Guideline for the management of accidental dural puncture

CLINICAL GUIDELINE FORGuideline for the Management ofAccidental Dural Puncture in obstetric patients1. Aim/Purpose of this GuidelineTo give guidance to obstetric anaesthetist on the management of a duralpuncture2. The GuidanceDefinitionAccidental dural puncture in obstetric practice describes the process wherebythe Epidural Tuohy needle or the Epidural Catheter accidentally punctures thedura at the level of the lumbar spine.DiagnosisDiagnosis is made by;Seeing cerebral spinal fluid (CSF) flow freely from the Tuohy needleAspirating CSF from the epidural catheter – confirmation of CSF bytesting for glucose(+ve) or litmus paper (CSF is slightly alkaline) Over athird of accidental dural punctures may only diagnosed by recognitionthat the epidural catheter is placed intrathecally. 1The woman complaining of a low pressure headache 24 -48hours afterthe procedure following an undetected dural puncture.IncidenceRates may vary depending on the anaesthetist’s experienced, combined withindividual patient factors such as patient compliance and anatomy. (RCHT dataincidence approximately 1%)BackgroundDural puncture with a 16G Touhy needle, leads to a high incidence (80%) ofpost dural puncture headache (PDPH), which is severe and associated with anumber of characteristic features 3. The headache is typically frontal,exacerbated by movement or sitting upright, associated with photophobia,nausea and vomiting, and relieved when lying flat.Young patients, especially obstetric patients, are more susceptible than theelderly.The headache is thought to be due to the leakage of CSF through the puncturesite.The optimal means of prevention, management, and treatment of this disorderare still uncertain 4 .Guideline for the Management of Accidental Dural Puncture in obstetric patients/CJR/February 2012/review February 2015/version 1.2Page 1 of 8

Immediate ActionIf you experience a needle tap, try to thread the epidural catheter so that 3cmis in the subarachnoid space 5 .If you elicit pain or paraesthesia do not advance the catheter further.If catheter tap, leave catheter in CSF.Clearly LABEL the intrathecal catheter and tell the patient and midwife thatthe anaesthetist must do all top ups.Give 1ml 0.25% Bupivicaine with 25mcg Fentanyl for labour analgesia. Thiscan be flushed with 2ml 0.9% sodium chloride.Expect to repeat intrathecal doses every 1-2 hours with doses ranging from0.5-1.5mls plain 0.25% bupivicaine.Alternatively, you can re-site the epidural catheter at a different space andremove the old one. If a further tap occurs a consultant anaesthetist must becalled.If you do re-site the epidural catheter, the bolus regimen given by themidwifery team should only be considered if several bolus top-ups by theAnaesthetist have not exhibited excessively fast onset or unusually extensiveblock (because of the previous dural puncture/tear).Explain what has happened to the mother and that pain relief can beprovided.Make sure that the midwifery/obstetric and senior anaesthetic staffunderstand the nature of the block and your management plan.Document management plan in the notes.Remember: High blocks may occur with intrathecal catheters, or resitedepidurals in patients who have had inadvertent dural puncture 5DeliveryThe presence of a dural puncture does not require a change of plan fordelivery.For a vaginal delivery use the above intrathecal dosing regime.If caesarean section required titrate 0.5ml increments of 0.5% plainBupivicaine to the required level of block.One dose of Morphine 0.1mg can be given additionally for post-operativeanalgesia.After the delivery, the catheter should be removed as normal.Do not perform a prophylactic blood patch.Post DeliveryThere is no good evidence that enforced recumbency, is of any use in theprevention of post dural puncture headache (PDPH).Encourage good hydration ( IV fluids and oral)Review the woman daily until dischargedDo not enforce a prolonged inpatient stay, but if discharged allow mother anopen appointment to return to post natal ward.Guideline for the Management of Accidental Dural Puncture in obstetric patients/CJR/February 2012/review February 2015/version 1.2Page 2 of 8

