Epidural Hydroxyethyl Starch Ameliorating Postdural Puncture Headache After Accidental Dural Puncture
Postdural puncture headache (PDPH) remains a significant complication following accidental dural puncture (ADP) during obstetric epidural procedures. Despite various prophylactic strategies, no method has been universally accepted as completely effective in preventing PDPH. This study evaluates the efficacy and safety of epidural administration of hydroxyethyl starch (HES) in preventing PDPH after ADP, providing a comprehensive analysis of its prophylactic role.
Accidental dural puncture is a common complication during obstetric epidural anesthesia and analgesia, with an estimated risk of subsequent PDPH ranging between 76% and 85% when using a 16 to 18-gauge needle. Although PDPH is typically self-resolving within one to two weeks, it can cause significant morbidity, including subdural hematoma, cerebral venous thrombosis, bacterial meningitis, persistent headache, or depression. Severe headaches and the expectant treatment of PDPH often lead to delayed discharge and increased healthcare costs. Preventing PDPH after ADP is as crucial as treating it, yet no universally effective prophylactic modality has been established.
The study was conducted at Peking University First Hospital, a tertiary obstetric referral center with 6000 to 7000 deliveries annually. From January 2019 to February 2021, patients who experienced ADP during epidural procedures for labor or cesarean delivery were retrospectively reviewed. The primary objective was to assess the efficacy of epidural HES in preventing PDPH, while secondary objectives included evaluating the severity and duration of headache, adverse events associated with prophylactic strategies, and hospital length of stay postpartum.
Patients were categorized into three groups based on the prophylactic strategies employed: (1) Epidural analgesia alone (Epidural-alone), (2) Epidural HES on epidural analgesia (HES-Epidural), and (3) Two doses of epidural HES, respectively, on and after epidural analgesia (HES-Epidural-HES). The incidence of PDPH, headache severity, duration, and adverse events were recorded and analyzed.
A total of 105 patients who experienced ADP received a re-sited epidural catheter. Among them, 46 patients received Epidural-alone, 25 received HES-Epidural, and 34 received HES-Epidural-HES. The incidence of PDPH was significantly different across the groups: 67.4% in the Epidural-alone group, 40.0% in the HES-Epidural group, and 14.7% in the HES-Epidural-HES group (P < 0.001). The HES-Epidural-HES strategy was associated with the lowest incidence of PDPH, demonstrating a significant reduction in risk compared to the other strategies.
The duration of headache lasted for a median of 7.0 days, with onset at a median of 30 hours for all patients. The headache was typically occipital/frontal in location, with 26.1% of patients reporting severe headache during the course of PDPH. A discharge delay due to PDPH was observed in 13% of headache patients. No neurologic deficits, including paresthesias and motor deficits related to prophylactic strategies, were reported from at least 2 months to up to more than 2 years after delivery. An overall backache rate related to HES administration was 10%.
Multivariable regression analysis revealed that the HES-Epidural-HES strategy was significantly associated with a reduced risk of PDPH following ADP (OR = 0.030, 95% confidence interval: 0.006–0.143; P < 0.001). This finding suggests that the combination of continuous epidural analgesia with two doses of epidural HES provides an additive and extended effect in reducing PDPH.
The mechanism by which epidural HES reduces PDPH is hypothesized to involve increasing pressure in the epidural space, limiting cerebrospinal fluid (CSF) leakage, and inducing a mass effect that causes a cephalad shift of CSF in the spinal compartment. Previous studies have suggested that epidural administration of colloids, such as HES, can provide short-term relief of PDPH by temporarily increasing epidural pressure. The second dose of epidural HES immediately before catheter removal appears to help prevent late-onset PDPH, as evidenced by the lower incidence of PDPH in the HES-Epidural-HES group.
The safety of epidural HES administration was also evaluated. No serious adverse events, such as neurological deficits, were reported. Mild back pain or headache, potentially due to a mass effect on neurological tissue within the epidural space, was observed in some patients. The incidence of these adverse events was comparable to that associated with epidural blood patch (EBP), a commonly used treatment for PDPH. However, the noninvasive nature and ease of administration of epidural HES make it a potentially safer alternative to EBP, especially in patients with contraindications to EBP, such as local/systemic infection or coagulopathy.
The study has several limitations, including its retrospective design, single-center setting, and limited sample size. The decision to employ a specific prophylactic strategy was made by the parturients themselves, introducing potential selection bias. Additionally, the study was underpowered to adequately address some secondary outcomes, such as headache severity and delayed discharge. Despite these limitations, the findings suggest that the HES-Epidural-HES strategy is associated with a significant reduction in the incidence of PDPH following ADP.
In conclusion, the incorporation of continuous epidural analgesia with two doses of epidural HES appears to be an effective prophylactic strategy for reducing the risk of PDPH after ADP during obstetric epidural procedures. The efficacy and safety profiles of this strategy warrant further investigation in prospective, randomized, and double-blinded trials before it can be widely recommended in clinical practice.
doi.org/10.1097/CM9.0000000000001967
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