EFFECT OF NEURAXIAL TECHNIQUE AFTER

INADVERTENT DURAL PUNCTURE ON

OBSTETRIC OUTCOMES AND ANESTHETIC
COMPLICATIONS
D.K. Jagannathan, A.F. Arriaga, K.G. Elterman, B.S.
Kodali, J.N. Robinson, L.C. Tsen, A. Palanisamy

September, 2015

JENNILYN M. DE JESUS
 INTRODUCTION
In developed countries, epidural analgesia
is a popular mode of pain relief during
labor. An important complication of the
epidural technique is inadvertent dural
puncture (IDP) with an associated
post-dural puncture headache (PDPH).

Risk of IDP during epidural placement

varies between 0.5%-1.5%, and the risk
for developing PDPH is as high as 50%.
 INTRODUCTION
Avoid additional procedures and minimize
the incidence of PDPH while being
observant of patient safety.

Preference of the anesthesiologist to

either resite the epidural catheter at a
different vertebral interspace, or insert
an epidural catheter through the dural
hole created by the IDP
 INTRODUCTION
It is unknown if the choice of neuraxial technique
after IDP alters either the course of labor or the
mode of delivery.

In the absence of IDP, combined spinal-epidural

technique has been reported to be associated with
more rapid cervical dilatation in nulliparous women
compared with epidural analgesia. Furthermore,
early (<4 cm cervical dilatation) initiation of
intrathecal analgesia with fentanyl as part of CSE
technique has been found to have a shorter
duration of first stage of labor
 INTRODUCTION
To study labor outcomes in parturients
managed either with an intrathecal or
resited epidural catheter following IDP
METHODS

IDPs
• recognized at the time of
needle placement
• after catheter insertion
• after administration of the
test dose.
Age, BMI, parity, gestational
age, use of long-acting
neuraxial opioids, duration
of second stage labor, mode
of delivery and rate of
catheter replacement for
inadequate analgesia
 METHODS
Epidural catheter successfully inserted
METHODS
 RESULTS
 The total number of patients meeting
the inclusion criteria was 235, including
one patient who had two pregnancies
(each labor included an IDP) over the
study period, for a total of 236 cases.
 RESULTS
 173 women (73%) who were managed
with an intrathecal catheter (ITC group)
 63 (27%) women who had an epidural
catheter resited in a different lumbar
interspace (epidural resite group)
RESULTS
 RESULTS
 Over 80% of cases resulted in a
spontaneous or instrumented vaginal
delivery, with the remainder being
cesarean deliveries
 Seventeen parturients had either a
forceps or a vacuum delivery (13/173 in
the ITC Group vs. 4/63 in the Epidural
Resite Group)
 Seventy percent of IDP cases (166/236)
resulted in a PDPH, and nearly 50% of
cases (104/236) had a PDPH that
RESULTS
 RESULTS
 A difference was not observed in the proportion
of cases of prolonged second stage of labor in
the ITC Group versus the Epidural Resite Group
(13% vs. 16%, P=0.57)
 There is no association between intrathecal
catheter placement and prolonged second stage
of labor in the multivariate model adjusting for
age and nulliparous status (with clustering at
the patient level); although nulliparous status
was associated with an increased odds of
prolonged second stage of labor (P=0.002).
 RESULTS
 There is no association between the choice of
neuraxial technique and the incidence of
cesarean delivery (ITC Group 17% vs.
Epidural Resite Group 16%, P=0.78) or PDPH
(ITC Group 68% vs. Epidural Resite Group
78%, mean difference 0.10, 95% CI –0.023 to
0.23). However, we did observe an
association with failed labor analgesia
resulting in the need for catheter
replacement in the ITC Group versus Epidural
Resite Groups (14% vs. 2%, P=0.005).
RESULTS
 RESULTS
 We observed a lower rate of PDPH in the
cesarean delivery with neuraxial
morphine group compared to the vaginal
delivery group (53% vs. 74%,
respectively, P=0.007).
 DISCUSSION
 There is no difference either in the incidence of
prolonged second stage of labor or cesarean delivery
between the ITC Group and the Epidural Resite
Group.
 Cesarean delivery, compared to spontaneous vaginal
delivery, was associated with a 35% lower incidence
of PDPH.
 Intrathecal catheters are associated with higher
rates of replacement compared to resiting of
epidural catheters.
 Placement of an intrathecal catheter does not reduce
the occurrence of PDPH.
 DISCUSSION
CHOICE OF TECHNIQUE DID NOT INFLUENCE
EITHER THE DURATION OF SECOND STAGE OF
LABOR OR THE INCIDENCE OF CS

