The Parturient With an Intrathecal Catheter Ivan A. Velickovic, M.D. SUNY Downstate Medical Center, Brooklyn, NY

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1 Session: L225 Session: L444 The Parturient With an Intrathecal Catheter Ivan A. Velickovic, M.D. SUNY Downstate Medical Center, Brooklyn, NY Disclosures: This presenter has no financial relationships with commercial interests. Stem Case and Key Questions Content You arrive to relieve a colleague who is performing an epidural on a 28-year-old, 96 kg, gravida 1, para 0, woman with no previous medical history when suddenly, a clear fluid starts filling up the epidural syringe. Your colleague looks at you and asks if you are comfortable managing an intrathecal catheter or if you would prefer that he withdraw the epidural needle and start the procedure at another level. 1. Is it OK to advance the epidural catheter into the intrathecal space? 2. What are the risks associated with this procedure? 3. What drugs, what concentration and what dose should be used for intrathecal labor analgesia? 4. How should this patient be monitored? Your choice is patient controlled spinal anesthesia (PCSA) with your favorite mix of local anesthetic and narcotic. The patient is pain free throughout labor. However, 5 hours later the obstetrician tells you that she wants to take the patient to the operating room for Cesarean section due to failure to progress. 1. Should you remove the spinal catheter and start Cesarean section anesthesia from scratch? 2. What medication and what doses should be used to establish a T4 block? 3. Is there any advantage in using ED 50 vs. ED 95 of your favorite local anesthetic? Page 1

2 4. Is there any benefit in adding narcotics to the local anesthetic that you plan to use? Your choice is CSA with your favorite mix of local anesthetic and narcotic. The Cesarean section goes uneventfully and a female newborn is delivered with Apgar scores of 9 and 9, at 1 and 5 minutes, respectively. Hemodynamic parameters remained stable throughout the procedure. The patient is transferred to the recovery room 1 hour after the incision and by the time you are done signing-off the patient to the recovery room nurse, she complains of incisional pain 4/ Can you use this catheter for post-operative pain control? 2. What is the risk of infection? 3. Is PCSA better than intermittent manual bolusing? The postpartum course was unremarkable and you evaluate the patient 24 hours after the Cesarean section. PCSA was used and the patient remained pain free throughout the night. She is very pleased with your care and thanks you for everything that you have done for her. 1. Is there anything that can be done to further decrease the possibility of post dural puncture headache (PDPH)? 2. Should this patient receive a prophylactic epidural blood patch? 3. Is it appropriate to bill for this visit? Model Discussion Content Continuous spinal anesthesia (CSA) is an established anesthetic technique with several clinical advantages. CSA can be titrated to the desired dermatomal level, it offers a definite end point (cerebrospinal fluid aspiration), the catheter can be reinjected as needed with improved hemodynamic stability, and it requires only a fraction of the epidural local anesthetic dose with much faster onset and denser block.1 It was rarely used before December 1989 in the United States, when new gauge microcatheters became available. With these new catheters, there was hope that CSA would become the technique of choice for labor analgesia due to an acceptably low risk of headache. However, in the next 29 months, there were 11 cases of cauda equina syndrome when 5% lidocaine was administered through spinal microcatheters.1 As a result of this, the FDA issued a Safety Alert on May 29, 1992: "We are concerned that the use of small-bore catheters in continuous spinal anesthesia is increasing, and thus that the potential for new cases of cauda equina syndrome associated with this technique may be increasing. Because of these safety concerns, we are advising Page 2

