Neuraxial morphine after unintentional dural puncture is not associated with reduced postdural puncture headache in obstetric patients

Brinser, Molly E.; Seng, David L.; Mandell, Gordon L.; Waters, Jonathan H.; Dalby, Patricia L.; Lim, Grace

doi:10.1016/j.jclinane.2018.09.009

Cited by 14 publications

(22 citation statements)

References 16 publications

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“…The difference between our results and those of Al-metwalli is surprising, given that spinal and epidural morphine presumably work by similar mechanisms. In addition to the route of morphine administration, the two studies differed in the total dose and timing of administration, the Al-metwalli protocol included a second morphine dose after 24 h. Similar to our findings, in a retrospective analysis of 80 patients exposed to either epidural or intrathecal morphine after an unintentional dural puncture, Brinser et al 25 reported no difference in the incidence of post-dural puncture headache with morphine exposure (48.2%) compared with no exposure (51.8%). After controlling for a history of preeclampsia and mode of delivery the adjusted odds ratio for a post-dural puncture headache was 1.24 (95% CI, 0.13 to 2.33) with neuraxial morphine exposure.…”

Section: Perioperative Medicinesupporting

confidence: 81%

Prophylactic Intrathecal Morphine and Prevention of Post–Dural Puncture Headache

et al. 2020

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Background Prophylactic epidural morphine administration after unintentional dural puncture with a large-bore needle has been shown to decrease the incidence of post–dural puncture headache. The authors hypothesized that prophylactic administration of intrathecal morphine would decrease the incidence of post–dural puncture headache and/or need for epidural blood patch after unintentional dural puncture. Methods Parturients with an intrathecal catheter in situ after unintentional dural puncture with a 17-g Tuohy needle during intended epidural catheter placement for labor analgesia were enrolled in this randomized, double-blind trial. After delivery, subjects were randomized to receive intrathecal morphine 150 µg or normal saline. The primary outcome was the incidence of post–dural puncture headache. Secondary outcomes included onset, duration, and severity of post–dural puncture headache, the presence of cranial nerve symptoms and the type of treatment the patient received. Results Sixty-one women were included in the study. The incidence of post–dural puncture headache was 21 of 27 (78%) in the intrathecal morphine group and 27 of 34 (79%) in the intrathecal saline group (difference, −1%; 95% CI, −25% to 24%). There were no differences between groups in the onset, duration, or severity of headache, or presence of cranial nerve symptoms. Epidural blood patch was administered to 10 of 27 (37%) of subjects in the intrathecal morphine and 11 of 21 (52%) of the intrathecal saline group (difference 15%; 95% CI, −18% to 48%). Conclusions The present findings suggest that a single prophylactic intrathecal morphine dose of 150 µg administered shortly after delivery does not decrease the incidence or severity of post–dural puncture headache after unintentional dural puncture. This study does not support the clinical usefulness of prophylactic intrathecal morphine after an unintentional dural puncture. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

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Section: Perioperative Medicinesupporting

confidence: 81%

Prophylactic Intrathecal Morphine and Prevention of Post–Dural Puncture Headache

et al. 2020

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“…We found 16 studies detailing labour analgesia through an intrathecal catheter after accidental dural puncture [2, 8, 15, 18, 19, 21–31] (Table 1 and online Supporting Information Table S1). Of these, 13 were retrospective [2, 8, 18, 19, 22, 23, 25–31], two were prospective observational [21, 24] and one was a randomised controlled trial [15]. All of these studies exclusively discussed only the management of accidental dural puncture occurring during labour [2, 15, 18, 19, 21–31], except that of Verstraete et al, which also discussed accidental dural punctures occurring during caesarean sections and fetal surgery [8].…”

Section: Resultsmentioning

confidence: 99%

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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“…In contrast, other studies did not prove the protective effect of neuraxial opioids for the prevention of PDPH after ADP with epidural analgesia. [ 21 22 ] Brinser et al . [ 22 ] depended on retrospective medical records.…”

Section: Discussionmentioning

confidence: 99%

“…[ 21 22 ] Brinser et al . [ 22 ] depended on retrospective medical records. Moreover, their sample size was small, and the mode of delivery was significantly different between both groups i.e., incidence of vaginal delivery was 50% in the morphine group vs. 2% in the group not administered morphine.…”

Section: Discussionmentioning

confidence: 99%

Effect of intrathecal fentanyl on the incidence, severity, and duration of postdural puncture headache in parturients undergoing caesarean section: A randomised controlled trial

2020

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Background and Aims: Postdural puncture headache (PDPH) is a side effect of spinal anaesthesia (SA). This study was conducted to investigate the effect of intrathecal fentanyl on the incidence, severity, and duration of PDPH. Methods: This was a prospective randomised controlled study including 220 parturients, who underwent Caesarean section (CS). They were divided into two groups for administration of SA with bupivacaine (bupivacaine group [B0], n = 111) or bupivacaine with fentanyl (bupivacaine fentanyl group [BF], n = 109). Haemodynamics, quality of anaesthesia, maternal side effects, and postoperative analgesia were noted. The neonatal Apgar score was recorded. The patients were followed up for 14 days after CS for the occurrence of PDPH, and its severity and duration. The collected data were statistically analysed, using the Statistical Package for the Social Sciences software version 25. Results: Regarding haemodynamics, heart rate increased at 5 min post-induction and blood pressure decreased at 2min post-induction in both groups. Excellent intraoperative anaesthesia was obtained in 91.7% and 79.3% of cases in groups BF and B0, respectively ( P < 0.01). Longer duration of postoperative analgesia was present in the BF group as compared to the B0 group ( P < 0.001). The incidence of PDPH decreased in the BF group in a non-significant manner, whereas its severity and duration increased significantly in the B0 group. Conclusion: Although the addition of intrathecal fentanyl to bupivacaine for SA in CS patients did not reduce the incidence of PDPH significantly, its severity and duration decreased significantly.

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Neuraxial morphine after unintentional dural puncture is not associated with reduced postdural puncture headache in obstetric patients

Cited by 14 publications

References 16 publications

Prophylactic Intrathecal Morphine and Prevention of Post–Dural Puncture Headache

Prophylactic Intrathecal Morphine and Prevention of Post–Dural Puncture Headache

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

Effect of intrathecal fentanyl on the incidence, severity, and duration of postdural puncture headache in parturients undergoing caesarean section: A randomised controlled trial

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