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North American survey of the management of durai puncture occurring during labour epidural analgesia

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Abstract

Purpose

To document the range and the most common strategies for the management of the parturient with inadvertent durai puncture (DP) during labour epidural analgesia.

Methods

A confidential survey form was mailed to 46 academic units in Canada and USA. The responses were compiled into Canadian, US and joint North American databases.

Results

Thirty-six centres (78%) responded, representing 137,250 annual deliveries. The reported incidence of DP was 0.04–6%. The most common initial response to DP was re-siting the catheter at another level, Most centres made little change in routine practice regarding epidural top-ups and infusion rates after DP. Unrestricted mobilisation was advocated by 86% of centres following delivery; enhanced oral hydration was encouraged by 61%. Prophylactic epidural blood patch (PEBP) was recommended by 37% of centres, with twice as many US as Canadian centres doing so. In the presence of PDPH, EBP was offered most commonly at or within 24 hr of diagnosis. Complications were common after EBP: 86% of centres reported patch failures; 44% reported persistent headache after ≥2 EBP. Despite this, centres remained optimistic about EBP success, quoting cure rates >90% in 58% of centres.

Conclusion

There is little difference between the practices reported by Canadian or US centres. The expressed optimism regarding the efficacy of EBP is not supported by the evidence available and may be unwarranted. More research is needed to define the issue better.

Résumé

Objectif

Documenter l’étendue du problème et les stratégies les plus utilisées pour traiter la parturiente avec ponction accidentelle de la dure-mère (PDM) durant l’analgésie pour le travail.

Méthodes

Une enquête confidentielle a été adressée par la poste à 46 départements académiques au Canada et aux États-Unis. Les réponses ont été compilées dans les bases de données canadienne, américaine et nordaméricaine conjointe.

Résultats

Trente-six centres (78%) ont répondu, ce qui représentait 137,250 accouchements. Lincidence rapportée de PDM était de 0,04–6%. La réaction initiale la plus fréquente à une PDM était de reprendre la technique à un autre niveau. La plupart des centres ne modifiaient pas leur routine concernant les vitesse d’infusion et les bolus après PDM. La mobilisation à volonté à la suite de l’accouchement était prônée par 86% des centres; 61 % encourageaient une hydratation orale accrue. Le pansement de sang épidural (PSE) prophylactique était recommandé par 37% des centres, et ce deux fois plus souvent aux USA qu’au Canada. En présence de céphalée post-ponction de la dure-mère (CPPDM), le PSE était offert le plus souvent au moment du diagnostic ou dans les 24 heures subséquentes. Les complications sont fréquentes après PSE : 86% des centres rapportent des échecs; 44% rapportent des céphalées persistantes après ≥2PSE. Malgré ceci, les centres demeurent optimistes quant au succès du PSE, 58% des centres rapportent des taux de succès de >90%.

Conclusion

Il y a peu de différence entre la pratique au Canada et aux États-Unis. Loptimisme démontré quant à l’efficacité du PSE n’est pas corroboré par les données disponibles et est peut-être injustifié. Des recherches additionnelles pour quantifier ce problème sont nécessaires.

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Correspondence to Edward T. Crosby.

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Berger, C.W., Crosby, E.T. & Grodecki, W. North American survey of the management of durai puncture occurring during labour epidural analgesia. Can J Anaesth 45, 110 (1998). https://doi.org/10.1007/BF03013247

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Keywords

  • Caffeine
  • Dural Puncture
  • Epidural Blood Patch
  • Post Dural Puncture Headache
  • Oral Hydration