3 against the use of any small-bore catheter for continuous spinal anesthesia of any local anesthetic agent."2 All small-bore catheters were subsequently removed from the market. The FDA did, however, announce that it would consider applications for clinical studies of the use of CSA.1 Today we believe that these cases of cauda equina syndrome were caused by 5% lidocaine pooling directly into the nerve causing neurotoxicity and not by the use of spinal catheters per se. When we look at the literature there is only one case of cauda equina syndrome caused by local anesthetic other than lidocaine (tetracaine) when the medication was given through the spinal microcather.1,3 Since 1992, spinal microcatheters have been used in the USA only in clinical trials. A recent study found that the quality of anesthesia was as good as with epidural anesthesia and that the incidence of post dural pun ture headache (PDPH) was 9% (epidural group 4%) with 5.3% of patients requiring blood patch (epidural group 2%) with no persistent neurologic deficit.4 Whether the spinal microcatheters will reappear on the market remains to be seen. Therefore, the only catheters available for intrathecal use for a majority of US anesthesiologists are regular 19 and 20 gauge epidural catheters. This limits the use of CSA to a few clinical cases where post dural puncture headache is not a real concern and where hemodynamic stability is very important (neuroaxial anesthesia in a patient with valvular stenotic disease or severe cardiac disease). Continuous peripheral nerve catheters have also been inserted into the intrathecal space but experience with these catheters is even more limited than with epidural catheters. The concentration and dose of local anesthetic/opioid combination that should be given through the intrathecal catheter is a subject of clinical research. Although 1/10 of the epidural dose (1 ml/h)5 is usually suggested, we found it inadequate for our patient population. Our patients receive 2 ml/h of our regular epidural mixture (0.1% ropivacaine + fentanyl 2 μg/ml or % bupivacaine + fentanyl 2 μg/ml). Breakthrough pain can be treated with either manual bolus of this solution or with the use of a patient controlled pump. Patient controlled pump - bolus of 2 ml of the same solution every 10 minutes with a maximum of 3 boluses per hour will help keep the catheter closed. This way we avoid multiple manipulations of the intrathecal catheter that may be associated with hub contamination and an increased risk of infection.6 However, each patient is different and all of these doses should be adjusted to the individual patients' characteristics and needs. A continuous spinal catheter can also be used for Cesarean sections. A recent study has shown that ED 50 and ED 95 of spinal hyperbaric bupivacaine are 6.7 mg and 11 mg.7 If the goal is to start the Cesarean section as soon as possible, ED 95 is appropriate. If the Cesarean section is elective, ED 50 may be used. If the block is inadequate, it can easily be extended. Limiting the bupivacaine dose has been advocated, with the goals of decreasing maternal hypotension, vasopressor requirements, nausea, and time to discharge from the PACU, in addition to improving maternal satisfaction.8 Prevention of PDPH is another area where intrathecal catheters have a potentially important role. Even today, the mechanism (or mechanisms) of PDPH is only partially understood. It is, however, Page 3

4 generally accepted that persistent loss of cerebrospinal fluid (CSF) leads to sagging of the brain and traction on pain sensitive structures within the skull. It is also believed that compensatory cerebral vasodilatation and vascular congestion that follow the loss of CSF represent a significant component of PDPH. Although the majority of patients with PDPH will have decreased CSF pressures, some patients will have normal CSF pressures.9 The degree of CSF leakage does not correlate with the severity of PDPH. Without a clear agreement on the etiology of the headache, definitive answers as to how to treat the headache are impossible. Several studies in the past 15 years have significantly affected the way we treat PDPH. A study in the early 1990s found no advantage in the insertion of the epidural catheter into the subarachnoid space in the case of accidental dural puncture.10 A very similar study11 published in 2003 had completely different results and has sparked a lot of debate in the anesthesia community. Dr. Ayad and his team would, in case of accidental dural puncture, thread the epidural catheter into the intrathecal space, use it as a continuous spinal catheter, and then leave it in situ for 24 hours. Only 3% of their patients needed an epidural blood patch. To the best of our knowledge, no one was ever able to replicate Dr. Ayad's