PDPH and FOCAL NEUROLOGIC DEFICIT after obstetric regional anesthesia

Transcription

1 PDPH and FOCAL NEUROLOGIC DEFICIT after obstetric regional anesthesia Eva Roofthooft, MD Consultant Anesthetist, Department of Anesthesiology, ZNA Middelheim and Paola Children s Hospital, Antwerp Marc Van de Velde, MD, PhD, EDRA Professor of Anaesthesia, Catholic University Leuven (KUL) Chair Department of Anaesthesiology, University Hospitals Leuven (UZL) Leuven, Belgium ZNA Middelheim Hospital Paola Children s Hospital Antwerp, Belgium

2 Lecture outline PDPH FOCAL NEUROLOGIC DEFICIT

3 PDPH lecture outline Clinical Picture Differential Diagnosis Pathophysiology Spinal Anesthesia Epidural Anesthesia and Accidental Dural Puncture (ADP) Risk Factors and Prevention of ADP Prevention PDPH when ADP occurred Management of PDPH Long Term Effects of PDPH, Bloodpatch and ADP

4 PDPH characteristics. History of a procedure that perforated the dura: LP Spinal, epidural, CSE Myelography Spontanuous PDPH has been described. Onset within 5 days after procedure. Duration 2 to 7 days, occasionally longer. Clinical diagnosis no validated diagnostic tools.

5 Photophobia. Nausea and vomiting. Neck stiffness Tinnitus. Diplopia. Dizziness. Low back pain. Postural aspect

6 Clinical Picture Differential Diagnosis Pathophysiology Spinal Anesthesia Epidural Anesthesia and Accidental Dural Puncture (ADP) Risk Factors and Preevntion of ADP Prevention PDPH when ADP occurred Management of PDPH Long Term Effects of PDPH, Bloodpatch and ADP

7 - Radiologic evidence. - Sagging of pons against bone can result in cranial nerve palsies. Low CSF volume Brain volume = constant upright CSF moves into spinal sac Lost CSF must be replaced Brain moves and loses cusheon in intracranial blood volume Downward tension on meninges, nerves and vessels Arterial and venous vasodilation CSF leakage CSF hypovolemia (>10%) Doppler Ultrasound Adenosine receptor, therapeutic effect of caffeine

8 Risk factors for PDPH. Bezov et al. Headache 2010; 50,

9 Risk factors for PDPH. More then 60 years: no PDPH. Highest incidence: years. Young children????? Women/men : 2/1 Prior PDPH: 3x higher chance of developing PDPH Chronic headache. Obesity protects against PDPH. Bezov et al. Headache 2010; 50,

10 Clinical Picture Differential Diagnosis Pathophysiology Spinal Anesthesia Epidural Anesthesia and Accidental Dural Puncture (ADP) Risk Factors and Preevntion of ADP Prevention PDPH when ADP occurred Management of PDPH Long Term Effects of PDPH, Bloodpatch and ADP

11 Type and size of the spinal needles. Strupp Atraumatic Sprotte needle reduces the incidence of postlumbar puncture headaches. Neurology, (12), Quincke: 24G: 11.2 %. 25G: 6.3 %. 26G: 5.6 %. 27G: 2.9 %. Whitacre: 25G: 2.2 %. 27G: 1.7 %. Choi et al. Can J Anaesth 2003; 50,

12 Reinsertion of stylet: less PDPH. Strupp et al. J Neurol 1998; 245,

13 Modifiable risk factors. Bezov et al. Headache 2010; 50,

14 Clinical Picture Differential Diagnosis Pathophysiology Spinal Anesthesia Epidural Anesthesia and Accidental Dural Puncture (ADP) Risk Factors and Prevention of ADP Prevention PDPH when ADP occurred Management of PDPH Long Term Effects of PDPH, Bloodpatch and ADP

15 Normal ADP rates. 1,8 1,6 1,4 1,2 1 0,8 0,6 0,4 0,2 0 Saline Air IJOA 1998 Gleeson and Reynolds Anaesthesia 1993 Stride and NORMAL Cooper ADP Anesth Analg 2004 Evron et al. IJOA 2001 Cowan and Moore rate: % Van de Velde et al. IJOA 2008: % Darvish et al. Acta Anaesthesiol Scand 2011; 55,

16 Operator experience. MacArthur et al. BMJ 1993; 306,

17 Size of Tuohy needle Sadashivaiah et al. Anaesthesia 2009; 64,

18 Accidental dural puncture rates increase when air is used for LOR. Practice in tertiary referral OB unit in Australia: epidurals 25% of all epidurals with air. 75% of all epidurals with saline. ADP rate overall of 0.8%. Prospective audit of 100 consecutive accidental dural taps Saline Air Number of ADP Air: earlier onset of PDPH with air. ADP rate with air: 2.3 % ADP rate with saline: 0.3 % Paech et al. IJOA 2001; 10,

