Side effects after epidural blood patch

The patient was admitted to the hospital on the first postoperative day due to severe headache that started from the nape of the neck and that involved the entire head.

The headache was accompanied by tinnitus ringing in both ears and motor noise and nausea—vomiting and was more prominent in the standing and sitting positions. The patient was chiefly discomforted by the tinnitus.

The headache diminished while in the lying position, but the tinnitus did not subside. An intravenous access was established in the patient, and she was hydrated. An oral caffeinated analgesic and antiemetic were started. The headache alleviated on the second day of admission, but the tinnitus remained. The patient was unable to sleep and expressed that she was extremely discomforted by this.

Given that it was accompanied by headache, we thought that the patient could benefit from an epidural blood patch. Following appropriate site cleaning, approximately 12 mL of the blood patch was epidurally administered by accessing the same space. The tinnitus in the left ear immediately improved following the injection, while it disappeared within approximately 12 h in the right ear. Additionally, the complaint of pain, which lost its severity with the medical treatment, completely disappeared.

Aetiology regarding symptoms related to hearing following spinal anaesthesia is not very clear. One of the proposed hypotheses is the decrease in intra-labyrinth pressure. The cochlear duct provides an anatomical connection between the cochlea and the subarachnoid distance.

The composition of the perilymph in the cochlea closely resembles the cerebrospinal fluid. One of the proposed views is that a decrease in cerebrospinal fluid pressure causes a decrease in intra-labyrinth pressure and that this causes functional inability in the ear in transmitting sounds 5. Symptoms could spontaneously subside; however, there are patients who became chronic.

The relationship of chronic cases with spinal anaesthesia can only be revealed by obtaining a good medical history. These patients can benefit from an epidural blood patch 1 , 2 , 4. In a patient who developed tinnitus following spinal anaesthesia 4 years , it was learned, upon obtaining medical history by the ear, nose and throat specialist, that the complaint started 24 h after spinal anaesthesia, and the patient was directed to an anaesthetist.

The tinnitus was successfully treated by administering 20 mL of an epidural blood patch to the patient 2. A patient with postspinal 8 years tinnitus complaint underwent epidural anaesthesia for another surgical operation.

Because his headache persisted to the next day, an anesthesiologist was consulted and requested to perform an epidural blood patch. After the incremental administration of intravenous midazolam to a total of 2. Autologous blood was placed into the epidural space at a rate of approximately 0. His respirations remained spontaneous. Oxygen was administered immediately along with 0. The patient awakened over the next 10—15 min but still complained of headache.

The headache worsened over the following hours, he became more somnolent, and he developed a clear CSF rhinorrhea. An emergent computed tomography scan obtained approximately 4 h after the administration of the blood patch Figure 1 showed a significant increase in the size of the cerebral ventricles, including the third ventricle. The patient was transferred to the pediatric intensive care unit, where an external ventricular drain was placed and the ICP, although not specifically measured, was assessed as increased.

Figure 1. A computed tomography scan obtained 4 h after the administration of an epidural blood patch demonstrating hydrocephalus. Attempts to eliminate the need for the external ventricular drain persistently failed over the next 2 days. Therefore, a ventriculoperitoneal shunt was placed, which improved the drainage of CSF. He was discharged to home without any apparent neurologic compromise 5 days after his admission through the emergency department.

Intraoperative drainage of CSF by means of a lumbar subarachnoid drain relaxes intracranial contents, reducing the need for brain retraction. Occasionally, the spinal drain produces a persistent CSF leak, which can be treated with epidural blood patch. The patient in this report had an obvious CSF leak from the spinal drain site and an associated headache, which was worse when he was erect.

Both of these features support the diagnosis of postdural puncture headache. Curative treatment for the CSF leak and postdural puncture headache frequently is accomplished with an epidural blood patch.

The technique of epidural blood patch has been described elsewhere. Neurologic complications related to epidural blood patch include those occurring at the time of the procedure and symptoms predominately happening after epidural blood patch. This latter group includes paresthesias, neck ache, facial nerve palsy, and lumbovertebral syndrome. Increased CSF pressure may play a role in the rapid resolution of a postdural puncture headache after epidural blood patch and suggests an etiology for some of the reported immediate complications.

In our patient, communicating hydrocephalus was a consequence of his operative procedure. His headache likely was also secondary to increased ICP, even though it had a postural component.

