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Immediate management of inadvertent dural puncture during insertion of a labour epidural: a survey of Australian obstetric anaesthetists.

SUMMARY

Immediate management of inadvertent dural puncture during insertion of an epidural needle during labour is controversial and evidence to guide clinical practice is limited. We surveyed Australian obstetric anaesthetists by anonymous postal questionnaire. Of the 671 surveys sent, 417 (62%) were returned. Following dural puncture, 265 respondents (64%) indicated that they "would usually remove the Tuohy needle and resite" The most common reason for this decision was concern regarding the safety of intrathecal catheters (ITC) (n=236, 89%), in particular, the risk of misuse (n=182, 70%).

The most frequently reported reason for "usually inserting an ITC" was that this reduced the incidence (n=120, 84%) and severity (n=110, 77%) of post dural puncture headache. Increased frequency of ITC insertion was reported by respondents who practised more frequent sessions of obstetric anaesthesia, had fewer years of experience as a consultant anaesthetist and worked in a public hospital. The more widespread use of ITCs seems to be limited by safety concerns.

Key Words: survey, obstetric anaesthesia, dural puncture, intrathecal catheter, epidural analgesia, post dural puncture headache

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Inadvertent dural puncture occurs in 1 to 2% of epidural insertion attempts (1,2). With a 16 to 18 gauge Tuohy needle this results in a post dural puncture headache (PDPH) in up to 80% of cases (1-4). PDPH is a leading cause of morbidity and litigation in obstetric anaesthesia practice (5,6). This often debilitating headache can render the parturient bedridden and result in reduced maternal-infant bonding (7,8), as well as increased length of hospital stay and healthcare costs (4,7-10).

The traditional approach of managing an inadvertent dural puncture is to remove the epidural needle and resite it at the same or a different level. In addition to PDPH, further complications may arise from this technique, including an unexpectedly high block and repeat dural puncture (3). A 1993 survey revealed that 99% of U.K. maternity units used this approach (11).

More recently, a trend has been to intentionally insert an intrathecal catheter (ITC) following an inadvertent dural puncture and to leave it in situ for at least 24 hours. This practice is based on the hypothesis that such a technique will reduce the incidence and severity of PDPH while providing rapid, reliable, good quality analgesia (12). If the incidence of PDPH is reduced by this technique, there would be significant gains in patient care, healthcare costs and avoidance of complications of PDPH and epidural blood patches such as subdural haematoma (13,14), paraplegia and cauda equina syndrome (15). When the survey of U.K. maternity units was repeated in 2003, a substantial change in reported practice was noted, with 28% of units routinely placing an ITC rather than resiting the epidural catheter. A further 31% of units allowed either technique (16). Unfortunately, the evidence supporting this approach is not strong. Several authors have published case reports describing the prevention of headache with ITCS (12,17-20). Most notably Kuczkowski reported only a 6.6% incidence of PDPH with a technique that aims to maintain cerebrospinal fluid (CSF) volume (21). While no prospective randomised control trial has been reported, conflicting results have been demonstrated in retrospective studies in obstetric populations (3,22-25). Only two retrospective trials have investigated the use of ITCs left in place for variable lengths of time. These studies suggest that the reduction of PDPH is greatest if the ITC is left in place for 24 hours after delivery (22,23). In addition, safety concerns with the use of ITCs exist (26), with complications including high block (3), accidental misuse (27,28), meningitis (29), CSF leak (30), tinnitus (31) and breakage of the catheter requiring surgical intervention (32).

In view of the lack of definitive evidence to guide clinical practice, we surveyed obstetric anaesthetists regarding their current practice following an inadvertent dural puncture during the conduct of an epidural block for labour analgesia.

METHODS

Following institutional Ethics Committee approval, a pilot survey of obstetric anaesthetists was conducted at the main tertiary referral centre for obstetrics in South Australia. The final version of the survey was forwarded to the Australian and New Zealand College of Anaesthetists (ANZCA), for approval and distribution anonymously to all 671 Australian-based members of the Obstetric Anaesthesia Special Interest Group (OASIG). The surveys were accompanied with a covering letter and a stamped self-addressed envelope to the lead investigator (MN). Four weeks after the surveys were posted, an email reminder was sent through ANZCA to the 631 members of OASIG with a current email address.

The survey asked respondents to describe their management of an inadvertent dural puncture that occurs while attempting to place a labour epidural. The specific scenario outlined in the survey was: "While attempting to place a labour epidural, an inadvertent dural puncture occurs with cerebrospinal fluid flowing through the epidural (Tuohy) needle".