Discuss the dural puncture again with the mother and discuss the signs ofPDPH and the possibility that some headaches will resolve spontaneouslywithin 6 weeks 6 . Ensure regular analgesia is prescribed: Paracetamol + Codeine +Diclofenac. Also a laxative should be prescribed to avoid straining: Fybogel. Consider Sumatriptan and Caffeine therapy 7, 8 . If PDPH symptoms are severe and not abating with simple treatments asabove, then a blood patch should be considered and discussed with thepatient. Plans should be made for a blood patch, ideally with a consultantobstetric anaesthetist the next morning. Two anaesthetists must be presentduring the procedure. The success of an epidural blood patch depends on using as much as 20 mlof blood, injected no higher than the dural puncture about 48 hours after thedural puncture. The patient should be kept horizontal (slight head up allowed) for 2 hoursafter patching, and advised to avoid bending or straining afterwards 9 . If a mother has a blood patch, she should be offered follow up by one of theConsultant Obstetric Anaesthetists.Important pointsPostdural puncture headache must be distinguished from tension headache,migraine, pre-eclampsia, meningitis, cortical vein thrombosis, intracerebralhaemorrhage, subdural haematoma and intracranial tumour. A history ofdural puncture may be absent. An MRI may assist in the differentialdiagnosis.The headache varies in character but is relieved by lying down and byabdominal compression. Associated symptoms include neck ache, nausea,vomiting, photophobia and diplopia.A neglected dural leak may result in convulsions or cranial subduralhaematoma, coning and death.If the epidural catheter is not retained intrathecally, it can be resited at ahigher interspace. This may risk a second dural puncture and can cause ahigh block 10 .All women require careful documentation, close monitoring, and top-upsadministered by an anaesthetist.Bed rest is of no prophylactic value but, in the presence of headache,mobilisation should be postponed pending definitive treatment. Hydrationand analgesia provide only symptomatic relief. Epidural saline providestransient relief and some discomfort. Epidural blood patch relieves symptomsand stops the CSF leak and is therefore definitive treatment. Some womenwill experience a mild backache following the procedure.Alternatives to blood, such as dextran 40, may be useful for women whodecline blood products or if there is bacteraemia.Guideline for the Management of Accidental Dural Puncture in obstetric patients/CJR/February 2012/review February 2015/version 1.2Page 3 of 8

Leaving the intrathecal catheter insitu for 24-hours post delivery may reducethe incidence of PDPH from 80 to 60% 5 , however all epidural catheters mustbe removed before women are transferred to the post-natal ward.References1. Van de Velde M, Schepers R, et al. Ten years of experience with accidental dural puncture and postdural puncture headache in a tertiary obstetric anaesthetic department. International Journal ofAnaesthesia.2009; 17:329-335.2. Gleeson CM, Reynolds E. Accidental dural puncture rates in UK obstetric practice. International Journalof Obstetric Anaesthesia. 1998 Oct;7(4):242-63. Stride PC, Cooper GM: Dural taps revisited. A 20-year survey from Birmingham Maternity Hospital.Anaesthesia 1993; 48:247-55.4. Harrington BE, Schmitt AM. Meningeal puncture headache, unintentional dural puncture, and theepidural blood patch: a national survey of United States practice. Reg Anaesth Pain Med, 2009Sep-Oct;34(5):430-7.5. Rutter SV, Shields F et al. Management of accidental dural puncture in labour with intrathecal catheters:an analysis of 10 years experience. International Journal of Obstetric Anaesthesia.2001; 10:177-181.6. Turnbull DK, Shepherd DB. Post dural puncture headache pathogenesis, prevention and treatment.British Journal of Anaesthesia 2003; 91: 718–29.7. Camann WR, Murray RS etal. Effects of oral caffeine on postdural puncture headache. A double-blind,placebo-controlled trial. Anaesthesia & Analgesia. 1990; 70:181-4.8. Carp H, Singh PJ et al. Effects of the serotonin receptor agonist sumatriptan on postdural punctureheadache; report of six cases. Anaesthesia & Analgesia 1994;79:180-2M Rupasinghe. Recognition and treatment of post-dural puncture headache.Anaesthesia&intensive care medicine3. Compliance monitoring and effectivenessElement to bemonitoredAll women with a post dural puncture will be followed up bythe Obstetric Anaesthetist on-call and feedback given to theAnaesthetist who performed the procedures.LeadToolFrequencyReportingarrangementsActing onrecommendationsand Lead(s)Change inpractice andlessons to besharedObstetric anaesthtic lead consultantReview of notes of all woman with a post dural punctureEvery woman with a post dural punctureThrough the maternity risk management forumMaternity risk management forum will monitor any action plansarisingOne to one feedback to individual anaesthetistsAny training needs will be addressed by the training lead foranaesthetics4. Equality and Diversity4.1. This document complies with the Royal Cornwall Hospitals NHS Trust serviceEquality and Diversity statement.Guideline for the Management of Accidental Dural Puncture in obstetric patients/CJR/February 2012/review February 2015/version 1.2Page 4 of 8

