Considerations for Epidural Blood Patch and Other Postdural Puncture Headache Treatments in Patients with COVID-19

Abstract

Background: A primary concern in the use of EBP in these patients is the possibility of seeding the virus in the CNS. Another important concern is related to the known hypercoagulable state in COVID-19 positive patients and associated organ dysfunction that may alter the metabolism of anticoagulants. The safety of the providers performing the EBP, the position of the patient and choices for image guidance (blind, fluoroscopic) are also key considerations to review. It is also important to explore the current state of knowledge about using allogenic instead of autologous blood as well as emerging techniques to eliminate the coronavirus from the blood. Objectives: In this article we pose the questions of how to manage PDPH in the COVID-19 positive patient and more specifically, the use of epidural blood patch (EBP). Methods: Literature review. Results: EBP is usually considered after the failure of conservative and pharmacological treatments. Because of the additional risks of EBP in COVID-19 patients it is important to also consider less traditional pharmacological treatments such as theophylinnes and cosyntropin that may offer some additional benefit for COVID-19 patient. Finally, other interventions other than EBP should also be considered including occipital nerve blocks, sphenopalatine ganglion blocks (infratemporal or transnasal). Limitations: A narrative review with paucity of literature. Conclusion: Going forward, an effective treatment for COVID-19 or a safe vaccine and a deeper understanding of the pathophysiology of the virus will certainly change the risk calculus involved in performing an EBP in a COVID-19 patient. Key words: COVID-19; PDPH; Epidural Blood Patch; Post-dural Puncture Headache

Efficacy of greater occipital nerve block for pain relief in patients with postdural puncture headache

“…However, the indications for this technique remain an important concern in certain clinical scenarios such as potential seeding of malignant cells [ 28 ] or viral particles [ 29 , 30 ] in the central nervous system as well as the effects of anticoagulants used for the known hypercoagulable state in COVID-19-positive patients. [ 29 , 30 ] Other complications from EBP also included secondary low back pain, lumbar vertebral syndrome, intrathecal blood injection, subacute subdural hematoma, and adhesive arachnoiditis. [ 27 , 31 ] Besides, many patients may not be candidates for EBP such as those with local infection or those who refuse the invasive procedure.…”

Recent update on epidural blood patch

“…Although more than 90% of PDPHs are self-limiting and resolve spontaneously in 7 to 10 days [ 1 , 14 ], long-term complications of PDPH may include chronic HA, hypoacusis, diplopia, sinus thrombosis, and subdural hematoma [ 8 , 15 ]. Moreover, in severe cases, it can cause cerebral herniation and even death if not treated promptly [ 1 , 4 , 5 , 16 , 17 ].…”

“…Information about the EBP, including risks, benefits, and alternative treatment, must be discussed and documented [ 4 ]. The patient is positioned prone with a pillow under the chest (for cervicothoracic EBP) or abdomen (for lumbar EBP) [ 17 ]. Strict asepsis should be ensured for both collecting blood and accessing the epidural space.…”

“…Strict asepsis should be ensured for both collecting blood and accessing the epidural space. Double asepsis with povidone iodine and chlorhexidine-alcohol is usually recommended [ 17 ]. The epidural space is first localized with fluoroscopy, and blood is drawn from the patient by an assistant.…”

Anesthesia Considerations for Pregnant People With COVID-19 Infection

“…For management of severe postdural puncture headache, an epidural blood patch should be discussed case by case because not treating severe postdural puncture headache is not recommended due to the risk of severe complications, 75 and alternative treatments such as sphenopalatine ganglion blocks are not recommended. 63 , 76 Safe use of epidural blood patch in obstetric cases with COVID-19 have been reported, one after labor epidural analgesia 77 and one after cesarean delivery, 78 although caution has been suggested 79 , 80 due to the hypercoagulable state and possible risk of central nervous system inoculation associated with autologous neuraxial blood injection.…”