19 Accidental dural puncture rates increase when air is used for LOR. 1,8 1,6 1,4 1,2 1 0,8 0,6 0,4 0,2 0 Saline Air IJOA 1998 Gleeson and Reynolds Anaesthesia 1993 Stride and Cooper Anesth Analg 2004 Evron et al. IJOA 2001 Cowan and Moore Accidental dural puncture rates Gleeson and Reynolds. IJOA 1998; 7, Evron et al. Anesth Analg 2004; 99, Stride and Cooper. Anaesthesia 1993; 48, Cowan and Moore. IJOA 2001; 10,

20 Does CSE prevent ADP and PDPH?

21 Bevel orientation. Richman et al. Neurologist 2006; 12,

22 Prevention of ADP. Sitting versus supine: no clear effect. Epidural needle rotation: avoid! Ultrasound guidance: no difference. Use of acoustic device: no difference.

23 Clinical Picture Differential Diagnosis Pathophysiology Spinal Anesthesia Epidural Anesthesia and Accidental Dural Puncture (ADP) Risk Factors and Prevention of ADP Prevention PDPH when ADP occurred Management of PDPH Long Term Effects of PDPH, Bloodpatch and ADP

24 Prophylactic immobility and bed rest

25 Prevention PDPH following witnessed ADP Prolonged Intrathecal Catheter Prophylactic epidural blood patch Epidural morphine IV Cosyntropin

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27 Blood patch need significantly better P = PDPH just not significant P = 0.06

28 Verstraete et al. Acta Anaesthesiol Scand 2014; 58,

29 62% 42% Verstraete et al. Acta Anaesthesiol Scand 2014; 58,

30 Retrospective data 238 cases of ADP. 184: epidural catheter at another interspace. 54: intrathecal catheter. Epidural: 54% PDPH Intrathecal catheter: 37% PDPH

31 Insertion of catheter intrathecally: other advantages. Quality of subsequent anesthesia / analgesia. No risk of subsequent ADP. Speed of anesthesia.

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33 X/$ - see front matter Ó 2015 Elsevier Ltd. All rights reserved. ORIGINAL ARTICLE Complications of 761 short-term intrathecal macrocatheters in obstetric patients: a retrospective review of cases over a 12-year period J. Cohn, a D. M oaveni, a J. Sznol, b J. Ranasinghe a a University of M iami M iller School of M edicine, Jackson M emorial Hospital, M iami, FL, USA b University of M iami Public Health Sciences, M iami, FL, USA ABSTRACT Background: A continuous spinal catheter isa reliable alternative to standard neuraxial techniques in obstetric anesthesia. Despite the potential advantages of intrathecal catheters, they remain underutilized due to fear of infection, nerve damage or post-dural puncture headache. In our tertiary care center, intrathecal catheters are either placed intentionally in high-risk obstetric patients or following inadvertent dural puncture using a 19-gauge macrocatheter passed through a 17-gauge epidural needle. M ethods: A retrospective review of 761 intrathecal catheters placed from 2001 to 2012 was conducted. An institutional obstetric anesthesia database was used to identify patients with intrathecal catheters. M edical records were reviewed for procedural details and complications. Results: There were no serious complications, including meningitis, epidural or spinal abscess, hematoma, arachnoiditis, or cauda equina syndrome, associated with intrathecal catheters. The failure rates were 2.8% (3/108) for intentional placements and 6.1% (40/653) for placements following accidental dural puncture. The incidence of post-dural puncture headache was 41% (312/761) and the epidural blood patch rate was 31% (97/312). Conclusions: This review demonstrates that intrathecal catheters are dependable and an option for labor analgesia and surgical

34 Prevention PDPH following witnessed ADP Prolonged Intrathecal Catheter Prophylactic epidural blood patch Epidural morphine IV Cosyntropin

35 Randomized evidence!

36 -no decrease in incidence of PDPH -no decrease in need for criteriadirected therapeutic EBP Prophylactic EBP may be beneficial. -shortens the length and severity pdph -no increase in incidence of backache/other adverse effects

37 Stein et al. Anaesthesia 2014, 69, If ADP; placement epidural catheter level +1 - Informed consent once optimal analgesia or PACU - Randomly assigned into - Prophylactic EBP group ml autologous blood- 1h supine - >5h following last dose LA - Removal of the catheter - Therapeutic EBP group - Conservative management (clinician s preference) - Therapeutic EBP if persistent headache ml autologous blood- 1h supine

