Accidental Dural Puncture Management: 10-Year Experience at an Academic Tertiary Care Center

The use of spinal catheters for extended periods after accidental dural puncture (ADP) and administration of intrathecal saline via spinal catheters have been advocated to decrease the incidence of postdural puncture headache and the subsequent need for epidural blood patch (EBP), with mixed results observed.

We reviewed the medical records of 218 patients with ADP who either had the epidural resited or had a spinal catheter (with or without the administration of intrathecal saline). We compared the incidence of headache and the need for blood patch between these groups. We also assessed complications when a standard lidocaine epidural test dose was administered intrathecally and compared this with complications when a solution normally used for labor combined spinal epidurals was administered.

There was no difference in the incidence of postdural puncture headache between the resited epidural group and the spinal catheter group, 68.0% versus 55.9% (odds ratio [OR], 1.7; 95% confidence interval [95% CI], 1.0-2.9; P = 0.07). Resiting the epidural catheter was associated with a significant increase in the number of EBPs when compared with using a spinal catheter, 52.0% versus 20.3% (OR, 4.2; 95% CI, 2.4-7.6; P < 0.001) and when compared with spinal catheters with intrathecal saline, 52.0% versus 8.1% (OR, 12.3; 95% CI, 4.3-35.4; P < 0.001). There was a significant difference in the number of blood patches between normal body mass index patients and morbidly obese patients, 55.2% versus 25.0% (OR, 3.7; 95% CI, 1.2-11.2; P = 0.02). Complications (hypotension prompting pressors, high spinal, and emergency cesarean delivery because of nonreassuring fetal status) occurred more frequently when a lidocaine test dose was immediately administered after ADP versus administering a labor combined spinal epidural solution.

Insertion of spinal catheters after ADP and administration of intrathecal normal saline via spinal catheters reduce the need for EBP compared with resiting the epidural. Administration of the standard epidural test dose intrathecally is associated with frequent and significant complications.