Respondents who reported that they would usually insert an ITC were asked the reasons for inserting an ITC, the length of time that the ITC was left in post-delivery and any circumstances in which an ITC would not be inserted. Respondents who reported that they would usually remove the epidural needle and resite, were asked the reasons for not inserting an ITC and circumstances in which an ITC would be inserted.

Demographic data were also requested relating to years of experience as a consultant anaesthetist, location and type of obstetric anaesthesia practice and the average number of weekly sessions practised in obstetric anaesthesia.

Data are presented as descriptive statistics, with total number of responses to the question as the denominator.

RESULTS

We received 417 responses to the 671 surveys posted (62%). The demographic data collected from respondents are outlined in Table 1. Following an inadvertent dural puncture, 265 respondents (64%) would usually remove the epidural needle and resite, while 146 (35%) reported they would usually insert an epidural catheter into the intrathecal space. Two of these stated that they would tie a knot in the catheter after delivery to prevent accidental misuse.

Within the group of 265 anaesthetists who would resite the epidural, 11 commented that they would inject a low-dose local anaesthetic and/or opioid intrathecally prior to removal of the epidural needle. Three respondents reported that they would perform an immediate epidural blood patch; two stated that they would attempt to carefully withdraw the epidural needle and resite at the same level and one reported injecting 10 ml of intrathecal saline prior to resiting.

Five respondents reported other techniques in the event of an inadvertent dural puncture. Of these, four would inject a low-dose local anaesthetic and/or opioid intrathecally and then reassess the patient's analgesic requirements, while one would abandon attempts at a regional technique. One respondent no longer practises obstetric anaesthesia and did not complete the survey.

The reasons for respondent's preferred techniques are outlined in Tables 2 and 3.

In the group of 145 respondents who would insert an ITC, 40 (28%) reported that they would remove it immediately after delivery, whereas 86 (61%) would remove it after at least 24 hours.

In the ITC group, 87 (60%) reported that they would not insert an ITC in a hospital without 24-hour on-site anaesthetic cover. Other specific circumstances when an ITC would not be inserted included concern about the ability of labour ward staff to safely manage an ITC (n=11, 8%); specific concern that the patient had a high risk of infection or neurological complication (n=9, 6%); if the anaesthetist was unavailable to personally follow-up the management of the ITC (n=5, 3%); patient refusal (n=3, 2%); and inability to thread the ITC (n=3, 2%).

In the resite group, 102 respondents (39%) reported that they would consider inserting an ITC after a difficult or lengthy attempt, while 136 (51%) would insert an ITC if a caesarean section was expected soon. Other specific circumstances when an ITC would be considered by respondents who would usually resite the epidural included patients for whom vaginal delivery was expected soon (n=5, 2%); extreme maternal distress (n=2, 1%); in a hospital with registrar anaesthetic cover (n=2, 1%); in a patient at high risk of general anaesthetic (n=2, 1%); if the anaesthetist was able to personally manage the ITC (n=2, 1%); and when the perceived benefits of an ITC outweigh the risks (n=1, 0.4%). Only 97 of all respondents (23%) indicated that there were no circumstances in which they would consider inserting an ITC.

The rate of insertion of ITCs was greater amongst anaesthetists who work in public hospitals (39%) or both public and private hospitals (39%) compared to those who work solely in private hospitals (24%). Figure 1 shows that respondents with more years of experience as a consultant anaesthetist had lower ITC insertion rates. Figure 2 shows that respondents who practised more sessions of obstetric anaesthesia per week were more likely to insert an ITC. Figure 3 outlines the ITC insertion rate according to the predominant site of practice.

DISCUSSION

This study is the first Australian survey of the immediate management of inadvertent dural puncture while inserting an epidural needle for labour analgesia. Previous surveys in the U.K. and U.S.A. have surveyed obstetric anaesthesia units rather than individual obstetric anaesthetists. The overall ITC insertion rates in our study are comparable with a U.K. survey in 2003, where 28% of maternity units routinely used an ITC following inadvertent dural puncture and another 31% allowed their use (16). This was in contrast to a survey conducted a decade earlier when only 1% of units allowed the use of ITCs (11).

Obstetric anaesthetists with fewer years of experience are more likely to use an ITC. This may be because of the recent trend towards the greater use of ITCs in obstetric anaesthesia practice. Anaesthetists with fewer years of experience may have trained in teaching hospitals using this technique, whereas more senior anaesthetists may have had limited exposure to ITC placement.

