Intrathecal catheterisation after observed accidental dural puncture in labouring women: update of a meta-analysis and a trial-sequential analysis

Hilber, N.; Rijs, K.; Marel, C. van der; Rossaint, Rolf; Schäffer, Leonhard; Klimek, Markus

doi:10.1016/j.ijoa.2019.08.001

Cited by 23 publications

(24 citation statements)

References 31 publications

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“…It should be noted that we did not find any benefit from intrathecal catheter placement in the prevention of persistent headache, a result that is in line with the negative outcome from a recent meta‐analysis [25]. However, epidural blood patch had a protective impact on the incidence and severity of persistent headache at 18 months, consistent with other studies [14,16].…”

Section: Discussionsupporting

confidence: 89%

Persistent headache and low back pain after accidental dural puncture in the obstetric population: a prospective, observational, multicentre cohort study

et al. 2021

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Summary Accidental dural puncture following epidural insertion can cause a post‐dural headache that is defined by the International Headache Society as self‐limiting. We aimed to confirm if accidental dural puncture could be associated with persistent headache and back pain when compared with matched control parturients. We performed a prospective multicentre cohort study evaluating the incidence of persistent headache following accidental dural puncture at nine UK obstetric units. Parturients who sustained an accidental dural puncture were matched with controls who had undergone an uneventful epidural insertion. Participants were followed‐up at six‐monthly intervals for 18 months. Primary outcome was the incidence of persistent headache at 18 months. Ninety parturients who had an accidental dural puncture were matched with 180 controls. The complete dataset for primary analysis was available for 256 (95%) participants. Incidence of persistent headache at 18 months was 58.4% (52/89) in the accidental puncture group and 17.4% (29/167) in the control group, odds ratio (95%CI) 18.4 (6.0–56.7), p < 0.001, after adjustment for past history of headache, Hospital Anxiety and Depression Scale (depression) and Hospital Anxiety and Depression Scale (anxiety) scores. Incidence of low back pain at 18 months was 48.3% (43/89) in the accidental puncture group and 17.4% (29/167) in the control group, odds ratio (95%CI) 4.14 (2.11–8.13), with adjustment. We have demonstrated that accidental dural puncture is associated with long‐term morbidity including persistent headache in parturients. This challenges the current definition of post‐dural puncture headache as a self‐limiting condition and raises possible clinical, financial and medicolegal consequences.

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Section: Discussionsupporting

confidence: 89%

Persistent headache and low back pain after accidental dural puncture in the obstetric population: a prospective, observational, multicentre cohort study

et al. 2021

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“…Most studies have indicated satisfactory labour analgesia with intrathecal catheters [2, 15, 18, 21–23, 26, 28]. In a recent meta‐analysis, the overall relative risk (95%CI) for adequate analgesia after intrathecal catheter insertion compared with re‐siting the epidural catheter was 1.05 (0.83–1.32), showing no difference between the two techniques [7]. Since this meta‐analysis was published, a retrospective study found that women with accidental dural puncture managed by intrathecal catheter insertion had less pain throughout labour compared with women managed by re‐siting the epidural [18].…”

Section: Resultsmentioning

confidence: 99%

“…In a recent meta‐analysis and trial sequential analysis of 13 studies representing a total of 1653 patients, the relative risk (95% CI) of developing a post‐dural puncture headache after intrathecal catheter insertion (compared with epidural catheter re‐siting) was 0.82 (0.71‐0.95) and the relative risk (95% CI) of requiring an epidural blood patch was 0.62 (0.49‐0.79). However, the trial sequential analysis suggested that there was insufficient evidence to draw a firm conclusion [7]. A recent study that was not included in this 2020 meta‐analysis was a retrospective study published with 129 women in the intrathecal catheter group and 52 in the re‐sited epidural group; this study showed a significant decrease both in post‐dural puncture headache (21.7% vs. 67.3%, p < 0.001) and the need for epidural blood patch (12.4% vs. 50.0%, p < 0.001) when an intrathecal catheter was inserted, compared with epidural catheter re‐siting after an accidental dural puncture [18].…”

Section: Resultsmentioning

confidence: 99%

“…Whether an intrathecal catheter for labour analgesia reduces the incidence of post‐dural puncture headache or need for an epidural blood patch has been questioned [7]. Moreover, there is limited information on the practical clinical management of an intrathecal catheter for labour analgesia, which can lead to variation in practices and an increased risk of adverse effects, including total spinal anaesthesia.…”

