Cosyntropin for Cosyntropin for Prophylaxis against Prophylaxis against Postdural Puncture Postdural Puncture Headache after Headache after Accidental Dural Accidental Dural Puncture Puncture Department of Anesthesiology, Faculty of Department of Anesthesiology, Faculty of Medicine, Ain Shams University, Cairo, Medicine, Ain Shams University, Cairo, Egypt Egypt Anesthesiology :August 2010 Anesthesiology :August 2010 Sheeba Hakak. Sheeba Hakak.
Transcript
Cosyntropin for Cosyntropin for Prophylaxis against Prophylaxis against Postdural Puncture Postdural Puncture
Headache after Headache after Accidental Dural Accidental Dural
PuncturePunctureDepartment of Anesthesiology, Faculty of Department of Anesthesiology, Faculty of Medicine, Ain Shams University, Cairo, EgyptMedicine, Ain Shams University, Cairo, Egypt
► Investigate the effect of administration Investigate the effect of administration of cosyntropin after accidental dural of cosyntropin after accidental dural puncture (ADP) on the incidence of puncture (ADP) on the incidence of post-dural puncture headache (PDPH) post-dural puncture headache (PDPH) and the need for therapeutic epidural and the need for therapeutic epidural blood patch (EBP).blood patch (EBP).
►A secondary aim was to study the effect A secondary aim was to study the effect of this intervention on the severity of of this intervention on the severity of PDPH and the need for repeat EBP.PDPH and the need for repeat EBP.
BackgroundBackground
► Incidence of inadvertent dural tap at Incidence of inadvertent dural tap at attempted epidural placement in obstetric attempted epidural placement in obstetric patients is 0.4–6%.patients is 0.4–6%.
► 75–86% of the incidents are complicated by 75–86% of the incidents are complicated by postdural puncture headache .postdural puncture headache .
► Associated with a significant increase in the Associated with a significant increase in the hospital length of stay.hospital length of stay.
► Role of prophylactic administration Role of prophylactic administration cosyntrophin on PDPH is unclear.cosyntrophin on PDPH is unclear.
Cosyntrophin in PDPHCosyntrophin in PDPH
►Precise mechanism of action not Precise mechanism of action not known.known.
►ACTH stimulates aldosterone release.ACTH stimulates aldosterone release.► Increased CSF production.Increased CSF production.►ACTCH interaction with opioid ACTCH interaction with opioid
►95 parturients, who had epidural 95 parturients, who had epidural analgesia for normal vaginal delivery analgesia for normal vaginal delivery and who suffered an inadvertent dural and who suffered an inadvertent dural tap, were included in this study. tap, were included in this study.
►Exclusion criteria were Exclusion criteria were contraindication to steroid or ACTH contraindication to steroid or ACTH therapy (therapy (e.g., hypertension or diabetes e.g., hypertension or diabetes mellitus), preeclampsia, or mellitus), preeclampsia, or contraindication to EBP (e.g., fever or contraindication to EBP (e.g., fever or leukocytosis).leukocytosis).
Technique of Epidural blockTechnique of Epidural block► Anaesthesiologist.Anaesthesiologist.► 16 or 18 g Needle.16 or 18 g Needle.► Sitting or lying down.Sitting or lying down.► Loss of resistance to saline.Loss of resistance to saline.► Median or paramedian approach.Median or paramedian approach.► Site of block.Site of block.► Dural Tap……… Withdraw needle and try epidural at Dural Tap……… Withdraw needle and try epidural at
other space.other space.► Catheter threaded 3 cm into the epidural space and Catheter threaded 3 cm into the epidural space and
tested with 3 ml of 2% lidocaine with 1:200,000 tested with 3 ml of 2% lidocaine with 1:200,000 epinephrine.epinephrine.
► Loading dose of 8–15 ml of 0.125% bupivacaine and 50 Loading dose of 8–15 ml of 0.125% bupivacaine and 50 μg of fentanyl .μg of fentanyl .
► Infusion of 0.125% bupivacaine with fentanyl 2 μg/ml at a Infusion of 0.125% bupivacaine with fentanyl 2 μg/ml at a rate of 8–15 ml/h.rate of 8–15 ml/h.
Diagnosis of post dural puncture Diagnosis of post dural puncture headacheheadache
►Headache within 5 days after dural Headache within 5 days after dural puncture, which worsened within 15 min puncture, which worsened within 15 min of sitting or standing, and improved within of sitting or standing, and improved within 15 min after lying, with at least one of the 15 min after lying, with at least one of the following criteria: neck stiffness, tinnitus, following criteria: neck stiffness, tinnitus, hypacusia, photophobia, or nausea.hypacusia, photophobia, or nausea.
►Patients who did not develop PDPH for 48 Patients who did not develop PDPH for 48 h after ADP and who were ambulating h after ADP and who were ambulating normally were discharged from the normally were discharged from the hospital with the instruction to come back hospital with the instruction to come back for reassessment if they experience any for reassessment if they experience any headache.headache.
Management of acute dural Management of acute dural puncturepuncture
►Patient admitted to hospital for 48 hrs.Patient admitted to hospital for 48 hrs.►Patient to report headache and Patient to report headache and
encouraged to ambulate ,take plenty encouraged to ambulate ,take plenty of fluids and stool softners prescribed.of fluids and stool softners prescribed.
►Headache inquired every 8hrs.Headache inquired every 8hrs.
Management of post dural Management of post dural puncture headachepuncture headache
►Conservative management for 48hrs. Conservative management for 48hrs. Fluids/NSAIDS/ Mepireden.Fluids/NSAIDS/ Mepireden.
►Epidural blood patch.Epidural blood patch.►Redo epidural blood patch if no Redo epidural blood patch if no
improvement within 24 hrs of blood improvement within 24 hrs of blood patch.patch.
►Patients followed up for 14 days post Patients followed up for 14 days post blood patch.blood patch.
ResultsResults
ConclusionConclusion
►Significant reduction in the incidence of Significant reduction in the incidence of PDPH and the need for EBP. PDPH and the need for EBP.
►Significant prolongation of the time from Significant prolongation of the time from ADP to occurrence of PDPH.ADP to occurrence of PDPH.
►No influence either the duration or the No influence either the duration or the severity of the headache. severity of the headache.
► In patients who developed PDPH, In patients who developed PDPH, prophylactic administration of cosyntropin prophylactic administration of cosyntropin did not seem to influence the need of either did not seem to influence the need of either EBP or repatching.EBP or repatching.
