a headache and display typical PDPH symptoms shall be treated as having had an ADP.
|
Women without a history of ADP and an atypical headache should be referred for physician/neurological assessment prior to consideration for an epidural blood patch.
|
Conservative management is indicated for women with a PDPH of mild to moderate severity without limitation of activity.
|
Discharge follow-up
|
Following discharge, women will be contacted by phone at one month and at six months to ensure symptoms have not returned or that new problems have not arisen.
|
Anyone needing a review will be seen by an anaesthetic registrar or consultant in the emergency department (if considered urgent) or in the Anaesthetic Assessment Clinic in Pre-admission Clinic (if considered non-urgent).
|
References
|
Dennehy KC, Rosaeg OP. Intrathecal catheter insertion during labour reduces the risk of post dural puncture headache. Can J Anaesth. 1998; 45:42-45.
|
Schwalbe S. Pathophysiology and management of post dural puncture headache: a current review. SOAP Newsletter (Fall 2000).
|
Sudlow C, Warlow C. Posture and fluids for preventing post dural puncture headache. The Cochrane Database of Systematic Reviews. 2001, Issue 2.
|
|
