sábado, 23 de julio de 2011

Cefalea post punción dural

Inyecciones caudales de salino normal para el tratamiento de la cefalea post punción dural
Caudal normal saline injections for the treatment of post-dural puncture headache.
Abdulla S, Abdulla W, Eckhardt R.
Department of Anaesthesiology and Intensive Care Medicine Klinikum Bernburg, Teaching Hospital, Martin Luther University Halle-Wittenberg, Bernburg, Germany.
Pain Physician. 2011 May-Jun;14(3):271-9.
BACKGROUND: Post-dural puncture headache (PDPH) is the most common complication of procedures in which the dura mater is penetrated. OBJECTIVES: To evaluate the effectiveness of caudal saline injections as a therapeutic approach for handling post-dural puncture headache. STUDY DESIGN: Prospective observational study between 1995 and 2010. SETTING: Associated teaching hospital. METHODS: A 5-cm 20-gauge short-beveled needle, connected by extension tube to a 20-mL syringe filled with normal saline was used for injection. During injection in increments (limited by patient discomfort), the patients were asked continually to quantify their pain experience on a visual analog scale (VAS) and on a 0-3 verbal categorical rating scale (VRS) after 50, 80 and 100 mL of infusion over a 20 minute period. LIMITATIONS: This study is limited by its sample size, observational design, and lack of long-term outcomes. RESULTS: PDPH occurred in 60 of 1,716 patients undergoing dural puncture (3.5%). It was significantly more common in women and occurred more often in young adults. The rate was highest in the spinal catheter group (13%) and lowest in the Sprotte needle group (0.98%). Fifty-six patients underwent caudal saline injections which were repeated in sessions of 1-2 times a day for 1-2 days. Most patients (n = 48) needed 3 or 4 (n=18) sessions. Mean volumes during the 4 sessions were 120.0 mL, 114.9 mL, 106.5 mL, and 97.8 mL. Four patients were finally treated with a blood patch. CONCLUSIONS: The use of fine gauge pencil-point needles may reduce the incidence of PDPH. The technique of repeated caudal saline injections is easy, rapid, and effective in providing the patient with almost immediate headache relief. In cases where this treatment fails, a blood patch should be considered. Observations from this study suggest that randomized, controlled, double-blind studies may be warranted. 
Cefalea post-epidural: ¿Que tan tarde puede suceder?
Post-epidural headache: how late can it occur?
Reamy BV.
United States Air Force and the Department of Family Medicine, Uniformed Services University, Bethesda, MD, USA.
J Am Board Fam Med. 2009 Mar-Apr;22(2):202-5.
BACKGROUND: Complications of labor epidural anesthesia include a post-dural puncture headache (PDPH). A 2003 meta-analysis described the onset of PDPH as occurring from 1 to 7 days after the procedure. Presented here is the first published case of a PDPH occurring 12 days postpartum. METHODS: Twelve days after an uncomplicated labor epidural a patient was awakened by a "crushing" postural headache. The initial diagnosis was "possible subarachnoid hemorrhage." Lumbar puncture and computed tomography angiogram were normal. Despite medications a severe postural headache persisted and she was referred for an epidural blood patch. Consultants felt the headache onset after 7 days made PDPH impossible. Ultimately a delayed EBP was performed with immediate resolution of her headache. Discussion: Meta-analyses describe that parturients have a 1.5% risk of accidental dural puncture during epidural placement. Onset of the headache occurs as early as 1 or as late as 7 days after the procedure. Epidural blood patch is the most effective treatment for PDPH and a rapid response is diagnostic. CONCLUSION: Described is the first reported case of a PDPH occurring well outside the normal range of onset 1 to 7 days after epidural anesthesia. The delayed diagnosis and treatment of PDPH in this patient illustrates the limitations of over-rigorous application of pooled analyses to the care of individual patients

Inicio rápido no usual de cefalea post punción dural despues de raquianestesia con aguja Whittacre 27G 
Unusually early onset of post-dural puncture headache after spinal anaesthesia using a 27G Whittacre needle.
Lomax S, Qureshi A.
Anaesthetic Department, Wexham Park Hospital, Wexham, Slough, Berkshire SL2 4HL, UK.
Br J Anaesth. 2008 May;100(5):707-8. Epub 2008 Mar 26.
We present a case of a post-dural puncture headache occurring 20 min after spinal anaesthesia using a 27-Gauge Whittacre needle. The unusually early occurrence of this complication is thought to be the first of its kind reported in the literature and highlights the novelty of this case.

Anestesiología y Medicina del Dolor
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