|Year : 2018 | Volume
| Issue : 1 | Page : 35-41
Postdural puncture headache and maternal hemodynamics after single-shot and continuous spinal anesthesia using epidural kit for cesarean section
Essam F Abdelgalel, Osama A Nofal, Mona A Shahin
Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Zagazig University, Zagazig, Egypt
|Date of Web Publication||24-Jan-2018|
Essam F Abdelgalel
Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Zagazig University, Housing and Development Buildings, Building No. 14, Zagazig, Sharkia Governorate, 44519
Source of Support: None, Conflict of Interest: None
Background The aim of this study was to compare the incidence of postdural puncture headache and maternal hemodynamics after single-dose spinal anesthesia and continuous spinal anesthesia using epidural kit with prophylactic intrathecal saline injection for a cesarean section.
Patients and methods Ninety patients scheduled for elective cesarean section were randomly allocated to one of the three groups. Group A (30 patients) received single-dose spinal anesthesia using a 25-G Quincke type point spinal needle. Groups B and C (30 patients each) received continuous spinal anesthesia using 18-G epidural needles and intrathecal 20-G epidural catheters. In group C, the patients received 5 ml normal saline intrathecally before local anesthetic injection and 10 ml just before catheter removal 24 h after insertion. Incidence and severity of postdural puncture headache, block characteristics, patient satisfaction, hemodynamic parameters, and incidence of complications were recorded.
Results Significantly longer sensory and motor regression times with higher total bupivacaine dose in group A compared with groups B and C. The hypotension and ephedrine dose needed were significantly more in group A compared with the other two groups. Nausea and vomiting were significantly more in group A compared with the other two groups. Incidence of postdural puncture headache was 16.7% in group B and 10% in both groups A and C. Patient satisfaction was significantly more in group C compared with the other two groups. Mean arterial pressure and heart rate were significantly lower in group A compared with the other two groups at 10, 15, 20, and 25 min
Conclusion Incidence of postdural puncture headache with continuous spinal anesthesia with keeping of the intrathecal catheter for 24 h and prophylactic intrathecal saline is comparable to single-dose spinal anesthesia for a cesarean section. It allows using lower doses of local anesthetic with better hemodynamic stability, fewer complications, and better patient satisfaction.
Keywords: continuous spinal anesthesia, obstetric, postdural puncture headache, saline
|How to cite this article:|
Abdelgalel EF, Nofal OA, Shahin MA. Postdural puncture headache and maternal hemodynamics after single-shot and continuous spinal anesthesia using epidural kit for cesarean section. Res Opin Anesth Intensive Care 2018;5:35-41
|How to cite this URL:|
Abdelgalel EF, Nofal OA, Shahin MA. Postdural puncture headache and maternal hemodynamics after single-shot and continuous spinal anesthesia using epidural kit for cesarean section. Res Opin Anesth Intensive Care [serial online] 2018 [cited 2018 Feb 19];5:35-41. Available from: http://www.roaic.eg.net/text.asp?2018/5/1/35/223835
| Introduction|| |
Single-dose spinal anesthesia (SDSA) being an easy technique with fast onset is the most commonly used anesthetic technique for a cesarean section (CS) being an easy technique with fast onset . Using a large dose of local anesthetic for spinal anesthesia to get effective block (T4 sensory level) can result in hemodynamic instability, while using a small dose even with the addition of intrathecal opioids may require supplementary analgesia or shift to general anesthesia ,,.
Continuous spinal anesthesia (CSA) is a reliable technique allowing local anesthetic dose titration with decreasing the risk of high spinal blockade . However, CSA is still not commonly used among anesthetists because of its possible complications especially postdural puncture headache (PDPH) . Many measures attempted to prevent or decrease the incidence and severity of PDPH in obstetric and nonobstetric patients including: intrathecal saline injection , epidural saline injection or infusion ,,, epidural morphine , continuous postoperative intrathecal analgesia , prophylactic epidural blood patch ,, and intrathecal insertion of epidural catheter through the dural puncture . Using epidural catheter for CSA was accepted because intrathecal microcatheters (28 G or less) were accompanied with some insertion difficulties and reports of cauda equina syndrome, so its use was discontinued by the Food and Drug Administration in Australia and the USA .
