|Year : 2009 | Volume
| Issue : 1 | Page : 30-34
Intrathecal Catheterization by Epidural Catheter: Management of Accidental Dural Puncture and Prophylaxis of PDPH
Ashok Jadon1, Swastika Chakraborty2, Neelam Sinha3, Rajiv Agrawal4
1 Senior Consultant and Head of the Department, Tata Motors Hospital, Jamshedpur- 831001, Jharkhand, India
2 Consultant, Tata Motors Hospital, Jamshedpur- 831001, Jharkhand, India
3 Senior Registrar, Tata Motors Hospital, Jamshedpur- 831001, Jharkhand, India
4 Senior Medical Officer, Department of Anaesthesia, Tata Motors Hospital, Jamshedpur- 831001, Jharkhand, India
|Date of Web Publication||3-Mar-2010|
44, Beldih Lake Flats,Dhatkidih,Jamshedpur-831001, Jharkhand
Source of Support: None, Conflict of Interest: None
Accidental or inadvertent dural puncture during epidural anaesthesia results in high incidence of post dural puncture headache (PDPH). Spinal or intrathecal catheter in such a situation, provides aconduit for administration of appropriate local anaesthetic for rapid onset of intraoperative surgical anaesthesia and postoperative pain relief. This procedure prevents PDPH if catheter left in situ for > 24 hrs and also avoids the associated risks with a repeat attempts at epidural analgesia.
Primary aim of this study was to observe the effect of spinal catheter on incidence of PDPH, and to assess early and delayed complications of spinal catheterization by epidural catheter.
In prospective clinical study 34 patients who had accidental dural puncture during epidural anaesthesia were included. The catheter meant for epidural use was inserted in spinal space and used for spinal anaesthesia and postoperative analgesia. Catheter was removed between 24-36hrs after surgery.
The incidence of accidental dural puncture was 4% (34/ 846). Two patients 5.88% (2/34) had transient paresthesia duringspinal catheter insertion. Postdural puncture headache occurred in 11.76% (4/34) patients. Two patients required epidural blood patch and two patients were managed with conservative treatment. No patient had any serious intraoperative or postoperative side effects.
Epidural catheter can be used as spinal catheter to manage accidental dural puncture without serious complications, and it also prevents PDPH.
Keywords: Epidural anaesthesia, Accidental dural puncture, Post dural puncture headache (PDPH), Intrathecal catheter
|How to cite this article:|
Jadon A, Chakraborty S, Sinha N, Agrawal R. Intrathecal Catheterization by Epidural Catheter: Management of Accidental Dural Puncture and Prophylaxis of PDPH. Indian J Anaesth 2009;53:30-4
|How to cite this URL:|
Jadon A, Chakraborty S, Sinha N, Agrawal R. Intrathecal Catheterization by Epidural Catheter: Management of Accidental Dural Puncture and Prophylaxis of PDPH. Indian J Anaesth [serial online] 2009 [cited 2017 Jun 26];53:30-4. Available from: http://www.ijaweb.org/text.asp?2009/53/1/30/60253
| Introduction|| |
Accidental dural puncture during epidural occurs in 0.4 to 6.0% patients.  Due to large opening and associated CSFleak, large number of patients (75-86%) develop post-dural puncture headache (PDPH), which is mostly severe in nature.  Epidural blood patch is an effective treatment of severe post-dural puncture headache however, its effectiveness decreases if dura mater puncture is caused by a large bore needle.  Epidural catheters have been used to prevent severe PDPH and manage accidental dural puncture by insertion of epidural catheter in to the subarachnoid space and using them as spinal catheter for continuous spinal anaesthesia. , Intrathecal catheter insertion following unintentional dural puncture reduces the requirement for epidural blood patch. 
Thirty-four cases intended for epidural anaesthesia were managed successfully with epidural catheter inserted in subarachnoid space after accidental dural puncture.
This is a prospective clinical study of thirty-four patients who had inadvertent dural puncture during epidural or combined spinal epidural anaesthesia between 1.1.2004 to 15.5.08. Hospital Ethical committee approval and informed (written) consent was taken from all the patients before procedure.
Technique: Epidural space was identified by loss of resistance to air in all cases with due asepsis. If in advertent dural puncture occurred, epidural catheter (18G or 20G)was inserted 2-3 cm in subarachnoid space by one of the senior anaesthetist(one of the authors), who had previous experience of spinal catheterization and more than 15 years experience in anaesthesia. Catheter position was confirmed by easy aspiration of clear CSF and initial dose of 0.5% heavy bupivacaine (0.5-1.0ml) was given. Catheter was fixed and level of anaesthesia was assessed. Increments of 0.5% heavy bupivacaine was given as and when required.