results, but many centers started their own research with epidural converted to spinal catheters. As a result, a recent survey found that anaesthetists at 59% of maternity units in the United Kingdom prefer to use an epidural catheter as a spinal catheter in the case of accidental dural puncture. The two most commonly cited reasons for intrathecal catheterization were to avoid further dural puncture (76%) and to allow immediate analgesia for labor (75%).12 Dr. Ayad, however, argued that the most significant effect of the intrathecal catheter is the formation of inflammatory fibrous reaction around the catheter at the site of the dural tear that further seals the tear and stops the leakage of CSF. The presence of a fibrous capsule around epidural/spinal catheter at its entrance into spinal space was shown in study done by Sjoberg et al.13 Another apparently benign suggestion came from Dr. Charsley,14 who suggested that at the time of accidental dural puncture, 10 ml of normal saline should be administered into the intrathecal space. Although this maneuver reduced the incidence of PDPH, the best results were in the group that had an epidural catheter placed intrathecally and 10 ml of saline injected through the catheter. So, this study14 further emphasizes the importance of intrathecal catheters in the prevention of PDPH. Kuczkowski and Benumof reported a case series of 7 patients where CSF in the glass syringe was injected back into the subarachnoid space through the epidural needle, and a small amount of preservative free saline (3-5 ml) was injected into the subarachnoid space through the intrathecal catheter.15 PDPH occurred in 1 of the 7 patients in this case series. Both of these papers14,15 emphasize the importance of maintaining CSF volume. The first meta-analysis that evaluated all published data in the past 18 years came out in late Van De Velde et al. first presented their own data, which showed no benefit from the use of an intrathecal catheter. However, when they evaluated all of the published data, prolonged intrathecal catheter placement significantly reduced the risk of PDPH (51% vs. 66%). The need for epidural blood patch was reduced from 59% to 33%.16 The second meta-analysis came out in September Apfel et al. stated that the majority of interventions investigated showed at least some efficacy for the Page 4

5 prevention of PDPH, but the immediate placement of an intrathecal catheter or the use of a prophylactic epidural blood patch (PEBP) before catheter removal demonstrated the best risk/benefit ratio. No clinical recommendations for how to best to avoid PDPH after accidental dural puncture can be made, according to these authors, until the superiority of one preventative intervention over another has been unequivocally proven in a definitive multicenter RCT.17 The third meta-analysis came out in October The main author was Michael Heesen but one of the authors was Marc Van De Velde who published meta-analysis on this topic in According to this meta-analysis intrathecal catheter placement significantly reduces the need for an EBP although significant reduction in the incidence of PDPH was not seen.18 A possible explanation could be that the patients with intrathecal catheter even if they get a headache, have a milder headache that does not require a blood patch. This study also gave an explanation for the relative lack of efficacy of intrathecal catheters in Russell s19 study. Heesen stated that a randomized trial by Russell was stopped early and type-2 error cannot be excluded as a cause of the lack of effect of intrathecal catheterization on PDPH frequency.18 The review article from 2003 suggested that the benefit of prophylactic blood patch is not clear but deserves consideration in those most at risk for headaches, such as the parturient, and after accidental dural perforation with a Tuohy needle.20 A recent study has shown no significant benefits from the procedure.21 The newest Cochrane Database Review on epidural blood patch was published in January The review authors do not recommend prophylactic epidural blood patches over other treatments because there are too few trial participants to allow reliable conclusions to be drawn.22 A meta-analysis done by Agerson in 2012 had the same results - prophylactic blood patch cannot be recommended.23 Conservative treatment of PDPH can be attempted in mild to moderate cases. Although caffeine has been used for