Section: Introductionmentioning

confidence: 99%

“…Whether an intrathecal catheter for labour analgesia reduces the incidence of post-dural puncture headache or need for an epidural blood patch has been questioned [7].…”

Section: Introductionmentioning

confidence: 99%

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Intrathecal catheter use after accidental dural puncture in obstetric patients: literature review and clinical management recommendations

et al. 2021

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Summary If an accidental dural puncture occurs, one option is to insert a catheter and use it as an intrathecal catheter. This avoids the need for a further injection and can rapidly provide labour analgesia and anaesthesia for caesarean section. However, there are no recommendations for managing intrathecal catheters and, therefore, significant variation in clinical practice exists. Mismanagement of the intrathecal catheter can lead to increased motor block, high spinal anaesthesia, drug error, hypotension and fetal bradycardia. Care must be taken with an intrathecal catheter to adhere to strict aseptic technique, meticulous labelling, cautious administration of medications and good communication with the patient and other staff. Every institution considering the use of intrathecal catheters should establish a protocol. For labour analgesia, we recommend the use of dilute local anaesthetic agents and opioids. For caesarean section anaesthesia, gradual titration to the level of the fourth thoracic dermatome, with full monitoring, in a facility equipped to manage complications, should be performed using local anaesthetics combined with lipophilic opioids and morphine or diamorphine. Although evidence of the presence and duration of intrathecal catheters on the development of post‐dural puncture headache and need for epidural blood patch is limited, we suggest considering leaving the intrathecal catheter in for 24 hours to reduce the chance of developing a post‐dural puncture headache while maintaining precautions to avoid drug error and cerebrospinal fluid leakage. Injection of sterile normal saline into the intrathecal catheter may reduce post‐dural puncture headache. The level of evidence for these recommendations was low.

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Consensus Practice Guidelines on Postdural Puncture Headache From a Multisociety, International Working Group

Uppal,

Russell,

Sondekoppam

et al. 2023

JAMA Netw Open

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ImportancePostdural puncture headache (PDPH) can follow unintentional dural puncture during epidural techniques or intentional dural puncture during neuraxial procedures, such as a lumbar puncture or spinal anesthesia. Evidence-based guidance on the prevention, diagnosis, and management of this condition is, however, currently lacking.ObjectiveTo fill the practice guidelines void and provide comprehensive information and patient-centric recommendations for preventing, diagnosing, and managing PDPH.Evidence ReviewWith input from committee members and stakeholders of 6 participating professional societies, 10 review questions that were deemed important for the prevention, diagnosis, and management of PDPH were developed. A literature search for each question was performed in MEDLINE on March 2, 2022. Additional relevant clinical trials, systematic reviews, and research studies published through March 2022 were also considered for practice guideline development and shared with collaborator groups. Each group submitted a structured narrative review along with recommendations that were rated according to the US Preventive Services Task Force grading of evidence. Collaborators were asked to vote anonymously on each recommendation using 2 rounds of a modified Delphi approach.FindingsAfter 2 rounds of electronic voting by a 21-member multidisciplinary collaborator team, 47 recommendations were generated to provide guidance on the risk factors for and the prevention, diagnosis, and management of PDPH, along with ratings for the strength and certainty of evidence. A 90% to 100% consensus was obtained for almost all recommendations. Several recommendations were rated as having moderate to low certainty. Opportunities for future research were identified.Conclusions and RelevanceResults of this consensus statement suggest that current approaches to the treatment and management of PDPH are not uniform due to the paucity of evidence. The practice guidelines, however, provide a framework for individual clinicians to assess PDPH risk, confirm the diagnosis, and adopt a systematic approach to its management.

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Intrathecal catheterisation after observed accidental dural puncture in labouring women: update of a meta-analysis and a trial-sequential analysis

Cited by 23 publications

References 31 publications

Persistent headache and low back pain after accidental dural puncture in the obstetric population: a prospective, observational, multicentre cohort study

Persistent headache and low back pain after accidental dural puncture in the obstetric population: a prospective, observational, multicentre cohort study

Intrathecal catheter use after accidental dural puncture in obstetric patients: literature review and clinical management recommendations

Consensus Practice Guidelines on Postdural Puncture Headache From a Multisociety, International Working Group

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