Epidural blood patch

Dr. S. Parthasarathy MD., DA., DNB, MD (Acu), Dip.Diab. DCA, Dip.

Software statistics PhD (physio)

Mahatma Gandhi Medical college and research institute , puducherry India

Definition

• Administration of 15 to 20 mL of the patient’s

blood, aseptically obtained, into the epidural

space possibly to treat a postdural puncture

headache is called an epidural blood patch

It was accidentalin 1930’s

• Gormley stated that the incidence of PDPH was lower than anticipated after inadvertent bloody spinal taps.

• Ozdil claimed a 100 percent success rate in preventing PDPH undergoing spinal anesthesia by depositing 2.5 ml of clotted autologous blood epidurally as the spinal needle was being withdrawn.

• DiGiovanni popularized and named it

Indications

• PDPH incapacitating with characteristic features

• not been relieved by 2-3 days of conservative management but

• no active neurological disease• no infection Iocalised to the lumbar area or

septicaemia,• no coagulopathy

Indications other than postdural puncture headache

• case of intracranial hypotension caused by spontaneous CSF leak originating at the C2 level, treated by an epidural blood patch performed at the site of the leak.

• non-surgical treatment of lumbar cerebrospinal fluid fistula

Procedure

• Preferably, 48-72hrs after the puncture which caused the PDPH

• Consent • Premed • IV crystalloid • (L) lateral position – fully flexed

Procedure

• two-operator technique• Both should scrub gown

• Operator 1.• 1. Cleans and drapes the patient's back using a

standard epidural kit and technique,• 2. Identifies the site of original puncture and

locates the epidural space using a standard technique

Procedure

• Operator 2• cleans and drapes the antecubital area of

(usually) the left (downside) arm.• When epidural space is located by operator 1,

the second operator performs a venepuncture, withdraws 22ml of blood, hands the syringe to the first operator (without breaching the integrity of the sterile fields) - sterile dressing to the venepuncture site (unheparinized blood)

How should the blood should be injected?

• 1. Inject the blood slowly until either, the patient complains of tightness in the buttocks, lower back or thighs (usually when 12 to 15ml are injected)

• 2. Withdraw needle, apply sterile dressing, turn supine.

• 3. Inject residual blood to a fresh, sterile needle into a blood culture bottle and send for C/S

Post procedure advice

• Rest with pillow under the knees for half an hour.

• No straining • No bending • No heavy weight carrying for 2 – 3 weeks • PATCH BLOW OUT • Report for fever, backache PDPH

Why use – results fascinating • EBP has an extremely high success rate of close

to 100% when placed in the epidural space at the same level as the initial needle puncture

• Less than 2% will also have mild, transient paraesthesiae, neck pain or radicular pain

• should not cause obliteration of the epidural space, infection, cauda equina syndrome or adhesive arachnoiditis

Possible mechanisms

• The blood patch works as a gelatinous glue which prevents CSF leakage and allows the dural hole to heal

• Blood may also be forced through the dural puncture forming a plug .

• The immediate relief from PDPH may be due to an increase in CSF pressure.

Other areas

• Epidural blood patch has traditionally been performed in the lumbar area, with few cases reported in the thoracic and lower cervical spine ( upto C 2)

• Caudal Epidural Blood Patch for the Treatment of Postdural Puncture Headache

• Other gadgets ?

Flouroscopic control

CT guided EBP

Then why not ultrasound

15 – 20 ml ??

• smaller volumes of blood in older and shorter patients.

• This may also be true in pregnant patients

• 7.5 ml and 10 ml are reported instead of 15 ml in these patients

Complications

• Transient paresthesias in their legs and toes, stiff neck,

• abdominal cramping, • tinnitus,• vertigo during the blood injection.• Later mild backache and fever • Neurological sequalae – epidural abscess

formation and adhesive arachnoiditis very rare

If bleeding occurs during EBP

• the procedure should be discontinued, since subsequent hematoma formation may cover the dural hole

• the addition of the EBP may lead to nerve root compression.

• If fails, second blood patch is administered.

Other causes of headache • Migraine • PIH • CVT • Subdural haemorhage • Cerebral tumour • Nonspecific • Meningitis

Epidural saline

• Large volumes of saline deposited in the

epidural space will relieve PDPH but saline is

readily absorbed and consequently the relief

produced may only be temporary

Thank you all