Ep. 171- Postpunktionaler Kopfschmerz

Im Juli diesen Jahres wurde folgende Arbeit im BMJ Journal Regional Anesthesia & Pain Medicine veröffentlicht

Evidence-based clinical practice guidelines on postdural puncture headache_ a consensus re.

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Folgende Zusammenfassung gibt es:

Zehn Fragen wurden gestellt und beantwortet. hier einige Auszüge aus dem Artikel (ich empfehle sehr das Lesen der Seiten 3-22:

Question 1: when should PDPH be suspected? A recent observation of 1001 laboring women with PDPH revealed that only 40% showed classical signs (postural component and at least one of the following symptoms: neck stiffness, tinnitus, hypoacusia, photophobia and nausea). Statement: PDPH should be suspected if headache or neurological symptoms, which may be relieved when lying flat, occur within fivedays of a neuraxial procedure (Moderate Level of Certainty). ► Recommendation: Inpatients who have received a neuraxial procedure should be reviewed and evaluated for symptoms of PDPH. Outpatients should be instructed to report symptoms of PDPH to their physicians

Question 2: what patient factors are associated with the incidence of PDPH?

Statement: The preponderance of evidence suggests that in the adult population, younger age may be associated with an increased risk of PDPH (High Level of Certainty).

Statement: The preponderance of evidence suggests that female sex is associated with an increased risk of PDPH.

The preponderance of evidence suggests that a history of headaches (chronic, contemporaneous, or prior PDPH) may be associated with an increased risk of PDPH. The association specifically with migraine is less clear

Question 3: what procedural characteristics are associated with PDPH?

Statement: Compared to cutting needles, non-cutting spinal needles are associated with decreased risk of PDPH (High Level of Certainty). However, there is limited evidence regarding a particular design of non-cutting spinal needle (Low Level of Certainty). ► Recommendation: Routine use of non-cutting spinal needles for LP for all populations is recommended (Grade A; High Level of Certainty).

Statement: Evidence does not support the paramedian over the midline approach to decrease the risk of PDPH when performing LP (Moderate Level of Certainty).

Statement: Evidence suggests an association between the number of attempts at LP and the risk of PDPH (Moderate Level of Certainty).

Statement: Evidence suggests that increased operator experience level decreases the incidence of PDPH, but net benefit may be small (Moderate Level of Certainty).

Statement: Evidence suggests that all neuraxial techniques (ie, spinal, epidural, and CSE) have similar PDPH risk profiles (Moderate Level of Certainty).

Statement: Evidence does not suggest an association of PDPH with the level of epidural insertion (Moderate Level of Certainty).

Statement: Evidence suggests a decreased risk of PDPH with techniques performed with the patient in the lateral decubitus position. (Moderate Level of Certainty)

Question 4: what measures may be used to prevent PDPH? Continuous spinal or epidural analgesia following inadvertent dural puncture

Statement: Following inadvertent dural puncture during attempted epidural catheter insertion, evidence is insufficient to confirm that placement of an intrathecal catheter decreases the risk of PDPH and EBP (Low Level of Certainty).

► Recommendation: After inadvertent dural puncture during epidural catheter placement, an intrathecal catheter may be considered to provide anesthesia/analgesia. This decision must consider potential risks associated with. (würde ich eher nicht machen).

Statement: Prophylactic EBPs via an existing epidural catheter or as a standalone procedure have been performed following inadvertent dural punctures in both obstetric and non-obstetric populations with variable success. Not every patient who experiences a dural puncture develops a PDPH. Therefore, a policy of routine prophylactic blood patching exposes some patients to unnecessary potential risks.

► Recommendation: A prophylactic EBP is not recommended as routine as there is insufficient evidence to support its effectiveness in preventing PDPH (Grade C; Low Level of Certainty).

 Statement: Evidence of a reduction in severity of PDPH with prophylactic bed rest is inconclusive (Moderate Level of Certainty).