almost 70 years, a recent review by Halker24 showed no benefit from its use. Another review was done in 2011 by Basurto Ona et al.25 This group of authors reached completely opposite conclusions evaluating the same problem. They stated that caffeine has shown effectiveness for treating PDPH, decreasing the proportion of participants with PDPH persistence and those requiring supplementary interventions, when compared with placebo.25 The efficiency of 5-day treatment with oral frovatriptan 2.5 mg/day for the prophylaxis of PDPH was tested in 50 inpatients. This nonrandomized open-label study suggests the efficiency of oral frovatriptan for prevention of PDPH.26 In the randomized, prospective, controlled study gabapentin significantly reduced pain, nausea and vomiting compared to ergotamine/caffeine combination in patients with PDPH.27 A combination of acetaminophen/ butalbital/caffeine (Fioricet) is also commonly used for mild to moderate headaches. Two recent case reports have looked at the relationship between untreated PDPH and subdural hematoma.28,29 Zeidan at al. found 46 reported cases of subdural hematoma after spinal or epidural Page 5

6 anesthesia while Amorim et al. have found 33 cases on literature review. Based on these reports, neuroimaging (MRI with contrast) should be done for PDPH that lasts more than 7 days as well as for headaches that change from postural to non-postural. Our current PDPH prevention/treatment protocol is similar to one suggested by Kuczkowski30 and consists of routine placement of the epidural catheter intrathecally in the case of accidental dural puncture. The catheter is then used as an intrathecal catheter and removed 24 hours later. Prior to the removal of the catheter, 10 ml of normal saline is administered through the intrathecal catheter. The patient is also advised to take p.o. pain medications as per her obstetrician's preference. In the case of persistent headache, a blood patch is performed. Strict sterile technique (i.e. hand washing, face mask and sterile gloves) is mandatory during the placement of the intrathecal catheter. In addition, we use an in-line bacterial filter and make sure that all caregivers are aware of the location of the catheter. Just as any anesthetic technique used today, CSA has its own disadvantages that include risks of postdural puncture headache and cauda equina syndrome, as well as the potential for a total spinal if epidural doses of local anesthetic are given intrathecaly. The use of larger gauge catheters and our choice of local anesthetic (bupivacaine/ropivacaine vs. lidocaine) may be associated with a smaller risk of cauda equina syndrome. This is probably because a larger catheter allows for more rapid injection and better mixing of anesthetic drugs with the CSF. Furthermore, the larger catheter size facilitates more effective aspiration of CSF to confirm proper catheter placement, initially and throughout the case. A study published in February of 2016 looked at the complications of 761 shortterm intrathecal macrocatheters in obstetric patients over 12 years period.31 There were no serious complications, including meningitis, epidural or spinal abscess, hematoma, arachnoiditis, or cauda equina syndrome, associated with intrathecal catheters.31 To summarize, CSA plays an important role in the prevention of PDPH and can also be used for labor analgesia and intraoperative anesthesia. References 1. Johnson ME. Potential neurotoxicity of spinal anesthesia with lidocaine. Mayo Clin Proc. 2000; 75: Benson JS. FDA safety alert: cauda equina syndrome associated with small-bore catheters in continuous spinal anesthesia [press release]. Rockville, Md: Food and Drug Administration; Rigler ML, Drasner K, Krejcie TC, et al. Cauda equina syndrome after continuous spinal anesthesia. Anesth Analg. 1991; 72: Arkoosh VA, Palmer CM, Yun EM, Sharma SK, Bates JN, Wissler RN, Buxbaum JL, Nogami WM, Gracely EJ. A randomized, double-masked, multicenter comparison of the safety of continuous Page 6