We propose the following mechanism for the observed sequence of events: The mass effect from the injection of a large amount of epidural blood acutely increased ICP, and the patient lost consciousness.

He gradually awakened after the effect of the benzodiazepine that had been administered was antagonized, but the seal of the dural defect resulted in a gradual further increase in ICP as new CSF was produced. Two issues particular to this case must be considered along with any conclusion.

First, our patient had received midazolam, which could have produced a relative hypercarbia and contributed to an initial ICP increase. Secondly, the administration of 20 ml of epidural blood is certainly generous and likely contributed to the resultant ICP increase. Whether the outcome would have been the same with a smaller dose of epidural blood is uncertain. We conclude that, under appropriate circumstances, the administration of an epidural blood patch to a patient with increased ICP can be associated with neurologic deterioration.

This possibility should be considered when epidural blood is administered to these patients. This is self-limited, generally resolving in days and preferable to the discomfort of a PDPH. Also, patients need to be made aware of signs and symptoms of infection at the injection site: fever, malaise, erythema, or purulence as injected blood may serve as a nidus for infection.

This requires urgent evaluation and care. These include limiting upright position, hydration, oral analgesics, and intravenous or oral caffeine. Caffeine is a cerebral vasoconstrictor. This, however, generally produces short-term relief. A patient who chooses conservative therapy should keep well hydrated and consume caffeine-containing beverages and oral analgesics as necessary at home.

The majority of patients who elect to have EBP are those that cannot minimize activity, for example, recent parturients with newborns or younger patients. Also, those patients that are extremely symptomatic some cephalgia even when supine and cannot tolerate any degree of upright positioning, tearful or crying at rest, photophobia will likely consent to EBP with or without conservative treatment.

It is important to keep in mind that not all headaches, even if the patient is a post-dural puncture, are PDPHs, and this must be considered in the workup before performing EBP. Furthermore, in mildly symptomatic patients, for example, mild cephalgia when standing 15 to 20 minutes will spontaneously resolve with conservative therapy, and may be preferable to risking a second, large-bore gauge dural puncture, back pain, and the possibility of infection.

An epidural blood patch is a highly effective way to treat a specific subset of post-dural puncture headache patients. It is an elective procedure that carries a relatively low degree of risk. Once PDPH has developed, healthcare workers including nurse practitioners, physician assistants, and primary care physicians should educate the patients.

The majority resolve within 2 weeks. Other supportive measures include limiting upright position, hydration, oral analgesics, and intravenous or oral caffeine. It is administered as mg sodium caffeine benzoate in mL of normal saline or lactated Ringer over 1 to 2 hours. An interprofessional team approach to caring for these patients will produce the best results.

This book is distributed under the terms of the Creative Commons Attribution 4. Turn recording back on. National Center for Biotechnology Information , U. StatPearls [Internet]. Search term. Epidural Blood Patch Robert E.

Author Information Authors Robert E. Continuing Education Activity An epidural blood patch EBP is a procedure in which a small volume of autologous blood is injected into a patient's epidural space to stop a leak of cerebrospinal fluid CSF. Introduction An epidural blood patch EBP is a procedure in which a small volume of autologous blood is injected into a patient's epidural space to stop a leak of cerebrospinal fluid CSF. Anatomy and Physiology The epidural space is bounded by the dural meninges anteriorly, the ligamentum flavum posteriorly and the sides of the vertebral walls laterally.

Equipment Equipment required for EBP includes a standard epidural kit and an gauge or gauge angiocatheter from which to draw autologous blood in a sterile fashion. Personnel Although EBP can be performed by a single operator, it usually requires a second operator for a sterile blood draw and, possibly, a third assistant to help with patient positioning.

Preparation Following an explanation of the procedure and obtaining informed consent, the patient is placed in a lateral or seated position. Technique The epidural space is identified in the standard fashion using loss-of-resistance to air or saline. Enhancing Healthcare Team Outcomes Once PDPH has developed, healthcare workers including nurse practitioners, physician assistants, and primary care physicians should educate the patients.

Review Questions Access free multiple choice questions on this topic. Comment on this article. References 1. Procedural predictors of epidural blood patch efficacy in spontaneous intracranial hypotension. Reg Anesth Pain Med. Post-dural puncture headache.