North American Survey of the Management of Dural Puncture Occurring During Labour Epidural Analgesia

Abstract

To the Editor: I read with great interest the recent article of Aubin et al. describing the use of high frequency ventilation during the intraoperative care of an infant with diffuse bullous lesions. 1 The authors should be congratulated for the care they provided this child. They demonstrated the overlap of the intensive care unit and the operating room as well as the need for anesthesiolo-gists to maintain a working knowledge of new technology in both settings. In their discussion, the authors rightly state that P ET CO 2 cannot be measured during high frequency ventilation. 2 Although the authors state that arterial blood gases must be sampled to frequently, I would like to suggest another alternative. We published our experience with transcutaneous CO 2 monitoring during respiratory failure and following cardiothoracic surgery in infants and children. 3,4 In addition to the obvious problems with P ET CO 2 monitoring during high frequency ventilation, other factors including ventilation-perfusion inequalities, sampling errors, and patient positioning can interfere with its accuracy. In infants and children with respiratory failure, we found that transcutaneous monitoring provided a better estimation of PaCO 2. 3 Despite our success with this technology, its use outside the neonatal period and especially in the operating room remains limited. with recent advancements in the technology, transcutaneous CO 2 has become a simple, non-invasive way of estimating PaCO 2. We are currently investigating the applications of this technology in the adult population.

Expectant management of postdural puncture headache increases hospital length of stay and emergency room visits

“…1,2 The reported incidence of unintentional DP during epidural placement varies widely (0.04-6%) in North America. 3 Though prophylactic epidural blood patching (EBP) has been advocated by some when a large gauge DP is recognized, [4][5][6][7][8][9] in many institutions, management of such punctures is expectant and associated with a high rate (75-86%) of PDPH. 10,11 While concerns related to the risks and effectiveness of prophylactic EBP limit its widespread use, 12 expectant management is also likely to be associated with "costs."…”

The effect of epidural needle type on postdural puncture headache: a randomized trial

“…The incidence of ADP with a Tuohy epidural needle in parturients varies between 0.04% and 6%. 5 Postdural puncture headache may occur in up to 80% of these patients and is often debilitating. 6 The Sprotte spinal needle (Pajunk GMBH, Geisingen, Germany) has been associated with a low incidence of PDPH in parturients.…”

Intracranial subdural hematoma following dural puncture in a parturient with HELLP syndrome

“…The differential diagnosis includes PDPH, preeclamptic toxemia, migraine, simple tension headache, subdural or subarachnoid hemorrhage, cortical vein thrombosis and meningitis. 7 …”