The more frequent use of ITCs amongst anaesthetists who work more regularly in obstetrics is also not unexpected. These consultants would tend to have more experience with ITCs and perhaps more confidence in the ability of the labour ward staff to safely manage them. A strong opinion expressed by respondents in this survey is that an ITC must be closely supervised by an anaesthetist. This is likely to explain the greater incidence of insertion by those who work at least partly in public hospitals, where it is more common for there to be 24-hour on-site anaesthetic cover.

The relatively high ITC insertion rate in the Australian Capital Territory (ACT) is explained by the protocol at their main teaching hospital, Canberra Hospital. Most of the six respondents from the ACT are likely to work there. Correspondence from an anaesthetist at Canberra Hospital explained that their policy is to routinely insert ITCs.

ITC placement appears to reduce the incidence of PDPH if the catheter is left in situ for at least 24 hours (22,23). Indeed, the vast majority of respondents who use ITCs reported placement of ITCs for at least 24 hours. It was surprising that only one-third of respondents who would resite the epidural, indicated that they believed an ITC does not reduce the incidence of PDPH. While there is some evidence to suggest that ITC placement reduces the incidence of PDPH, the majority of obstetric anaesthetists appear not to use them because of safety concerns. It is likely that even if a well-designed prospective randomised control trial demonstrated a reduction in PDPH with the use of ITCs, attention to safety concerns would be needed to facilitate their use. This might include labour ward staff training on ITCs, use of special intrathecal syringes with a unique interlocking mechanism to prevent accidental misuse and education to improve knowledge of the technique.

This study has a number of limitations. First, we only surveyed members of the OASIG in Australia. It is likely that anaesthetists who are not OASIG members practise less obstetric anaesthesia and our study findings suggest that such anaesthetists are less likely to insert an ITC. Second, while the response rate for this survey was comparable to others of this type (33), non-responders may represent a subgroup with a particular practice. Finally, only about 50% of inadvertent dural punctures will be detected by CSF flow through the needle (6), thus the scenario described in this study did not account for all situations in which a dural puncture occurs.

Conflicting evidence together with the possibility of selection, observer and publication bias in the studies reported to date suggests that a well-designed randomised trial is required to clarify this issue. This study has shown that despite the lack of definite evidence supporting the use of ITCs, a large minority of obstetric anaesthetists in Australia use this technique. This topic clearly needs further research to guide clinical practice. Future studies will need to address not only the effects of ITCs on PDPH, but also the risk of high block and other complications such as infectious and neurological sequelae. Despite substantial use of ITCs following an inadvertent dural puncture, the majority of obstetric anaesthetists in Australia prefer to remove the epidural needle and resite an epidural catheter, primarily for safety reasons. Advocates of the use of ITCs in this study stated that an ITC provided fast and reliable analgesia, prevented the risk of repeat dural puncture and reduced the incidence and severity of PDPH.

ACKNOWLEDGEMENTS

We thank OASIG members who responded so enthusiastically to our survey. Special thanks also to Juliette Mullumby (Executive Officer in Continuing Professional Development, ANZCA) for assistance with distribution of the surveys.

Accepted for publication on September 25, 2007.

REFERENCES

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(2.) Sharpe P. Accidental dural puncture in obstetrics. Br J Anaesth CEPD Reviews 2001; 1:81-84.

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(4.) Paech M, Banks S, Gurrin L. An audit of accidental dural puncture during epidural insertion of a Tuohy needle in obstetric patients. Int J Obstet Anesth 2001; 10:162-167.

(5.) Peng PWH, Smedstad KG. Litigation in Canada against anesthesiologists practicing regional anesthesia. A review of closed claims. Can J Anaesth 2000; 47:105-112.

(6.) Chadwick H, Posner K, Caplan RA, Ward RJ, Cheney FW A comparison of obstetric and nonobstetric anesthesia malpractice claims. Anesthesiology 1991; 74:242-249.

(7.) Angle P, Tang SLT, Thompson D, SzaIai JP Expectant management of postdural puncture headache increases hospital length of stay and emergency room visits. Can J Anaesth 2005; 52:397-402.

(8.) Weir EC. The sharp end of the dural puncture. BMJ 2000; 320:127.

(9.) Tetzlaff JE, Ayad S, Narouze S. Reply to Drs Rosenblatt et al and Lambert. Reg Anesth Pain Med 2004; 29:299-301.