Spinal catheters were removed between 24-36 hrs postoperatively. Patients were observed for 7 days in the hospital and later on follow-up was done either through concerned surgeon during patient's visit to the hospital or by personal communication. Intraoperative data was collected regarding patients profile, probable causeof dural puncture, type of surgery and immediate complication during or after catheter insertion. Postoperatively data was collected regarding total doses of intratheca ldrugs, post-spinal headache and any other complications. Patients who developed PDPH were managed with parenteral fluids, analgesic drugs and epidural blood patch.
| Results|| |
During1.1.2004to 15.5.08 accidental dural puncture was noticed in 34 (3.8%) patients out of 885 patients scheduled for various surgeries under epiduralor combined spinal epidural anaesthesia [Table 1] and [Table 2]. The possible causes of accidental dural puncture are shown in [Table 3]; anatomical difficulty and repeated attempts were responsible for dural puncture in 17 (50%) of the patients. Unable to identify loss of resistance at epidural space in 6(17.6%), turning the bevel after localization of epiduralspace to facilitate catheter insertion in 6 (17.6%), and Sudden movement of patient in 5 (14.7%) patients were the causes of accidental dural puncture in remaining half of the patients. Outcome and complications are shown in [Table 4]; insertion of epidural catheter in subarachnoid space was easily done in 32(94.11%) patients, and redirection during insertion was required in 2 (5.88%) patients due to paresthesia on initial insertion. All the catheters were left in subarachnoid space for more than 24 hrs (mean 28.85 ± 3.92 hrs), and 4(11.76%) patients developed postdural puncture headache (PDPH) after catheter removal. Epidural blood patch was offered to four patients who developed PDPH after catheter removal. Two patients refused and were managed conservatively by Tab paracetamol, diclofenac injections, intravenous fluids and bed rest. PDPH was cured after 4 th day and 7 th day consecutively in both patients. Epidural blood patch was given by 15 ml in one patient and 18ml in second patient on the same day after catheter removal, relieved the PDPH instantaneously. Patients'who received epidural blood patch complained of moderate backache which was treated with tab.paracetamol and was relieved next day. No patient showed any sign of CSF leak, neurological injury or recurrence of PDPH. No complication of catheter knotting or infection either at the entry (exit) site or in deeper tissues was seen.
| Discussion|| |
Incidence of accidental dural puncture during epidural varies 0.4% to 6.0%  , we had incidence of 3.84% [Table 1] which is well with in range. However, it was on the highe rside of mean. It may be because heterogeneous group of patients [Table 2], difference in experience of authors and method used for epidural localization. Accidental dural perforation is inversely proportional to anaesthesiologists' experience  and saline is better than air for epidural localization.  Repeated attempts have been associated with increased accidental dural puncture.  In present study the highest incidence of accidental dural puncture occurred during repeated attempts for epidural [Table 3],either due to difficult anatomy or anxious, uncooperative patients. In our study four patients [11.76%(4/34)] developed PDPH after removal of epidural catheter. Two patients were having mild symptoms and were managed with increased oral fluid intake and analgesics (Tablet paracetamol and diclofenac).
An epiduralblood patch (EBP) remains the standard against which all other treatments for aPDPH are compared however it is not without its complications. Back pain, neckpain, legpain and paresthesias have been reported following the administration of an EBP.  Two obstetric patients who did not respond to analgesics were given epiduralblood patch (15mland18ml) and PDPH was cured. Both the patients had moderate backache which resolved over next 24 hrs.
Paresthesia during catheter insertion is not uncommon but transient paresthesias are mostly benign. [ 11] Two patients of our study had paresthesia during catheter insertion, which resolved with redirection of catheter. No postoperative side effect was noticed. In our study all the thirty-four patients who had accidental dural puncture were managed by spinal catheter and no intraoperative or serious postoperative complications occurred. The continuous spinal anaesthesia is a standard anaesthesia technique, although the use of epidural catheter as spinal catheter was debatable. , The use of epiduralcatheter as spinalcatheter got acceptance slowly as it was noted that thin catheter which were meant for continuous spinal anaesthesia were actually responsible for neural complications and their insertion is also difficult. , More and more data is now becoming supportive of spinal catheterization. , Deliberate intrathecal insertion of an epidural catheter after accidental dural puncture has been reported in obstetric patients and found to be effective in prophylaxis of PDPH.  The incidence of PDPH in our study was 11.76% which is similar to other catheter related studies, ,, and this incidence is far less than the reported PDPH incidence of 46% - 86% in cases of accidental dural puncture without prophylaxis. 
Etiology by which spinal catheter prevents PDPH is not known however it is postulated that it stimulates inflammatory cells to accumulate near the entry of catheter and closing of dural tear. Formation of fibrin around the intrathecal catheter at the dural tear has also been described in an experimental study using cats.  This also explains that, why two of our patients responded to conservative treatment.
