Efficacy of a prophylactic epidural blood patch in preventing post dural puncture headache in parturients after inadvertent dural puncture. Epidural blood patch in the treatment of post dural puncture headache: a double blind study. Conventional treatment or epidural blood patch for the treatment of different etiologies of post dural puncture headache. A randomized controlled trial of prophylactic maneuvers to reduce head-to-body delivery time in patients at risk for shoulder dystocia. [Clinical study of prevention of epidural scar and adhesion with polylactic acid membrane]. Prophylactic epidural blood patch in parturients. Dural puncture with a 27-gauge Whitacre needle as part of a combined spinal-epidural technique does not improve labor epidural catheter function. Epidural blood patch in post dural puncture headache: a randomised, observer-blind, controlled clinical trial. Prophylactic transdermal scopolamine patches reduce nausea in postoperative patients receiving epidural morphine.
Postdural puncture headache (PDPH) occurs in up to 80% of parturients who experience inadvertent dural puncture during epidural catheter placement. The authors performed a randomized double blind study to assess the effect of prophylactic epidural blood patch on the incidence of PDPH and the need for therapeutic epidural blood patch.
                Sixty-four parturients who incurred inadvertent dural puncture were randomized to receive a prophylactic epidural blood patch with 20 ml autologous blood (prophylactic epidural blood patch group) or a sham patch (sham group). Subjects were evaluated daily for development of PDPH for a minimum of 5 days after dural puncture. Those who developed a PDPH were followed daily for a minimum of 3 days after resolution of the headache. Subjects with moderate headaches who reported difficulties performing childcare activities and all those with severe headaches were advised to receive a therapeutic epidural blood patch.
                Eighteen of 32 subjects in each group (56%) developed PDPH. Therapeutic blood patch was recommended in similar numbers of patients in each group. The groups had similar onset time of PDPH, median peak pain scores, and number of days spent unable to perform childcare activities as a result of postural headache. The median duration of PDPH, however, was shorter in the prophylactic epidural blood patch group.
                A decrease in the incidence of PDPH or the need for criteria-directed therapeutic epidural patch was not detected when a prophylactic epidural blood patch was administered to parturients after inadvertent dural puncture. However, prophylactic epidural blood patch did shorten the duration of PDPH symptoms. A randomised double blind controlled trial of 'epidural blood-patch' as treatment for post-dural puncture headache is presented. The method was successful in 11 out of 12 cases on its first application, the twelfth patient being relieved by a second procedure. None of six patients reported benefit from a 'sham' procedure. The rationale for the use of the technique is discussed. Post dural puncture headache (PDPH) represents a complication of anesthesia (with an increased incidence in obstetric patients) or as the consequence of a diagnostic lumbar puncture. The aim of the present study was to evaluate the efficacy of the epidural blood-patch (EBP) versus the conventional medical treatment of post-anesthetic headaches also including the PDPH following a diagnostic puncture, a category of patients rarely referred to the anesthesia consultation in our hospital because it was believed that they might have equal benefit from conventional measures due to the smaller size of needles used. We studied in a prospective, randomized, double-blinded manner 32 obstetric and non-obstetric patients with PDPH having the onset of the symptoms 24 hours before the inclusion in the study. The patients were randomly divided in two groups: group A (16 patients) receiving conventional treatment (oral and intravenous fluid replacement, non-steroidal anti-inflammatory drugs--NSAIDs--, caffeine) and group B (16 patients) in whom an epidural blood-patch was performed. The intensity of the headache was evaluated using a visual analogue scale (VAS) from 0-10, before, 2 hours and 24 hours after the EBP. There were no statistical differences concerning the demographic data and the cause of PDPH between the groups (p > 0.05). The intensity of PDPH was similar before performing the EBP (p > 0.05), with a value on VAS of 8.2 +/- 1,4. in group A and 8,0 +/- 1.6 in group B. Two hours after the treatment, the intensity of headache on VAS diminished extremely significant (p < 0.0001): in group B the value was 1.0 +/- 0,18 versus 8.2 +/- 1.4 in group A. The difference recorded after 24 hours remained statistically significant (p < 0.0001): the VAS scores were 0.7 +/- 0,16 and 7.8 +/- 1.2 respectively. The epidural blood patch represents the first choice treatment of PDPH no matter the etiology, being significantly superior to the conventional treatment which did not affect pain scores. In severe PDPH there is no reason to delay the EBP more than 24 hours after the diagnosis as all except two patients of the conventional treatment group required blood patching following the study period. To assess whether prophylactic use of the McRoberts maneuver and suprapubic pressure decreased the head-to-body time, as a proxy for shoulder dystocia, in at-risk patients.
                Patients with estimated fetal weights over 3800 g were randomized to undergo the McRoberts maneuver and suprapubic pressure before delivery of the fetal head (prophylactic maneuvers) or to undergo maneuvers only after delivery of the head, if necessary (controls). A total of 185 patients were enrolled in the study. After exclusions (eg, abdominal delivery), there were 128 evaluable vaginal deliveries. The study had the power to detect a 30% difference in head-to-body time between groups.
                Head-to-body delivery times did not differ between the prophylactic and control patients (24 +/- 18 seconds versus 27 +/- 20 seconds, P =.38). In addition, the two groups did not differ in rates of admission of the infant to the special care nursery or in birth injuries. There was a significant increase in the risk of delivering by cesarean for patients randomized to the use of prophylactic maneuvers.
