El volumen de sangre parche epidural en obstetricia. Estudio randomizado y ciego
The volume of blood for epidural blood patch in obstetrics: a randomized, blinded clinical trial.
Paech MJ, Doherty DA, Christmas T, Wong CA; Epidural Blood Patch Trial Group.
School of Medicine and Pharmacology, University of Western Australia, Crawley, Australia. michael.paech@health.wa.gov.a
Anesth Analg. 2011 Jul;113(1):126-33.
doi: 10.1213/ANE.0b013e318218204d. Epub 2011 May 19.
Abstract
BACKGROUND: Our aim in this multinational, multicenter, randomized, blinded trial was to determine the optimum of 3 volumes of autologous bloodfor an epidural blood patch. METHODS: Obstetric patients requiring epidural blood patch after unintentional dural puncture during epidural catheter insertion were allocated to receive 15, 20, or 30 mL of blood, stratified for the timing of epidural blood patch and center. Participants were followed for 5 days. The primary study end point was a composite of permanent or partial relief of headache, and secondary end points included permanent relief, partial relief, persisting headache severity, and low back pain during or after the procedure. RESULTS:One hundred twenty-one women completed the study. The median (interquartile range) volume administered was 15 (15-15), 20 (20-20), and 30 (22-30) mL, with 98%, 81%, and 54% of groups 15, 20, and 30 receiving the allocated volume. Among groups 15, 20, and 30, respectively, the incidence of permanent or partial relief of headache was 61%, 73%, and 67% and that of complete relief of headache was 10%, 32%, and 26%. The 0- to 48-hour area under the curve of headache score versus time was highest in group 15. The incidence of low back pain during or after the epidural blood patch was similar among groups and was of low intensity, although group 15 had the highest postprocedural back pain scores. Serious morbidity was not reported. CONCLUSIONS:Although the optimum volume of blood remains to be determined, we believe these findings support an attempt to administer 20 mL of autologous blood when treating postdural puncture headache in obstetric patients after unintentional dural puncture.
http://www.csen.com/patch.pdf#!
http://journals.lww.com/anesthesia-analgesia/pages/articleviewer.aspx?year=2011&issue=07000&article=00022&type=abstract
Dolor radicular tardio después de dos parches epidurales con gran volumen para CPPL. Informe de caso
Delayed radicular pain following two large volume epidural blood patches for post-lumbar puncture headache: a case report.
Desai MJ, Dave AP, Martin MB.
George Washington University Hospital, Washington, DC, USA. mdesai@mfa.gwu.edu
Pain Physician. 2010 May-Jun;13(3):257-62.
Abstract
INTRODUCTION: Postdural puncture headache (PDPH) is a known complication of diagnostic lumbar puncture. Multiple factors including needle size, type, and needle bevel orientation, have been postulated to contribute to the development of PDPH. The presentation of PDPH tends to have classic symptoms that include a postural headache, nausea, vomiting, tinnitus, and ocular disturbances. Conservative treatment measures include bed rest, intravenous hydration or caffeine, and analgesics. Resistant cases might require an epidural blood patch (EBP). Though complications are rare, cases of immediate post-procedural pain and subdural epidural hematoma have been reported. Here we present a case of PDPH treated with sequential EBPs that resulted in delayed radicular pain. CASE REPORT:A 29-year-old female presented to the emergency room with a severe frontal headache of several days duration. She underwent a diagnostic lumbar puncture as a part of her work-up. Then, 24-48 hours later she developed a severe postural headache unresponsive to conservative care. Two days later she underwent an epidural blood patch with 20 mL of autologous blood. Her symptoms did not abate, prompting a repeat EBP within 24 hours with an additional 20 mL of autologous blood. Five days later the patient began experiencing muscle spasms and radicular pain in the buttocks and left posterior leg that radiated to her posterior calf. The patient was initially started on pregabalin 25mg 3 times daily, and underwent a gadonlinum-enhanced MRI of the lumbar spine. She followed up 5 days later with unchanged symptoms and a negative MRI. She was then started on a methylprednisolone taper and continued the pregabalin. At the 10-day follow-up, there was 90% resolution of symptoms and a pain intensity of 1/10 on NRS. At this time she is continuing the pregabalin with plans to discontinue medication. DISCUSSION:Although EBP is typically a safe procedure, complications might occur. An inflammatory response, secondary to the injection ofblood, or mechanical compression, due to the total volume of blood injection, are highlighted as possible causative agents in the development of this complication. The role of fluoroscopic imaging, particularly in patients who have failed an initial EBP, must also be examined. Given the rates of false loss of resistance (17-30%) reported in the literature, the use of real-time imaging to ensure proper needle placement and subsequent injectate spread should be considered.
http://www.painphysicianjournal.com/2010/may/2010;13;257-262.pdf
Atentamente
Dr. Benito Cortes-Blanco
Anestesiología y Medicina del Dolor
www.anestesia-dolor.org
The volume of blood for epidural blood patch in obstetrics: a randomized, blinded clinical trial.
