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Postdural puncture headache (PDPH)

Postdural puncture headache (PDPH). by R2 吳佩諭 2002/12/2. Anatomy/Pathophysiology. Loss of CSF without compensatory replacement leads to the sequelae. PDPH usually occurs 24-48 hr after dura puncture The decrease of CSF amount elicits two main responses:

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Postdural puncture headache (PDPH)

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  1. Postdural puncture headache (PDPH) • by R2吳佩諭 • 2002/12/2

  2. Anatomy/Pathophysiology • Loss of CSF without compensatory replacement leads to the sequelae. • PDPH usually occurs 24-48 hr after dura puncture • The decrease of CSF amount elicits two main responses: • 1.cranial vasodilation, predominantly on venous side compared with arterial vessels. The pressure gradient may itself account for the PDPH. • 2.the loss of cushion places tension on sensitive nerves and vessels.

  3. Clinical presentation • In upright position with relief in supine position • Bilateral pain in frontal, temporal and occipital regions (fifth and third cranial n.) • Visual changes (sixth) may persist after resolution of the headache. • Tinnitus, hearing loss, vertigo, ataxia, neck stiffness, and localized muscle spasms

  4. Incidence/Severity • Spinal/epidural anesthesia; radiologic and diagnostic procedures • Overall incidence:1%-30% • mild(49%) moderate(35%) • Severe(15%)

  5. Cause • Age: inversely proportional to the age after 20 • Sex: female • Pregnancy • Antiseptics: povidone-iodine • Anesthetic agents: • lidocaine-glucose(9.54%); bupivacaine-glucose(7.64%); tetracaine-procaine(5.85)

  6. Prevention • Posture: supine for 24 hr • Needle design: Quinke vs. Whitacre • Needle diameter • Bevel direction: parallel to the longitudinal fibers of dura • Angle of insertion: acute angle of approach to the dura membrane

  7. Treatment • Only headaches affected by posture should be considered PDPH. • After spinal anesthesia the rate of headaches that are not PDPH varies between 5% and 16%. (tension headache, migraine headache, SAH, meningitis) • 24 hr of conservative tx (bed rest, analgesics)  if headache persists or nausea, vomiting, visual disturbance or tinnitus occurs, reconsider the dx.

  8. Treatment- pharmacologic intervention • Goals:(1) replace the lost CSF fluid, (2) seal the puncture site, (3)control the vasodilation with cerebral vasoconstrictors. • Methylxanthines • Cerebral vasoconstriction: antagonize the effect of adenosine • Increase CSF production by stimulating the Na-K pumps

  9. Adverse effects: GI disturbances, nervous ness, insomnia, tremors • Caffeine sodium bezoate(CSB) 0.5g • Theophylline • Sumatriptan: binding to 5-HT1d receptors

  10. Epidural blood patch(EBP) • Indications: failed conservative treatment; prophylaxis • Contraindications: pt refusal, coagulopathy, sepsis, local infection; febrile pt, HIV-infected pt • Timing: beyond 24 hr after dural puncture • Volume of injectate: 10-15 mL • 2 hours of recumbent positioning after patching may improve the efficacy of EBP.

  11. Does EBP prevent or reverse the complcations of dural pumcture? • Cranial n.palsy; auditory disturbance; seizure • Effectiveness: • >90% • 61-75% persistent relief; 90% initial relief • How does EBP work: • Plug theory • Pressure patch hypothesis

  12. Does EBP have an impact on future epidural work? • Previous dural puncture may impair subsequent epidural anesthesia, whether or not EBP is performed for PDPH. • Alternatives to blood in EBP: • Epidural crystalloid/ colloid administration • The exact volume and rate of epidural NaCl injection should be guided by pt’s symptoms. • Are prophylaxis epidural patches effective?

  13. References • A rational approach to the cause, prevention and treatment of postdural puncture headache. Can med assoc J 1993;149(8) 1087-1093 • The epidural blood patch.Resolving the controversies. Can J anesth 1999;46(9) 878-886 • Pharmacologic management of postdural puncture headache. The Annals of pharmacotherapy 1996; 30, 831-839 • Epidural blood patch. European Journal of anesthesiology 1999;16, 211-215 • Postdural puncture headache and extradural blood patch. British Journal of Anesthesia 1993; 71(2)179-181

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