BANFF, ALTA. — Initial conservative treatment of post-dural puncture headache, with delayed placement of a blood patch, may increase the likelihood of early treatment success, Dr. Paul Tan suggested at the annual meeting of the Society of Obstetric Anesthesia and Perinatology.
“One of the explanations for this is that local anesthetics are still residual in the epidural space and can inhibit the coagulation of the blood that's given in the blood patch,” said Dr. Tan of the Cleveland Clinic in an interview.
The study he presented reviewed 130 patients who received therapeutic epidural blood patches (EPB) for post-dural puncture headache. Forty-seven (36%) of the patients required a repeat EPB. In exploring factors that might be associated with the need for a repeat EPB, including body mass index, parity, needle type, amount of blood injected in the first EPB, time from dural puncture to headache onset, and time from headache onset to first EPB, the authors found that the time measurements were the only independent predictors of first EPB success.
“To my knowledge this is the first time that both the time from puncture to headache onset, and the time from headache onset to first blood patch, have been looked at separately,” he said, adding that although the time from puncture to headache onset is not modifiable, information about it can help in counseling patients. “If the patient develops a headache quickly after the puncture, they should be counseled it is likely the first blood patch will fail, and they may need more than one,” he said.
These patients can also be encouraged to undertake a trial of conservative treatment measures such as intravenous hydration, caffeine, and oral pain medications in an effort to delay placement of the first blood patch, he added.
Study patients needing a second EPB had a mean time from puncture to headache onset of 10 hours, and a mean of 16 hours from headache onset to placement of the first patch, compared with 17 hours and 29 hours, respectively, in those not needing a second patch.
“A doubling of the time from puncture to headache onset resulted in a 46% reduction in the odds of the patient needing a repeat patch, and a doubling of the time from headache onset to first blood patch resulted in a 41% reduction in the odds of needing a repeat patch,” he said.
Dr. Tan suggested that the shorter times associated with needing a repeat patch could also be a marker for the severity of the dural puncture, and that the self-limiting nature of post-dural puncture headache could explain why the longer time interval resulted in less requirement for a repeat blood patch.