(10.) Banks S, Paech M, Gurrin L. An audit of epidural blood patch after accidental dural puncture with a Tuohy needle in obstetric patients. Int J Obstet Anesth 2001; 10:172-176.

(11.) Sajjad T, Ryan TDR. Current management of inadvertent dural tapes occurring during siting of epidurals for pain relief in labor. A survey of maternity units in the United Kingdom. Anaesthesia 1995; 50:156-161.

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(13.) Gaucher DJ, Perez JA. Subdural hematoma following lumbar puncture. Arch Intern Med 2002; 162:1904-1905.

(14.) Vos PE, de Boer WA, Wurzer JAL, van Gijn J. Subdural hematoma after lumbar puncture: two case reports and review of the literature. Clin Neurol Neurosurg 1991; 93:127-132.

(15.) Drasner K, Rigler ML, Sessier DI, Stoller ML. Cauda equina syndrome following intended epidural anesthesia. Anesthesiology 1992; 77:582-585.

(16.) Baraz R, Collins RE. The management of accidental dural puncture during labour epidural analgesia: a survey of UK practice. Anaesthesia 2005; 60:673-679.

(17.) Cohen S, Daitch JS, Goldiner PL. An alternative method for management of accidental dural puncture for labor and delivery. Anesthesiology 1989; 70:164-165.

(18.) Dennehy KC, Rosaeg OP Intrathecal catheter insertion during labour reduces the risk of post-dural puncture headache. Can J Anaesth 1998; 45:42-45.

(19.) Gunaydin B, Karaca G. Prevention strategy for post dural puncture headache. Acta Anaesthesiol Belg 2006; 57:163-165.

(20.) Hall JM, Hinchliffe D, Levy DM. Prolonged intrathecal catheterisation after inadvertent dural taps in labour. Anaesthesia 1999;54:611-612.

(21.) Kuczkowski KM. Decreasing the incidence of post-dural puncture headache: an update. Acta Anaesthesiol Scand 2005; 49:594.

(22.) 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; 28:512-515.

(23.) Cohen S, Amar D, Pantuck EJ, Singer N, Divon M. Decreased incidence of headache after accidental dural puncture in caesarian delivery patients receiving continuous postoperative intrathecal analgesia. Acta Anaesthesiol Scand 1994; 38:716-718.

(24.) Norris MC, Leighton BL. Continuous spinal anesthesia after unintentional dural puncture in parturients. Reg Anesth 1990; 15:285-287.

(25.) Spiegel JE, Tsen LC, Segal S. Requirement for and success of epidural blood patch after intrathecal catheter placement for unintentional dural puncture. Abstract. Anesthesiology 2001; 94:A76.

(26.) Rosenblatt MA, Bernstein HH, Beilin Y. Are subarachnoid catheters really safe? Reg Anesth Pain Med 2004; 29:298.

(27.) Balestrieri PJ, Hamza MS, Ting PH, Blank RS, Grubb CT Inadvertent intrathecal injection of labetalol in a patient undergoing post-partum tubal ligation. Int J Obstet Anesth 2005; 14:340-342.

(28.) Gaiser R. Postdural puncture headache. Cuff Opin Anaesthesiol 2006;19:249-253.

(29.) Cohen S, Hunter CW, Sakr A, Hijazi RH. Meningitis following intrathecal catheter placement after accidental dural puncture. Int J Obstet Anesth 2006; 15:171.

(30.) Cohen S, Stricker P, Sakr A. Cerebrospinal fluid leak after disconnection of an intrathecal catheter adapter placed after accidental dural puncture. Reg Anesth Pain Med 2005; 30:591.

(31.) Ravi R. Isolated tinnitus following placement of an intrathecal catheter for accidental dural puncture. Int J Obstet Anesth 2006;15:180.

(32.) Ugboma S, Au-Truong Y, Kranzler LI, Rifai SH, Joseph NJ, Salem MR. The breaking of an intrathecally-placed epidural catheter during extraction. Anesth Analg 2002; 95:1087-1089.

(33.) Coldrey JC, Cyna AM. Suggestion, hypnosis and hypnotherapy: a survey of use, knowledge and attitudes of anaesthetists. Anaesth Intensive Care 2004; 32:676-680.