The present study aimed to compare the incidence and severity of PDPH in parturients scheduled for elective CS after a single-shot spinal anesthesia using 25-G spinal needles with CSA using 18-G Tuohy epidural needles with keeping the epidural catheter intrathecally for 24 h and prophylactic injection of intrathecal normal saline.
| Patients and methods|| |
This prospective, randomized, clinical trial was carried out after approval of our institutional review board. Written informed consents were obtained from all patients. Ninety ASA physical status II obstetric patients of more than 18 years old undergoing elective CS in Zagazig University Hospital from October 2015 to October 2016 were randomly allocated to one of the three studied groups using a randomized central computer-generated random number by an investigator not involved with the clinical management. Patients with predicted difficult airway, contraindications for regional anesthesia (coagulopathy, infection at the injection site, sever vertebral column deformity), history of previous PDPH, or suffering from intracranial hypertension or allergic reaction to local anesthetics were excluded from the study. Proper preanesthesia evaluation of the patients and explanation of the detailed steps of the study and the potential complications were done. Eighteen-gauge intravenous cannula was inserted and all patients were preloaded with 10 ml/kg Ringer’s lactate solution. Pulse oximetry, ECG, and noninvasive blood pressure were applied and baseline measurements (immediately before injection of local anesthetic) every 5 min for one hour and every 15 min for the next hour were recorded for all patients.
Under complete aseptic precautions, patients were placed in the sitting position and lumbar puncture was done at L3–L4 or L4–L5 intervertebral space through a midline approach in all patients. In group A, the puncture was done using 25-G Quincke type point spinal needle (B. Braun Melsungen, Melsungen, Germany) and 12.5 mg (2.5 ml) hyperbaric bupivacaine 0.5% with 25 μg (0.5 ml) fentanyl injected intrathecally as a single-shot dose, then the patients were turned to supine position with a left-sided tilt. In groups B and C, the puncture was done by using an 18-GTouhy epidural needle (B. Braun Melsungen), which was advanced gently until subarachnoid puncture was confirmed by observing the free cerebrospinal fluid flow. A 20-G epidural catheter was gently threaded for 2–4 cm cephalad into the subarachnoid space and tightly fixed, then the patients were turned to supine position and randomized to either groups B or C. Patients in group B received 5 mg (1 ml) hyperbaric bupivacaine 0.5% with 25 μg (0.5 ml) fentanyl through an intrathecal catheter (considering the dead space of epidural catheter volume 0.2 ml and filter 0.5 ml) with incremental doses of 2.5 mg (0.5 ml) hyperbaric bupivacaine every 5 min if needed until T4 sensory block level was achieved. In group C, the patients received slowly intrathecal 5 ml sterile normal saline before intrathecal injection of local anesthetic and opioid drugs (the same dose as group B) and 10 ml sterile normal saline slowly intrathecally just before catheter removal which was removed (in both groups B and C) 24 h after insertion. Patients were kept for 4 h in the hospital for observation before discharge.
The sensory level was assessed via bilateral pinprick method to determine the onset time of anesthesia (the time from local anesthetic drugs injection till T4 sensory block level was achieved). Assessment of motor block was done by the modified Bromage Scale; grade 0  ([Table 1]). Both sensory and motor blocks were assessed by an anesthetist blinded to the study every 2 min for the first 15 min, then every 15 min till resolution of the block. The surgeons and nurses were also blinded about the study groups.
Hypotension was diagnosed if the mean arterial blood pressure (MAP) decreased by 20% or more from the baseline. Hypotension was treated with increasing intravenous fluid and ephedrine 6 mg intravenous increments. Bradycardia was diagnosed if heart rate (HR) decreased up to 60 beats/min and was treated by atropine 0.5 mg intravenously.