38 11/60 PDPH 6/60 TBP 39/49 PDPH 36/49 TBP

39 Randomized and prospective Not double-blinded (only observer) No sham EBP Decrease in incidence Decrease in severity

40 Prevention PDPH following witnessed ADP Prolonged Intrathecal Catheter Prophylactic epidural blood patch Epidural morphine IV Cosyntropin

41 Epidural morphine Randomized evidence! 1 study only.

42 Prevention PDPH following witnessed ADP Prolonged Intrathecal Catheter Prophylactic epidural blood patch Epidural morphine IV Cosyntropin

43 COSYNTROPIN Cosyntropin is a synthetic ACTH analogue Mechanism? stimulates the release of aldosterone, which enhances salt and water retention and affects an expansion of blood volume increase in cerebrospinal fluid production involving active transport of sodium ions an increase in brain beta-endorphin that could modulate the perception of pain.

44 Hakim, Anesthesiology, (2),

45 1 RCT Significant reduction of PDPH Reproducibility to be determined - Encouraging!! - Simple IV Administration - Known but rare hypersensitivity reaction - Excretion in breast milk?- harmful to the newborn?

46 Clinical Picture Differential Diagnosis Pathophysiology Spinal Anesthesia Epidural Anesthesia and Accidental Dural Puncture (ADP) Risk Factors and Prevention of ADP Prevention PDPH when ADP occurred Management of PDPH Long Term Effects of PDPH, Bloodpatch and ADP

47 Treatment. Conservative management / IV fluids. Medical management: Methylxanthines (including caffeine). Tryptanes, ACTH, gabapentin, pregabalin, mirtazapine, hydrocortisone, methergine. Blood patch.

48 Conservative management. Bezov et al. Headache 2010; 50,

49 Methylxanthines. Blocking adenosine receptors vasoconstriction. Increase CSF production.

50 Methylxanthines. Small trials no conclusive benefits. Symptomatic therapy only. Methylxanthines have side-effects: Cardiac arrhytmias. Gastric irritation. CNS stimulation. Seizures. Bezov et al. Headache 2010; 50,

51 Treatment: caffeine.

52 Epidural blood patch (EBP) How does it work?: ICP. Leak is stopped CSF volume.

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54 Timing of EBP. After 48 hours?

55 Paech,et al, Epidural Blood Patch Trial Group. Anesthesia and Analgesia, 2011,113(1),

56 PDPH recurrence and pain scores after different volumes of bloodpatch. Complete resolution of headache, with no recurrence: group 15 10% group 20 32% group 30 26% Box & whisker plot: median (IQR), 10th-90th centiles, outliers represented by * Paech et al. Anesth Analg 2011; 113, for the EBP trial group (C. Wong, J. Douglas, M. Van de Velde, D. Elliott, JF. Brichant, J. Hill, W. Teoh, C. Caldwell, P. Angle, M. Paech).

57 Clinical Picture Differential Diagnosis Pathophysiology Spinal Anesthesia Epidural Anesthesia and Accidental Dural Puncture (ADP) Risk Factors and Prevention of ADP Prevention PDPH when ADP occurred Management of PDPH Long Term Effects of PDPH, Bloodpatch and ADP

58 Chronification of headache Webb. Anesthesia and Analgesia,2012,115(1),

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65 Conclusion. ADP % is the expected incidence. PDPH: %. PDPH after spinal anesthesia: %. CSE potentially adds 0.2% to the incidence in the worst case scenario.

66 Conclusion. Prophylaxis. Intrathecal epidural catheter. Prophylactic EBP? Cosyntropin Epidural Morphine? But we need more randomized evidence. Treatment: No caffeine. Blood patch.

67 Lecture outline PDPH FOCAL NEUROLOGIC DEFICIT

68 Postpartum neuropathy. Intrinsic obstetric palsies. Serious neurologic injuries related to anaesthesia.

69 Intrinsic obstetric palsies. Incidence reported: %. Most studies retrospective or prospective surveys. Two individual patient follow up studies. Dar et al. Wong et al.

70 Intrinsic obstetric palsies deliveries, 23 symptomatic women. Incidence: 5.8 / 1000 deliveries. 8 asymptomatic women with palsies: In 6 no regional block was performed. All had vaginal deliveries. Dar et al. IJOA 2002; 11,

71 Intrinsic obstetric palsies parturients evaluated prospectively. 56 (0.92%) patients with a palsy. Risk factors: Nulliparity. Prolonged second stage. Wong et al. Obstet Gynecol 2003; 101,

72 Mechanism of injury. Compression by the fetal head. by external aids (forceps, braces, etc ) Traction. Ischemia. Either lumbosacral plexus or lower extremity peripheral nerves. Positional changes during childbirth.

