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WHEN EPIDURAL BLOOD-PATCH DOESN’T WORK – WHAT COMES NEXT?
ESRA Academy. Lima G. Sep 8, 2016; 138621; 0507 Topic: SAFETY AND COMPLICATIONS OF REGIONAL ANAESTHESIA (RA)
Gisela Lima
Gisela Lima

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Abstract
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Background and Aims:

Epidural blood patch(EBP), first described in 1960, is the gold standard and definitive treatment of post-dural puncture headache(PDPH), when conservative management fails. Although the first EBP is effective in most cases in a second EBP, 70% of patients experience symptom recurrence. We present a case of a puerperal with headache after inadvertent PDPH, resistant to both conservative management and EBP. We considered a second blood-patch but the patient denied.

Methods:

Pregnant, 36 weeks, ASA I, G2P0, normal course of pregnancy, with previous membrane rupture, asks for an epidural for labour analgesia. During the procedure, dura was inadvertently puntured(L3-L4). The catheter was re-sited at L2-L3 and ropivacaine 0,15% and sulfentanyl were used during analgesia, uneventfully. Headache occurred after 24 hours and didn’t give away either with conservative management or EBP(11cc autologous blood, L4-L5 at 48 hours). At the fourth day, she was discharged home medicated with naproxen and acetaminophen. 

Results:

Two days later, due to maintenance of disabling symptoms, returned to anestesia consultation. After neurologic examination and with neurologists collaboration she was infused with dexamethasone 5 mg, with immediate relief. Dexamethasone, acetaminophen and pantoprazole were prescribed for one week as well as avoidance of heavy lifting and straining. After that period of time, she was asymptomatic.

Conclusions:

There is still no consensus data regarding alternative treatment to EBP. Here, dexamethasone, also controversial, solved the clinical situation, where the options were limited. As standardized medical care is becoming more widespread, more studies need to be run regarding PDPH management, especially when EBP fails.  

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