Prophylactic Intrathecal Morphine and Prevention of Post–Dural Puncture Headache

Abstract

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

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

“…Different intrathecal catheter medications have been evaluated to determine their ability to influence the rate of post‐dural puncture headache. Recent interest in the use of intrathecal morphine to prevent post‐dural puncture headache includes a small randomised controlled trial comparing 27 women who received intrathecal morphine 150 µg through the intrathecal catheter after delivery to a control group of 34 women who received 0.6–1 ml of intrathecal normal saline [33]. There was no difference in the incidence of post‐dural puncture headache or the need for epidural blood patch.…”

“…One study reported greater vasopressor use in the intrathecal catheter group than in the re‐sited epidural group (33/129 (25.6%) vs. 2/52 (3.8%), p < 0.001, OR (95%CI) 8.59 (1.98–37.28) [18]; the cause of this difference was presumed to be the effect of the lidocaine/epinephrine test dose in the intrathecal vs. epidural space. In a study using intrathecal morphine to diminish post‐dural puncture headache, respiratory rate and sedation level were assessed clinically by the nursing staff every hour for 12 h initially postpartum, followed by every 2 h for the next 12 h [33]. In a study of intrathecal catheter side‐effects by Izquierdo et al., women with intrathecal catheters received a post‐procedure assessment at 24, 48 and 72 h [18].…”

Comparison of external system and implanted system in intrathecal therapy for refractory cancer pain in China: A retrospective study

“…Other reasons include the regular disinfection measures and change of the external infusion tube in every visit with an interval of 2 weeks, care transitions in the long‐term ITT, and the careful prevention measures in daily life (Qin et al., 2020 ). The most frequent surgical complication was post‐dural puncture headache in both groups, which suggests no significant difference in the risk of pericatheter CSF leakage between the two ITT systems (Adler & Lotz, 2017 ; Peralta et al., 2020 ). The incidences of intrathecal opioid‐induced adverse events are much the same in the two groups, and the most frequent adverse events were nausea/vomiting and urinary retention, which is in accordance with other studies (J. H. Kim et al., 2013 ; Mastenbroek et al., 2017 ; Qin et al., 2020 ).…”

Risk Factors, Clinical Manifestation and Prevention of Post-Dural Puncture Headache in the Obstetric Field

“…A recent randomized double -blind controlled trial evaluated prophylactic intrathecal morphine injection for prevention of PDPH. The authors found that a single prophylactic morphine injection does not decrease the incidence or severity of PDPH [15]. Brinser et al [14] reviewed 80 cases where 38 women were given neuraxial morphine and 42 were not.…”