                This study does not support the hypothesis that prophylactic use of the McRoberts maneuver and suprapubic pressure speeds delivery in a population of patients at increased risk for shoulder dystocia. To investigate the clinical effect of polylactic acid membrane in prevention of epidural scar and adhesion.
                From July 1998 to April 2000, 62 patients with lumbar disc herniation were randomly assigned into two groups. All were treated surgically with discectomy by fenestration or laminectomy. One group were placed with a thin of polylactic acid membrane covering the interlaminar space(n = 32). The thickness of the film was 0.1 mm. The other group was blank control(n = 30). After 2 weeks of operation, we observed the local and systemic reactions. After 6 months clinical symptoms were revaluated and the degrees of epidural scar and adhesion were determined by CT scans.
                After 2 weeks, we found no adverse systemic reactions in all patients. Wound healing was excellent. No abnormalities of hepatic and renal functions as well as blood for routine were found. Temperature after operation was normal. After 6 months, the curative effects were as follows in experimental group and in control group: excellent in 27 patients and in 24 patients, good in 4 patients and in 4 patients, fair in 1 patient and in 1 patient, and poor in 0 patient and in 1 patient, respectively. There are no significant difference between two groups. The CT scans showed no adhesion between the epidural scar and the dural sac in all patients of experimental group. There existed various extents of adhesion in control group.
                The results demonstrate that the polylactic acid membrane can effectively prevent the epidural scar adhesion with a good biocompatibility and no toxity. Its clinical application was promising. nan This prospective, double-blind, randomized study was designed to examine whether the combined spinal-epidural technique without subarachnoid drug administration improved epidural catheter function when compared with the traditional epidural technique.
                After institutional review board approval and informed consent, 251 healthy laboring parturients were randomly assigned to either group DP (combined spinal-epidural technique with 27-gauge Whitacre needle dural puncture but without subarachnoid drug administration) or group NoDP (traditional epidural technique). Patient-controlled epidural analgesia was initiated with 0.11% bupivacaine and 2 microg/ml fentanyl. Top-up doses in 5-ml increments of 0.25% bupivacaine were administered if needed. Previous power analysis revealed that a sample size of 108 patients/group was needed to show a clinically useful reduction of the catheter manipulation rate from 32% to 15%.
                In groups DP and NoDP, 107 and 123 evaluable patients, respectively, completed the study. Demographics and outcome variables measured, including epidural catheter manipulation and replacement rate, sacral sparing, unilateral block, number of top-up doses, average hourly epidural drug usage, highest sensory blockade level, and labor analgesia quality, were not different between groups. A subgroup of 18 patients without cerebral spinal fluid return during dural puncture had a higher catheter replacement rate than those of groups DP and NoDP, but it did not reach statistical significance.
                Dural puncture with a 27-gauge Whitacre needle without subarachnoid drug administration during combined spinal-epidural labor analgesia did not improve epidural labor analgesia quality or reduce catheter manipulation or replacement rate when compared with a traditional epidural technique. To determine the efficacy of epidural blood patch (EDBP) for the treatment of post dural puncture headache (PDPH).
                We randomised 42 patients who presented with PDPH, lasting 24 h to 1 week, to receive EDBP (n = 19) or conservative treatment (n = 23). The primary end point was any headache at 24 h after the start of treatment. Secondary end points were presence and severity of headache after 1 week. Stratified Mantel-Haenzel analysis was used to adjust for confounders.
                Two patients refused to participate directly after randomisation and allocation to conservative treatment. They were excluded from the study. At 24 h after the start of treatment, headache was present in 11 (58%) patients allocated to EDBP and in 19 (90%) patients allocated to conservative treatment (RR 0.64, 95% CI 0.43 to 0.96). At day 7, headache was present in three (16%) patients allocated to EDBP and in 18 (86%) allocated to conservative treatment (RR 0.18, 95% CI 0.06 to 0.53). Headache was mild in all three EDBP patients, but in 10 of 18 conservatively treated patients who had not recovered by day 7 it was classified as moderate or severe. Adjustments for confounders did not affect these results.
                EDBP is an effective treatment for PDPH. It offers complete resolution of symptoms in a large proportion of patients. In the remaining patients, it reduces headache severity and allows them to return to their everyday activities. To evaluate the efficacy of prophylactic transdermal scopolamine in reducing nausea associated with postoperative epidural analgesia, we studied 32 healthy adult women undergoing major gynecologic surgery. The patients were randomized in a double blind fashion to receive either a cutaneous scopolamine patch or a visually identical cutaneous placebo patch. Postoperative analgesia was provided solely with epidural morphine. Nausea was treated with metoclopramide and droperidol. At 24 hours postoperatively, the mean nausea score was significantly lower with scopolamine than with placebo (1 +/- 2 vs 51 +/- 42, respectively, P less than 0.05). The number of patients reporting "zero nausea" was significantly greater with scopolamine patches than with placebo patches (13 vs 1, P less than 0.01). The mean number of times antiemetic drugs were administered per patient was lower with scopolamine than with placebo patches (0.2 +/- 0.4 vs 2.8 +/- 2.6, P less than 0.05). It is concluded that prophylactic transdermal scopolamine patches reduce nausea in postoperative patients receiving epidural morphine.
The review authors do not recommend prophylactic epidural blood patch over other treatments because there are too few trial participants to allow reliable conclusions to be drawn. However, therapeutic epidural blood patch showed a benefit over conservative treatment, based on the limited available evidence.