Paech MJ, Doherty DA, Christmas T, Wong CA; Epidural Blood Patch Trial Group.
School of Medicine and Pharmacology, University of Western Australia, Crawley, Australia. michael.paech@health.wa.gov.a
Anesth Analg. 2011 Jul;113(1):126-33.
doi: 10.1213/ANE.0b013e318218204d. Epub 2011 May 19.
Abstract
BACKGROUND: Our aim in this multinational, multicenter, randomized, blinded trial was to determine the optimum of 3 volumes of autologous bloodfor an epidural blood patch. METHODS: Obstetric patients requiring epidural blood patch after unintentional dural puncture during epidural catheter insertion were allocated to receive 15, 20, or 30 mL of blood, stratified for the timing of epidural blood patch and center. Participants were followed for 5 days. The primary study end point was a composite of permanent or partial relief of headache, and secondary end points included permanent relief, partial relief, persisting headache severity, and low back pain during or after the procedure. RESULTS:One hundred twenty-one women completed the study. The median (interquartile range) volume administered was 15 (15-15), 20 (20-20), and 30 (22-30) mL, with 98%, 81%, and 54% of groups 15, 20, and 30 receiving the allocated volume. Among groups 15, 20, and 30, respectively, the incidence of permanent or partial relief of headache was 61%, 73%, and 67% and that of complete relief of headache was 10%, 32%, and 26%. The 0- to 48-hour area under the curve of headache score versus time was highest in group 15. The incidence of low back pain during or after the epidural blood patch was similar among groups and was of low intensity, although group 15 had the highest postprocedural back pain scores. Serious morbidity was not reported. CONCLUSIONS:Although the optimum volume of blood remains to be determined, we believe these findings support an attempt to administer 20 mL of autologous blood when treating postdural puncture headache in obstetric patients after unintentional dural puncture.
http://www.csen.com/patch.pdf#!
http://journals.lww.com/anesthesia-analgesia/pages/articleviewer.aspx?year=2011&issue=07000&article=00022&type=abstract
Dolor radicular tardio después de dos parches epidurales con gran volumen para CPPL. Informe de caso
Delayed radicular pain following two large volume epidural blood patches for post-lumbar puncture headache: a case report.
Desai MJ, Dave AP, Martin MB.
George Washington University Hospital, Washington, DC, USA. mdesai@mfa.gwu.edu
Pain Physician. 2010 May-Jun;13(3):257-62.
Abstract
INTRODUCTION: Postdural puncture headache (PDPH) is a known complication of diagnostic lumbar puncture. Multiple factors including needle size, type, and needle bevel orientation, have been postulated to contribute to the development of PDPH. The presentation of PDPH tends to have classic symptoms that include a postural headache, nausea, vomiting, tinnitus, and ocular disturbances. Conservative treatment measures include bed rest, intravenous hydration or caffeine, and analgesics. Resistant cases might require an epidural blood patch (EBP). Though complications are rare, cases of immediate post-procedural pain and subdural epidural hematoma have been reported. Here we present a case of PDPH treated with sequential EBPs that resulted in delayed radicular pain. CASE REPORT:A 29-year-old female presented to the emergency room with a severe frontal headache of several days duration. She underwent a diagnostic lumbar puncture as a part of her work-up. Then, 24-48 hours later she developed a severe postural headache unresponsive to conservative care. Two days later she underwent an epidural blood patch with 20 mL of autologous blood. Her symptoms did not abate, prompting a repeat EBP within 24 hours with an additional 20 mL of autologous blood. Five days later the patient began experiencing muscle spasms and radicular pain in the buttocks and left posterior leg that radiated to her posterior calf. The patient was initially started on pregabalin 25mg 3 times daily, and underwent a gadonlinum-enhanced MRI of the lumbar spine. She followed up 5 days later with unchanged symptoms and a negative MRI. She was then started on a methylprednisolone taper and continued the pregabalin. At the 10-day follow-up, there was 90% resolution of symptoms and a pain intensity of 1/10 on NRS. At this time she is continuing the pregabalin with plans to discontinue medication. DISCUSSION:Although EBP is typically a safe procedure, complications might occur. An inflammatory response, secondary to the injection ofblood, or mechanical compression, due to the total volume of blood injection, are highlighted as possible causative agents in the development of this complication. The role of fluoroscopic imaging, particularly in patients who have failed an initial EBP, must also be examined. Given the rates of false loss of resistance (17-30%) reported in the literature, the use of real-time imaging to ensure proper needle placement and subsequent injectate spread should be considered.
http://www.painphysicianjournal.com/2010/may/2010;13;257-262.pdf
Atentamente
Dr. Benito Cortes-Blanco
Anestesiología y Medicina del Dolor
www.anestesia-dolor.org
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