73 Mechanism of injury: role of neuraxial anesthesia. Longer second stage. Failure to recognize early warning signals. Motor block: immobility! Hyperflexed pushing.

74 Intrinsic obstetric palsies. Dar et al. IJOA 2002; 11,

75 Types of intrinsic obstetric palsies. Wong et al. Obstet Gynecol 2003; 101,

76 Types of intrinsic obstetric palsies. Wong. Best Pract Res Clin Obstet Gynaecol 2010; 24,

77 Lateral femoral cutaneous nerve. Most common palsy Risk factors: Prolonged hip flexion Lumbar lordosis C-section Numbness and paresthesia to the lateral thigh No motor deficit

78 Femoral neuropathy. Second most common palsy Risk factors: External rotation and abduction of the thigh Knee compression: saphenous injury C-section Symptoms: Numbness and paresthesia to the anterior thigh and medial leg Weakness of thigh flexion and knee extension Decreased patellar reflex

79 Obturator nerve. Mechanism: compression between fetal head/forceps and pelvis Hematoma secondary to pudendal block Exagerated lithotomy position Symptoms: Numbness of medial thigh Weak thigh adduction

80 Lumbosacral plexus. Mechanism: compression between fetal head/forceps and pelvis Common peroneal nerve is injured more often Symptoms are variable: Foot drop Numbness lower lateral leg and dorsum of the foot

81 Common peroneal nerve. Compression at the head of the fibula Symptoms are variable: Foot drop Numbness lower lateral leg and dorsum of the foot

82 Diagnosis. Clinical. Evaluate paraspinous muscles and sensation of lower back: if normal: distal injury. EMG to determine site of injury, prognosis and age of injury.

83 Prognosis and therapy. Wong et al. Obstet Gynecol 2003; 101,

84 Direct neurologic injury. Epidural hematoma. Traumatic cord injury. Traumatic root injury. Infection: meningitis epidural abcess. Vascular injury.

85 Spinal hematoma. 1/ Higher risk with epidural anesthesia. Usually coagulation problems. Symptoms: Back pain radicular leg pain. Neurologic deficit both sensory and motor. Usually bilateral. Bladder and bowell dysfunction. Diagnosis: MRI. Surgical decompression within 8 hours.

86 Abscess. Organisms: S. Aureus. Symptoms: 4 10 days after epidural. Back pain. Fever. Headache. Neck stifness. MRI Surgery and antibiotics.

87 Meningitis. Organisms: S. Viridans. Symptoms: 1-4 days after epidural. Photofobia. Vomiting. Fever. Headache. Neck stifness. Lumbar puncture. Antibiotics: vancomycine.

88 Prevention. Chlorhexidine in alcohol. Mask cap sterile gloves. Gown? Handwashing no jewelry.

89 Direct trauma to the conus. Usually pain upon insertion. Usually to high. Reynolds. Anaesthesia 2001; 56,

90 Conus ends lower than L1, sometimes. Reynolds F. Anaesthesia 2001; 56,

91 Conus ends lower than L1, sometimes. Broadbent et al. Anaesthesia 2000; 55,

92 Correct identification of L3 L4. Broadbent et al. Anaesthesia 2000; 55, Van Gessel et al. Anesth Analg 1993; 76,

93 Errors. Whitty et al. Anesth Analg 2008; 106,

94 Errors. Schlotterbeck et al. Brit J Anaesth 2008; 100,

95 Evaluation of neurologic injury in the obstetric patient. Immediate evaluation of: Lower limb numbness. Weakness. Pain. Focal neurologic deficit. Common obstetric problems include: Urinary incontinence or retention. Anal dysfunction. Skeletal (back pain). Fever.

96 Evaluation of neurologic injury in the obstetric patient. History: Delivery details. Symptoms. Timing/onset. Progression. Unilateral or bilateral? Symptoms: Fever: infection. Bilateral: central problem. No dermatomal distribution: conus / hematoma. Sphincter problems: Conus / hematoma. Sensory deficits/motor deficits without pain: obstetric palsy.

97 Evaluation of neurologic injury in the obstetric patient. Paraspinous muscles: Differentiation between central and peripheral injury. Motor deficit bilateral symptoms: MRI. EMG: Site. Prognosis. Only changed after 3 weeks. Abormal in the first week: pre-existing injury.

98 Conclusions Most neuropathies are obstetric palsies. Vigilance for more serious complications is required. Puncture as low as possible!!!!!!!!!!!!!!

99 Lucas Fernando Mercier Van de Velde Roofthooft Ngan Kee

100 Lucas Fernando Mercier Van de Velde Roofthooft Ngan Kee