Insertion of epidural catheter in spinal space after accidental dural puncture is now becoming common. A survey in the United Kingdom aimed to explore the current management of accidental dural puncture compared the findings to a similar survey undertaken in 1993. In 47 units (28%), the epidural catheter is now routinely placed in trathecally following accidental dural puncture. This is in contrast to the previous survey, which found that catheters were re-sited in 99% of units.  Our study included cases from all specialties and therefore there is large variation in nature of surgery. Subarachnoid catheter placement after wet tap in obstetric patients reduces the PDPH rate and does so to a greater extent if left in place for 24 hours.  That's why our targetto keep the spinal catheter was>24 hrs however, if time of removal was commencing at late evening;the catheters were removed in the next morning. Therefore duration of catheter in situ is also quite variable because practically it wasvery difficult to remove catheter exactly after24 hrs.
Epidural catheter can be used as spinal catheter to manage accidental dural puncture during epidural anaesthesia. If catheter left in situ for 24-36 hrs provides prophylaxis against PDPH. In our experience of 34 cases of accidental dural puncture, we found it is safe to practice. However, a large double blind randomized trial is necessary to prove its ultimate safety.
| References|| |
|1.||Berger CW,Cros by ET, Groecki W.NorthAmericansurvey of the management of dural puncture occurring during labour epidural analgesia. Can J Anaesth 1998; 45:110-114. |
|2.||Gordon HM. Arational approach to the cause, prevention and treatment of post dural puncture headache. CanMedAssocJ1993; 149:1087-1093. |
|3.||Safa-Tisseront V,Thormann F, Malassine P,et al. Effectiveness of epidural blood patch in the management of post-dural puncture headache. Anesthesiology 2001; 95:334-9. |
|4.||Cohen S, Amar D, Pantuck EJ, et al. Decreased incidence of headache after accidental dural puncture in caesarean delivery patients receiving continuous postoperative intrathecal analgesia.ActaAnaesthesiol Scand 1994;38:716-8. |
|5.||Dennehy KC, Rosaeg OP. Intrathecal catheter insertion during labour reduces the risk of post-dural puncture headache. Can JAnaesth 1998; 45:42-5. |
|6.||Rutter SV, Shields F, Broadbent CR , et al. Management of accidental dural puncture in labour with intrathecal catheters: an analysis of 10 years' experience . International Journal of ObstetricAnesthesia 2001;10:177-181. |
|7.||Cowan CM, Moore EW.Asurveyof epidural technique and accidental dural puncture rates among obstetric anaesthetists. International Journal of Obstetric Anesthesia2001;10: 11-16. |
|8.||Chadwick HS.An analysis of obstetric anesthesia cases from the American Society of Anesthesiologists closed claims project database. International Journal of ObstetricAnesthesia1996; 5: 258-63. |
|9.||Chan T. Postpartum headaches: summary report of the National Obstetric Anaesthetic Database (NOAD). International Journal of Obstetric Anesthesia1999;12:107 -112. |
|10.||Abouleish E, Vega S, Blendinger I, et al. Long term follow up of epidural blood patch. Anesth Analg 1975; 54:459-63. |
|11.||Munoz H, Dagnino JA, Allende M, et al. Direction of catheter insertion and incidence of paresthesias and failure rate in continuous epidural anesthesia: a comparison of cephalad and caudad catheter insertion. RegionalAnesthesia1993;18:331-4. |
|12.||Norris MC, Leighton BL. Continuous spinal anesthesia after unintentional dural puncture in parturients. Regional Anesthesia1990;15:285-7. |
|13.||Blaise GA, Cournoyer S, Perrault C, et al. Spinal catheter does not reduce post-dural puncture headache after caesarean section. CanJAnaesthesia1992; 39:633-4. |
|14.||Puolakka R, Pitkanen MT, Rosenberg PH. Comparison of three catheter sets for continuous spinal anesthesia in patients undergoing total hip or knee arthroplasty. RegAnesthPainMed 2000;25:584-90. |
|15.||Horlocker TT, McGregor DG, MatsushigeDK,et al.Neurologic complications of 603 consecutive continuous spinal anesthetics using macro catheter and micro catheter techniques. AnesthAnalg1997;84:1063 -70. |
|16.||Lambert DH. Is continuous spinal anesthesia really so bad? AnesthAnalg 1997;86:214-5. |
|17.||Denny NM, Selander DE. Continuous spinal anaesthesia. Br JAnaesthesia1998; 81:590-7. |
|18.||Kevin CD, Ola PR. Intrathecal catheter insertion during labour reduces the risk of post- dural puncture headache. CanJAnaesth 1998; 45:42-5. |
|19.||Yaksh TL, NoueihedR, Durant PAC. Studies of the pharmacology and pathology of intrathecally administered 4-anilinopiperidine analogues and morphine in the rat and cat.Anesthesiology1986;64: 54-66.R. |
|20.||Baraz R, Collis RE. Themanagement of accidental dural puncture during labour epidural analgesia: a survey of UK practices. Anaesthesia2005; 60: 673-679. |
|21.||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. RegAnesthPain Med 2003; 28:512-515. |
[Table 1], [Table 2], [Table 3], [Table 4]