7 intrathecal labor analgesia using a 28-gauge catheter versus continuous epidural labor analgesia. Anesthesiology. 2008; 108: Gurlit S, Reinhardt S, Mollmann M. Continuous spinal analgesia or opioid-added continuous epidural analgesia for postoperative pain control after hip replacement. Eur J Anaesthesiol. 2004; 21: Hebl JR.The importance and implications of aseptic techniques during regional anesthesia. Reg Anesth Pain Med. 2006; 31: Ginosar Y, Mirikatani E, Drover DR, Cohen SE, Riley ET. ED50 and ED95 of intrathecal hyperbaric bupivacaine coadministered with opioids for cesarean delivery.anesthesiology. 2004; 100: Ben-David B, Miller G, Gavriel R, Gurevitch A: Low-dose bupivacaine-fentanyl spinal anesthesia for cesarean delivery. Reg Anesth Pain Med 2000; 25: Harrington BE. Postdural puncture headache and the development of the epidural blood patch. Reg Anesth Pain Med. 2004; 29: Norris MC, Leighton BL. Continuous spinal anesthesia after unintentional dural puncture in parturients. Reg Anesth. 1990; 15: Ayad S, Demian Y, Narouze SN, Tetzlaff JE. Subarachnoid catheter placement after wet tap for analgesia in labor: influence on the risk of headache in obstetric patients. Reg Anesth Pain Med. 2003; 28: Baraz R, Collis RE. The management of accidental dural puncture during labour epidural analgesia: a survey of UK practice. Anaesthesia 2005; 60: Sjoberg M, Karlsson PA, Nordborg C, Wallgren A, Nitescu P, Appelgren L, Linder LE, Curelaru I.Neuropathologic findings after long-term intrathecal infusion of morphine and bupivacaine for pain treatment in cancer patients Anesthesiology. 1992;76: Charsley MM, Abram SE. The injection of intrathecal normal saline reduces the severity of postdural puncture headache. Reg Anesth Pain Med. 2001; 26: Kuczkowski KM, Benumof JL. Decrease in the incidence of post-dural puncture headache: maintaining CSF volume. Acta Anaesthesiol Scand. 2003; 47: Van de Velde M, Schepers R, Berends N, Vandermeersch E, De Buck F. Ten years of experience with accidental dural puncture and post-dural puncture headache in a tertiary obstetric anaesthesia department. Int J Obstet Anesth. 2008; 17: Apfel CC, Saxena A, Cakmakkaya OS, Gaiser R, George E, Radke O. Prevention of postdural puncture headache after accidental dural puncture: a quantitative systematic review. Br J Anaesth. 2010; 105: Heesen M. Klöhr S, Rossaint R, Van De Velde M, Straube S. Can the incidence of accidental dural puncture in laboring women be reduced? A systematic review and meta-analysis. Minerva Anestesiol. 2013; 79: Russel IF. A prospective controlled study of continuous spinal analgesia versus repeat epidural analgesia after accidental dural puncture in labour. Int J Obstet Anesth. 2012;21: Turnbull DK, Shepherd DB. Post-dural puncture headache: pathogenesis, prevention and Page 7

8 treatment. Br J Anaesth. 2003; 91: Scavone BM, Wong CA, Sullivan JT, Yaghmour E, Sherwani SS, McCarthy RJ. Efficacy of a prophylactic epidural blood patch in preventing post dural puncture headache in parturients after inadvertent dural puncture. Anesthesiology. 2004; 101: Boonmak P, Boonmak S. Epidural blood patching for preventing and treating post-dural puncture headache. Cochrane Database Syst Rev. 2010; 20:CD Agerson AN, Scaveone BM. Prophylactic epidural blood patch after unintentional dural puncture for the prevention of postdural puncture headache in parturients. Anesth Analg 2012;115: Halker RB, Demaerschalk BM, Wellik KE, Wingerchuk DM, Rubin DI, Crum BA, Dodick DW. Caffeine for the prevention and treatment of postdural puncture headache: debunking the myth. Neurologist. 2007; 13: Basurto Ona X, Martínez García L, Solà I, Bonfill Cosp X. Drug therapy for treating post-dural puncture headache. Cochrane Database Syst Rev. 2011;10;(8):CD Bussone G, Tullo V, d Onofrio F, Petretta V, Curone M, Frediani F, Tonini C, Omboni S. Frovatriptan for the prevention of postdural puncture headache. Cephalalgia. 2007; 27: Erol DD. The analgesic and antiemetic efficacy of gabapentin or ergotamine/caffeine for the treatment of postdural puncture headache. Adv Med Sci. 2011;56: Zeidan A, Farhat O, Maaliki H, Baraka A. Does postdural puncture headache left untreated lead to subdural hematoma? Case report and review of the literature. Int J Obstet Anesth. 2006; 15: Amorim JA, Remígio DS, Damázio Filho O, de Barros MA, Carvalho VN, Valença MM. Intracranial subdural hematoma post-spinal anesthesia: report of two cases and review of 33 cases in the literature.rev Bras Anestesiol. 2010; 60:620-9, Kuczkowski KM. Post-dural puncture headache in the obstetric patient: an old problem. New solutions. Minerva Anestesiol. 2004; 70: Cohn J, Moaveni D, Sznol J, Ranasinghe J. Complications of 761 short-term intrathecal macrocatheters in obstetric patients: a retrospective review of cases over a 12-year period. Int J Obstet Anesth. 2016;25:30-6 Page 8