► Recommendation: Bed rest is not routinely recommended as prophylaxis against PDPH. (Grade D, Moderate Level of Certainty).

Question 5: what conservative measures may be used to treat PDPH?

Recommendation: Evidence does not support routine use of bed rest to treat PDPH, but it may be used as a temporizing measure for symptomatic relief (Grade C; Low Level of Certainty).

Recommendation: Adequate hydration should be maintained with oral fluids; intravenous fluid should be used when oral hydration cannot be maintained (Grade C; Low Level of Certainty).

Recommendation: Regular multimodal analgesia including acetaminophen and NSAIDs, unless contraindicated, should be offered to all patients with PDPH (Grade B; Low Level of Certainty).

► Recommendation: Short-term use of opioids may be considered in the treatment of PDPH if regular multimodal analgesia is ineffective (Grade C, Low Level of Evidence); long-term opioid use is not recommended in the treatment of PDPH (Grade D, Moderate Level of Certainty).

► Recommendation: Caffeine may be offered in the first 24 h of symptoms with a maximum dose of 900 mg per day (200–300mg if breastfeeding) and avoiding multiple sources to prevent untoward side effects (Grade B; Low Level of Certainty).

► Recommendation: Evidence does not support the routine use of hydrocortisone, theophylline, and gabapentin in the management of PDPH (Grade D; Low Level of Certainty).

Question 6: what procedural interventions may be used to treat PDPH?

Keine Evidenz für irgendein Verfahren

Question 7: is imaging required in PDPH management?

Statement: Current evidence is insufficient to assess the riskbenefit balance for routine cranial imaging before EBP for PDPH (Low Level of Certainty).

Recommendation: Brain imaging may be considered when non-orthostatic headache is present or develops after initial orthostatic headache, or when headache onset is more than fivedays after suspected dural puncture (Grade C; Low Level of Certainty).

► Recommendation: Focal neurological deficits, visual changes, alterations in consciousness, or seizures, especially in the postpartum period, should prompt neuroimaging to evaluate alternative diagnoses (Grade A; Moderate Level of Certainty)

Question 8: what are the contraindications to an EBP?

Statement: The risk of epidural hematoma is low when performing neuraxial procedures in obstetric patients with a platelet count≥70,000x 106 /L providing there is no defect in platelet function or other abnormality of coagulation (Moderate Level of Certainty).

► Statement: There is insufficient evidence for recommending prophylactic antibiotics before EBP (Low Level of Certainty).

► Recommendation: Clinicians should follow appropriate guidelines regarding neuraxial injection in patients on antithrombotics or with low platelet counts (Grade A; Moderate Level of Certainty).

► Recommendation: Caution should be exercised when considering an EBP in febrile patients or patients presenting with other systemic signs of infection. Deferring the procedure may be appropriate if there is risk of hematogenous infection (Grade C; Moderate Level of Evidence).

Question 9: when and how should an EBP be performed?

Recommendation: When PDPH is refractory to conservative therapy and impairs activities of daily living, an EBP should be considered to treat headache and other neurological sequelae of intracranial hypotension (Grade: B; Moderate Level of Certainty).

► Recommendation: In patients with PDPH with severe neurological symptoms (eg, hearing loss, cranial neuropathies), EBP should be considered as a therapeutic option (Grade: C; Moderate Level of Certainty).

Statement: High success rates for EBP reported in early studies have not been reproduced in more recent publications with complete headache remission varying between 33% and 91% (Low Level of Certainty).

Recommendation: If an EBP is performed within 48 h of dural puncture, patients should be counseled about a more likely need for repeat EBP to achieve symptom resolution (Grade B; Moderate Level of Certainty).

► Recommendation: Until symptom resolution, regular patient follow-up should be undertaken to determine the need for repeat EBP in cases of suspected persistent or severe CSF leak (Grade C; Low Level of Certainty).

Recommendation: When the site of dural puncture is known, an EBP should be performed ideally at, or one space below, this level (Grade B; Moderate Level of Certainty).