 Six out of 173 parturients in the ITC Group and 2 out

of 63 in the Epidural Resite Group were categorized
as having prolonged second stage of labor
 not statistically significant

 Only 17 instrumental deliveries in the dataset

 underpowered to detect a true difference
 DISCUSSION
 NO PDPH-SPARING EFFECT OF AN
INTRATHECAL CATHETER
 Intrathecal catheters were removed shortly
after delivery, instead of after 24 h.
 Findings are in agreement with other
studies including meta-analyses, which also
did not observe a substantial benefit of
intrathecal catheters in preventing PDPH
 DISCUSSION
 CS delivery, when compared to vaginal
delivery, reduced the incidence of PDPH by
almost 35%.
 Reduced cerebrospinal fluid (CSF) loss when
bearing down during the second stage of labor,
or to the use of long-acting opioids for
postoperative analgesia
 DISCUSSION
 A major concern with resiting the
epidural following an IDP is the 9-10%
risk of another IDP.
 No patient in the Epidural Resite Group
received an additional IDP
 High rate of repeat IDP reported previously
is not due to inexperience or lack of
supervision
 LIMITATIONS OF THE
STUDY
 Cannot establish causality between the
choice of neuraxial technique and the need
for replacement of a catheter or an EBP
 Individualized and not standardized
 However, a team of anesthesia providers
manages the patient’s care during the first few
postpartum days, with a consensus obtained
before an invasive intervention such as an EBP.
 This consensus approach, use of a large
database, and accurate record-keeping may
limit some variation in our outcomes.
 LIMITATIONS OF THE
STUDY
 Parturients where an IDP was not
obvious were excluded
 Because the incidence of unrecognized
dural puncture can vary between 16-35%, it
is possible that we excluded a number of
parturients from the study
 Unlikely to alter our primary outcome,
which is based entirely on the choice of
management after a recognized dural
puncture
 LIMITATIONS OF THE
STUDY
 Failure rate of 14% for intrathecal
catheters might seem excessive.
 May be due to our use of single end-hole
catheter and a low basal rate of intrathecal
infusion, which could potentially channel
drug spread and prevent adequate
dispersion of hypobaric local anesthetic
within the CSF
 SUMMARY
The choice of neuraxial technique
following inadvertent dural puncture
does not appear to alter the course of
labor and delivery. Cesarean delivery
decreased the incidence of post-dural
puncture headache by 35%. Intrathecal
catheters were associated with a higher
rate of failed analgesia.
 CRITICAL APPRAISAL
 Was the assignment of patients to
treatments randomised?
 No. Patients whose epidural catheter
cannot be placed intrathecally have their
catheter resited at different interspace,
thus forming the epidural resite group
whereas those with successful catheter
placed intrathecally becomes the
intrathecal group.
 Were the groups similar at the start
of the trial?
 Yes, as shown in Table 1 and 2.
RESULTS
 CRITICAL APPRAISAL
 Aside from the allocated treatment,
were groups treated equally?
 Yes. Apart from the intervention done, both
groups were treated equally.
 Were all patients who entered the
trial accounted for? And were they
analysed in the groups to which
they were randomized?
 Yes. Patients who suffer from an IDP are
actively followed for up to 5–7 days.
 CRITICAL APPRAISAL
 Were measures objective or were the
patients and clinicians kept “blind” to
which treatment was being received?
 Yes, measure was objective. The study aims to
evaluate labor and delivery outcome by
determining prolonged stage of labor (defined
according to American College of Obstetricians
and Gynecologists criteria for laboring women
with neuraxial analgesia as > 2 hrs for
multiparous women; > 3 hrs for nulliparous
women) and overall rate of CS deliveries.
Thanks!