The primary outcome measure was the incidence and severity of PDPH among the studied groups. Secondary outcomes included the onset time of the T4 block level, time to two segment sensory regression, time of motor regression (time to change from the modified Bromage scale grade 1 to grade 2). Total local anesthetic dose, patient satisfaction, hemodynamic parameters, ephedrine doses used, need for general anesthesia supplementation, and incidence of complications were recorded.
Patient satisfaction was rated by a questionnaire using the Visual Analog Satisfaction (VAS) score , into poor satisfaction (VAS 0–3), good satisfaction (VAS 4–7), and excellent satisfaction (VAS 8–10).
All patients of the present study were instructed about good hydration after allowance of oral intake, avoiding straining as well as prolonged standing or sitting.
PDPH was considered by being position dependent increased by standing or sitting and improved in flat position, mostly frontal or occipital and may be associated with generalized symptoms (dizziness, tinnitus, nausea, or neck rigidity).
Postdural lumber headache and any associated symptoms were monitored for 10 days after the block. Patients were contacted daily for 10 days (communication with the patients was by telephone after discharge from hospital). If patients complained of PDPH, conservative treatment in the form of bed rest, good hydration, oral paracetamol tablets 1 g every 6 h, oral caffeine tab 100 mg every 8 h, and diclofenac tab 75 mg every 8 h if needed. If conservative management failed after 48 h, epidural blood patch with 15–20 ml of the patient blood was planned.
The PDPH severity was based on the VAS pain score  graded from 0=no pain to 10=the worst imaginable pain as follows:
- Grade I: VAS score 0–3.
- Grade II: VAS score 4–7.
- Grade III: VAS score 8–10.
Sample size calculation
χ2-Test for independent samples was done on the frequency of PDPH as it was the primary outcome in the current study. A minimum sample size of 28 patients was required for each group to achieve a power of 0.8 and an α error of 0.05. Thirty patients were included in each group to compensate for any dropouts.
Statistical Package for Social Science, version 20.0 (SPSS Inc., Chicago, Illinois, USA) and MedCalc for windows, version 13 (MedCalc Software bvba, Ostend, Belgium) were used for the data analyzed. Continuous variables were expressed as mean±SD and checked by the Shapiro–Wilk test. Categorical variables were expressed as a number (%). One way analysis of variance test was used to compare the three groups of normally distributed data. Repeated measures analysis of variance test was used to compare between more than two dependent groups of normally distributed data. Post hoc test was done by the least significant difference method. χ2-Test was used for comparing the percentage of categorical variables. P value less than 0.05 was considered statistically significant.
| Results|| |
There were no significant differences among the three studied groups regarding the demographic data ([Table 2]).
|Table 2 Comparison between the studied groups as regard demographic data (N=30)|
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The onset time of T4 sensory block was nonsignificantly shorter in group A (7.17±2.10 min) compared with 7.86±1.83 and 6.96±1.88 min in groups B and C, respectively. Time to two segments sensory regression was significantly longer in group A (74.16±12.98 min) compared with 56.88±6.55 and 52.15±6.80 min in groups B and C, respectively. Time to motor regression was significantly longer in group A (67.70±13.71 min) compared with 44.93±6.19 min (group B) and 42.13±4.79 min (group C). Total hyperbaric bupivacaine dose received was significantly more in group A (12.50±0.00 mg) compared with7.50±0.56 mg in both groups B and C. The number of patients needed ephedrine was significantly more in group A (eight patients) compared with groups B and C (two and one patient, respectively). Ephedrine dose needed/patient was significantly more in group A (28.0±3.42) compared with 9.00±0.00 (group B) and 12.00±0.00 (group C). Only one patient in group A needed general anesthesia ([Table 3]).
|Table 3 Comparisons between the studied groups as regard block characteristics (N=30)|
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The total number of patients developed intraoperative complications was significantly more in group A (17 patients) compared with groups B and C (six and three patients, respectively). Hypotension was significantly higher in group A (11 patients) in comparison to three and two patients in groups B and C, respectively. No significant difference among the three studied groups regarding bradycardia (three patients in groups A and one patient in both groups B and C). Nausea was significantly more in group A (nine patients) compared with two and one patient in groups B and C, respectively. Significantly more patients complained of vomiting in group A (five patients) compared with one patient only in group B and no patients in group C. No neurological deficit was noticed in all groups ([Table 4]).
