Use of epidural blood patch

Published Date: 19th July 2016

Publication Authors: Yoxall PF

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Background

Epidural blood patch (EBP) is viewed as the "gold standard" treatment for headaches caused by accidental dural puncture (ADP), although it is not supported by strong evidence [1]. The mechanism of action is also poorly understood. Moreover, the success of EBP in treating headaches due to labour epidural related ADP is variable (30-75%) and 40% of patients will need a second EBP for complete relief of symptoms [1]. Complications reported include failure, back pain (may progress to become chronic), febrile reactions, second ADP, facial nerve palsy, cauda equina syndrome, seizures, epidural infections, arachnoiditis and meningitis although exact risk is not easily quantified due to insufficient data [1, 2].

Methods 

We retrospectively reviewed the cases of post dural puncture headache (PDPH) that were identified and treated in an 8 month period at our hospital.

Results 

Between 1/1/2013 and 31/8/2013, 2452 women delivered at the hospital. In 597 epidurals inserted during labour (24%), 10 PDPHs resulted (1.8%). In 8 of the identified PDPHs, ADP was suspected on initial insertion. All PDPHs identified required EBP (100%) and 5 required a second EBP (50%). All EBPs were carried out by consultant obstetric anaesthetists using 10-20 ml of autologous blood. 3 women reported back pain or discomfort on injection. Time interval between epidural and EBP varied between 1 and 9 days, with 5 patients (50%) receiving their first EBP with 2 days. Post-natal analgesia was prescribed according to local protocols. Paracetamol and codeine were used by 6 patients, 4 of whom combined these with a non-steroidal anti-inflammatory drug (NSAID). Three women used oral morphine sulphate solution along with paracetamol, codeine and an NSAID. Six women reported immediate relief of headache although 5 of these were after the second EBP. One patient did not obtain any relief from EBP.

Discussion 

The incidence of PDPH is within the national average although the number of patients requiring EBP is higher than previous studies (59%).[3] The number requiring a second EBP was also higher (15-40%) [1, 3]. All other aspects of PDPH management were in line with published national figures and guidelines. Whilst sufficient analgesia was prescribed, it is unclear whether there were problems with administration on the ward or with compliance especially after discharge. We feel that these factors may contribute to the high rate of uptake of EBP. Due to the higher than average need for EBP, further work is warranted to introduce a robust multidisciplinary protocol in the management of PDPH in the immediate post-natal period including a standardised optimal analgesic regimen with future re-audit.

Nielsen, D; Arunan, Y; Yoxall, P. (2014).  Use of epidural blood patch as a treatment of post-dural puncture headaches in obstetrics: A review of departmental practice . Anaesthesia. 69 (Suppl S3), 50

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