Links to key external standardsRelated Documents:Training Need Identified?Epidural analgesia in labourTraining as per training log bookVersion Control TableDateJanuary2006December2009February2012Version NoV1.0 Initial IssueSummary of ChangesV1.0 Added care post dural tap and follow up.V1.2Added compliance monitoring DocumentManager Upload Form.Changes Made by(Name and Job Title)DR Bill HarveyConsultantanaesthetistDr Catherine RalphConsultantanaesthetistDr Catherine RalphConsultantanaesthetist[Please complete all boxes and delete help notes in blue italics including this note]All or part of this document can be released under the Freedom of InformationAct 2000This document is to be retained for 10 years from the date of expiry.This document is only valid on the day of printingControlled DocumentThis document has been created following the Royal Cornwall Hospitals NHS TrustPolicy on Document Production. It should not be altered in any way without theexpress permission of the author or their Line Manager.Guideline for the Management of Accidental Dural Puncture in obstetric patients/CJR/February 2012/review February 2015/version 1.2Page 6 of 8

Appendix 2.Initial Equality Impact Assessment Screening Formme of service, strategy, policy or project (hereafter referred to as policy) to be assessed:Guideline for the Management of Accidental Dural Puncture in obstetric patientsDirectorate and service area:Is this a new or existing Procedure?Obstetrics and gynaecologyExistingName of individual completingTelephone:assessment: Jan Clarkson01872 2522701. Policy Aim* To inform obstetric anaesthetists in the correct managementof a dural tap2. Policy Objectives* To ensure appropriate management of a dural tap3. Policy – intendedOutcomes*5. How will youmeasure the outcome?5. Who is intended tobenefit from the Policy?Safety of the obstetric womanCompliance monitoring toolObstetric women6a. Is consultationrequired with theworkforce, equalitygroups, local interestgroups etc. around thispolicy?b. If yes, have thesegroups been consulted?c. Please list any groupswho have been consultedabout this procedure.*Please see Glossary7. The ImpactPlease complete the following table using ticks. You should refer to the EA guidance notesfor areas of possible impact and also the Glossary if needed. Where you think that the policy could have a positive impact on any of the equalitygroup(s) like promoting equality and equal opportunities or improving relationswithin equality groups, tick the ‘Positive impact’ box. Where you think that the policy could have a negative impact on any of the equalitygroup(s) i.e. it could disadvantage them, tick the ‘Negative impact’ box.Guideline for the Management of Accidental Dural Puncture in obstetric patients/CJR/February 2012/review February 2015/version 1.2Page 7 of 8

Where you think that the policy has no impact on any of the equality group(s) listedbelow i.e. it has no effect currently on equality groups, tick the ‘No impact’ box.EqualityGroupAgePositiveImpactNegativeImpactNoImpactReasons for decisionDisabilityReligion orbeliefGenderTransgenderPregnancy/MaternityRaceYesSexualOrientationMarriage / CivilPartnershipYou will need to continue to a full Equality Impact Assessment if the following havebeen highlighted: A negative impact and No consultation (this excludes any policies which have been identified as notrequiring consultation).8. If there is no evidence that the policypromotes equality, equal opportunitiesor improved relations - could it beadapted so that it does? How?Full statement of commitment to policy ofequal opportunities is included in the policyPlease sign and date this form.Keep one copy and send a copy to Matron, Equality, Diversity and Human Rights,c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, ChyveanHouse, Penventinnie Lane, Truro, Cornwall, TR1 3LJA summary of the results will be published on the Trust’s web site.Signed _Jan Clarkson_Date 10 th February 2012Guideline for the Management of Accidental Dural Puncture in obstetric patients/CJR/February 2012/review February 2015/version 1.2Page 8 of 8