|Table 4 Comparison between the studied groups as regard intraoperative complications (N=30)|
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Incidence of PDPH was nonsignificantly higher in group B (five patients) compared with three patients in both groups A and C. Postdural puncture headache was grade I in one patient in group A and in three patients in group B and two patient in group C. Two patients in group A had grade II PDPH compared with one patient in both other groups. Grade III PDPH was recorded only in one patient in group B with no patients in groups A and C complained of grade III PDPH. Epidural blood patch was recommended only in one patient in group B ([Table 5]).
Patients’ satisfaction was significantly more in group C compared with both other groups. Poor patient satisfaction in four patients in group B compared with three and two patients in groups A and C, respectively. Patient satisfaction was good in 20 patients in both groups A and B and in 10 patients in group C, whereas excellent patient satisfaction was significantly more in group C (18 patients) compared with seven and six patients in groups A and B, respectively ([Table 6]).
|Table 6 Comparison between the studied groups as regard patient satisfaction (N=30)|
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Hemodynamic data (MAP and HR) among the three studied groups is shown in [Figure 1] and [Figure 2]. Baseline measurements were nonsignificantly different among the three studied groups. MAP and HR measured after 10, 15, 20, and 25 min were significantly lower in group A compared with other two groups. There were no significant differences between the three studied groups regarding all hemodynamic parameters after the first 25 min till 2 h.
|Figure 1 Marker and error bars with connecting lines show comparison between the studied groups as regard heart rate (b/min). Marker represents mean, Y-error bar represents 95% confidence interval of mean. ‡Significant difference between group A and group B; #Significant difference between group A and group C; ¶Significant difference between group B and group C.|
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|Figure 2 Marker and error bar with connecting lines show comparison between the studied groups as regard mean arterial blood pressure (mmHg). Marker represents mean, Y-error bar represents 95% confidence interval of mean. ‡Significant difference between group A and group B; #Significant difference between group A and group C; ¶Significant difference between group B and group C.|
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| Discussion|| |
The advantage of possible intraoperative local anesthetic titration with CSA is encouraging to use small initial dose aiming to keep maternal hemodynamic stability and better neonatal outcome.
The significantly longer sensory and motor regression time reported in group A in comparison to both CSA groups can be explained by the higher total dose of hyperbaric bupivacaine used in group A. In agreement with these results Baydilek et al.  have reported faster recovery times with CSA versus SDSA in patients undergoing transurethral resection of prostate.
Better hemodynamic stability in CSA groups with significantly lower incidence of hypotension and lower dose of ephedrine needed can be attributed to the titration and the lower total dose of local anesthetic used during CSA. Favarel et al.  have reported more cardiovascular stability with CSA in comparison to SDSA in the elderly. More hemodynamic stability was achieved with smaller local anesthetic dose with CSA compared with SDSA in patients with cardiomyopathy during lower abdominal surgeries  and for high-risk patients with severe pulmonary impairment . In the current study, although the lumbar puncture was done at the same level for all groups (L3–L4 or L4–L5) through a midline approach the total dose of local anesthetic was significantly lower in both groups B and C. This may be due to the cephalad intrathecal advancement of epidural catheter. The presence of intrathecal catheter with the rapid onset of local anesthetic encourage using a smaller effective dose to avoid hemodynamic instability and avoid the possibility to need general anesthesia. Only one patient in the SDSA group needed to shift to general anesthesia due to a failed block, whereas no patients needed general anesthesia in both groups of CSA.
The incidence of PDPH in the present study using 25-G Quincke type point spinal needle was 10% (three cases). This incidence is close to the incidence found by Ross et al.  (9%) and Tabedar et al.  (8.3%) when they used the same needle for obstetric anesthesia. However, Pal et al.  in their study found a higher incidence of PDPH (28.12%) with spinal anesthesia for a cesarean section.