M.J. NEWMAN *, A.M. CYNA [dagger] Department of Women's Anaesthesia, Women's and Children's Hospital, Adelaide, South Australia, Australia

* M.B., B.S., Anaesthetic Registrar. ([dagger]) D.R.C.O.G., Dip.Clin.Hyp, ER.C.A., Senior Consultant Anaesthetist.

Address for reprints: Dr A. M. Cyna, Department of Women's Anaesthesia, Women's and Children's Hospital, 72 King William Road, North Adelaide, S.A. 5006.
TABLE 1

Demographic data of survey respondents

Years of experience
 Range 0-45 y
 Median 14 y

Location of practice Number (%)
 New South Wales 140 (34)
 Victoria 108 (26)
 Queensland 76 (18)
 South Australia 34 (8)
 Western Australia 33 (8)
 Tasmania 11 (3)
 Australian Capital Territory 6 (1)
 Northern Territory 1 (0.2)
Site of obstetric anaesthetic practice
 Only in public hospital 107 (26)
 Partly public and partly private 183 (44)
 Only in private hospitals 121 (29)
Average sessions per week
 0 42 (10)
 0.5 120 (28)
 1 116 (28)
 2 79 (19)
 3 20 (5)
 4 15 (4)
 >4 25 (6)

Values are the number of responses with percentage (n=417)
unless stated otherwise.

TABLE 2
Reasons for inserting intrathecal catheter following inadvertent
dural puncture

Reasons Number (%)

Reduces incidence of PDPH 120 (82)
Reduces severity of PDPH 110 (75)
For rapid onset of analgesia 107 (73)
To avoid risk of repeat dural puncture 97 (66)
To prevent further attempts 88 (60)
Other 10 (7)
 To reliably achieve analgesia 6 (4)
 Concern with high block when resiting 2 (1)
 Remove doubt after catheter placement 1 (1)
 Flexibility 1 (1)

Values are the number of responses with percentage (n=146).

TABLE 3
Reasons for resiting epidural following inadvertent dural puncture

Reasons Number (%)

Intrathecal catheter not safe 234 (90.7)
 Concerned about misuse 181 (69.6)
 Concerned about high block 153 (59.2)
 Concerned about infection 133 (51.2)
Intrathecal catheter does not reduce PDPH 89 (34.1)
Other 57 (21.7)
 Concerned about neurological complication 18 (9.8)
 Lack of confidence in labour ward to manage 13 (4.9)
 ITC
 Lack of experience with technique 7 (2.7)
 Time consuming and difficult to manage 6 (2.3)
 No anaesthetic cover in my hospital 4 (1.5)
 Want to see if patient develops headache 1 (0.4)
 May worsen PDPH 1 (0.4)
 Want epidural in situ for epidural blood patch at 1 (0.4)
 24 hours if required
 It is easy to resite 1 (0.4)
 Only postpones the problem 1 (0.4)
 Epidural catheter not designed for intrathecal use 1 (0.4)
 To avoid dense motor block 1 (0.4)
 I have told the patient I will give her an 1 (0.4)
 epidural, so I feel I should

Values are the number of responses with percentage (n=265).

FIGURE 1: Intrathecal catheter insertion rate according
to years of experience as a consultant anaesthetist.

Years as
consultant
anaesthetist

0-5 (n = 81)
6-10 (n = 90)
11-15 (n = 56)
16-20 (n = 63)
21-25 (n = 48)
>25 (n = 69)

Note: Table made from bar graph.

FIGURE 2. Intrathecal catheter insertion rate according to
years of experience as a consultant anaesthetist.

Number of
sessions of
obstetric
anaesthesia
worked
per week

0 (n = 42)
0.5 (n = 120)
1 (n = 116)
2 (n = 79)
>2 (n = 60)

Note: Table made from bar graph.

FIGURE 3: Intrathecal catheter insertion rate according to
Australian state of practice of obstetric anaesthesia.
ACT = Australian Capital Territory, NSW = New South Wales,
NT = Northern Territory, Qld = Queensland, SA = South Australia,
Tas = Tasmania, Vic = Victoria, WA = Western Australia.

Main location
for practising
obstetric
anaesthesia

ACT (n = 6)
NSW (n = 140)
NT (n = 1)
Qld (n = 76)
SA (n = 34)
Tas (n = 11)
Vic (n = 108)
WA (n = 33)

Note: Table made from bar graph.
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Author:Newman, M.J.; Cyna, A.M.
Publication:Anaesthesia and Intensive Care
Article Type:Clinical report
Geographic Code:8AUST
Date:Jan 1, 2008
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