CPPD en obstetricia

Tratamiento de la punción accidental de la duramadre y de la cefalea post punción dural después del parto: estudio en los países nórdicos  Management of accidental dural puncture and post-dural puncture headache after labour: a Nordic survey DARVISH, B., GUPTA, A., ALAHUHTA, S., DAHL, V., HELBO-HANSEN, S., THORSTEINSSON, A., IRESTEDT, L. and DAHLGREN, G. Acta Anaesthesiologica Scandinavica Volume 55, Issue 1, pages 46-53, January 2011. doi: 10.1111/j.1399-6576.2010.02335.x Background: A major risk with epidural analgesia is accidental dural puncture (ADP), which may result in post-dural puncture headache (PDPH). This survey was conducted to explore the incidence of ADP, the policy for management of PDPH and the educational practices in epidural analgesia during labour in the Nordic countries. Methods: A postal questionnaire was sent to the anaesthesiologist responsible for Obstetric anaesthesia service in all maternity units (n=153) with questions relating to the year 2008. Results: The overall response rate was 93%. About 32% (22-47%) of parturients received epidural analgesia for labour. There were databases for registering obstetric epidural complications in 13% of Danish, 24% of Norwegian and Swedish, 43% of Finnish and 100% of hospitals in Iceland. The estimated incidence of ADP was 1% (n≈900). Epidural blood patch (EBP) was performed in 86% (n≈780) of the parturients. The most common time interval from diagnosis to performing EBP was 24-48 h. The success rate for EBP was >75% in 67% (62-79%) of hospitals. The use of diagnostic CT/MRI before the first or the second EBP was exceptional. No major complication was reported. Teaching of epidurals was commonest (86%) in the non-obstetric population and 53% hospitals desired a formal training programme in obstetric analgesia. Conclusion: We found the incidence of ADP to be approximately 1%. EBP was the commonest method used for its management, and the success rate was high in most hospitals. Formal training in epidural analgesia was absent in most countries and trainees first performed it in the non-obstetric population. http://onlinelibrary.wiley.com/doi/10.1111/j.1399-6576.2010.02335.x/pdf   Cefalea post-epidural: ¿Que tan tardía puede ocurrir? 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. Abstract 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. http://www.jabfm.org/cgi/reprint/22/2/202

Atentamente Dr. Benito Cortes-Blanco Anestesiología y Medicina del Dolor www.anestesia-dolor.org