In the current study, the incidence of PDPH was 16.6% (five cases) in CSA with keeping intrathecal catheter for 24 h (group B). Many studies recommended the use of CSA in accidental dural puncture during epidural anesthesia. Cohen et al.  have found that after unintentional dural puncture the PDPH was reduced from 33% without intrathecal catheter insertion to 0% after catheter insertion and keeping for 24 h. Jadon et al.  have found that the incidence of PDPH was 11.76% in obstetric and nonobstetric patients in CSA with intrathecal insertion of epidural catheter that was kept for 24–36 h after accidental dural puncture. Ayad et al.  have found that the incidence of PDPH after epidural wet tap was significantly reduced from 31% with insertion of intrathecal catheter that was removed immediately after labor to 3% when the catheter was kept for 24 h. However, in contrast to these results Norris and Leighton  found no difference in PDPH in parturients when CSA was used after accidental dural puncture. But their findings may be attributed to keeping the intrathecal catheter for a shorter time (2 h) compared with the current study (24 h).
Keeping intrathecal catheter for 24 h or more may activate an inflammatory process with edema and fibrin exudates that may seal the dural tear and reduce CSF leakage after catheter removal .
Prophylactic injection of intrathecal saline may keep the intrathecal pressure preventing activation of adenosine receptors which is a possible explanation of PDPH through stretching of pain-sensitive cerebral structures and vasodilatation of cerebral blood vessels .
The incidence of PDPH with prophylactic injection of intrathecal saline in the current study was 10% (the same incidence with SDSA). Intrathecal injection of 5 ml of sterile isotonic saline after insertion of the catheter was done before injection of local anesthetic to avoid dilution or maldistribution of the local anesthetic drugs. Although 5 ml is a small volume compared with the total CSF volume, the aim was to compensate for the CSF leakage during catheter insertion or around the catheter to keep the CSF volume and avoid decrease of CSF pressure. Another 10 ml of isotonic saline was injected intrathecally just before catheter removal aiming to increase the CSF pressure with sealing effect at the puncture site. The use of catheter over needle technique for CSA which was unavailable to use in the current study may lead to more reduction of the incidence of PDPH.Some previous studies have shown the effect of intrathecal normal saline injection. Faridi et al.  have reported a significant reduction in the incidence of PDPH from 24 to 2% with intrathecal injection of 5 ml of saline before local anesthetic injection for a cesarean section under spinal anesthesia. Another small study by Charsley et al.  have found that no PDPH occurred after accidental dural puncture when subarachnoid catheter was inserted with 10 ml of intrathecal normal saline before removing the catheter in six patients. Kiki et al.  have found that injecting 20 ml of saline epiduraly after lumbar puncture decreased the incidence of PDPH from 48.8 to 16.4% and explained that by the possible increase of the epidural pressure with reduced CSF leak allowing dural repair.
Patient satisfaction was significantly better in group C with more patients having excellent satisfaction. This can be attributed to the smooth intraoperative block with stable hemodynamics and lower incidence of hypotension. Group C patients also had lower incidence of nausea and vomiting with low incidence of PDPH. In group C, the PDPH was grade I in two patients and grade II in one patient and all patients responded to conservative management without the need of epidural blood patch.
Longer hospital stay until removal of the intrathecal catheter is considered as a drawback as patients in CSA groups were kept for 24 h until catheter removal and then another 4 h for observation while with SDSA the patient was discharged after 12 h.
| Conclusion|| |
CSA with keeping of intrathecal catheter for 24 h and prophylactic intrathecal administration of normal saline can be used safely for a cesarean section. The incidence of PDPH is comparable to SDSA with better patient satisfaction. It allows using a lower dose of local anesthetic with better hemodynamic stability and less need for vasopressors with lower incidence of complications compared with single-dose spinal anesthesia. We recommend further studies to evaluate this technique in high-risk obstetric patients such as patients with predicted difficult airway, morbidly obese patients, and cardiac patients.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]