► Recommendation: The transforaminal approach to the epidural space with fluoroscopic guidance can be considered in cases of prior laminectomies near the site of dural puncture or after unsuccessful interlaminar EBP (Grade C; Moderate Level of Certainty).

Statement: Optimal EBP volume is unknown and likely varies among patients due to patient factors such as size, age, degree of spondylotic spine changes and relative size of the dural hole (Low Level of Certainty).

► Statement: Despite lack of correlation between EBP volume and success rates, most recommended volumes are between 15–20mL of blood (Low Level of Certainty).

► Statement: Injection of>30mL blood does not appear to increase the success of EBP (Moderate Level of Certainty).

Statement: Ultrasound-assisted EBP has the utility for landmark clarification before EBP or for image guidance in patients unable to receive fluoroscopy or CT (Low Level of Certainty). ► Recommendation: The decision to perform EBP under radiological guidance should be individualized based on patient factors, including age, BMI, degree of spondylotic change, context of dural puncture, and prior lumbar spine surgeries and, provider expertise (Grade I; Low Level of Certainty).

► Recommendation: Radiological guidance should consider risk-benefit analysis, available resources, and follow-up capabilities, and where the clinician determines that EBP cannot be safely performed with landmarks alone (Grade I; Low Level of Certainty).

Statement: Evidence is insufficient to recommend a specific duration of immobilization following EBP (Low Level of Evidence).

Recommendation: Informed consent for an EBP should include the potential for repeat dural puncture, backache, and neurological complications (Grade A, High Level of Certainty).

► Recommendation: To minimize complications, blood should be injected slowly and incrementally. If the patient develops significant backache or headache (eg, pressure paresthesia), injection of blood should be stopped and resumed based on the clinical judgement if symptoms resolve (Grade A; Moderate Level of Certainty).

► Recommendation: After an EBP, if backache persists, increases in severity, or changes in its nature, other diagnoses should be investigated (Grade C; Low Level of Certainty).

► Recommendation: Epidural analgesia and anesthesia can be effective following EBP and should not be withheld (Grade C; Low Level of Certainty).

Question 10: what are the long-term complications of PDPH and how should patients be followed up?

►Statement: Evidence shows an association between inadvertent dural puncture and/or PDPH with chronic headache, backache, neckache, depression, cranial nerve palsy, SDH or CVST (Moderate Level of Certainty).

► Statement: Evidence is insufficient to determine whether EBP mitigates, prevents, or treats these sequelae (Low Level of Certainty).

► Statement: PDPH is associated with the development of chronic headache (Moderate Level of Certainty).

► Recommendation: Before discharge, information regarding PDPH sequelae should be conveyed to patients with arrangements for appropriate follow-up and contact information with their anesthesia provider and other health care providers (Grade B, Moderate Level of Certainty).

► Recommendation: The person (or team member) responsible for dural puncture leading to PDPH should ensure that other specialties or primary care physicians are informed of PDPH management and potential for long-term symptoms (Grade B, Moderate Level of Certainty).

► Recommendation: Follow-up with patients who experience PDPH should be continued until headache resolves (Grade B; Moderate Level of Certainty).

► Recommendation: Following discharge from hospital, follow-up may be continued by the patient’s primary care physician. Information regarding PDPH diagnosis and/or inadvertent dural puncture should also be communicated to the patient’s primary care physician and other specialists with referrals to a pain or neurology specialist if indicated (Grade C; Low Level of Certainty).

► Recommendation: Urgent neuroimaging and referral to an appropriate specialist should be performed for any PDPH patient with worsening symptoms despite an EBP, new focal neurologic symptoms, or a change in the nature of headache (Grade B; Moderate Level of Certainty).

In diesem Sinne...

Es ist nicht die Frage ob sondern wann eure erste Duraperforation erfolgen wird.

Schaut euch unbedingt auch unsere Standard "Postpunktionskopfschmerz" im ELO an unter "Fachliches und spezielle Anästhesie"

lg norbert