Department of Anaesthesia, Hull Royal Infirmary, Hull, East Yorkshire, UK.
Int J Obstet Anesth. 2012 Jan;21(1):7-16. doi: 10.1016/j.ijoa.2011.10.005. Epub 2011 Dec 6.
After accidental dural puncture in labour it is suggested that inserting an intrathecal catheter and converting to spinal analgesia reduces postdural puncture headache and epidural blood patch rates. This treatment has never been tested in a controlled manner.
Thirty-four hospitals were randomised to one of two protocols for managing accidental dural puncture during attempted labour epidural analgesia: repeating the epidural procedure or converting to spinal analgesia by inserting the epidural catheter intrathecally. Hospitals changed protocols at six-month intervals for two years.
One hundred and fifteen women were recruited but 18 were excluded from initial analysis because of practical complications which had the potential to affect the incidence of headache and blood patch rates. Of the remaining 97 women, 47 were assigned to the repeat epidural group and 50 to the spinal analgesia group. Conversion to spinal analgesia did not reduce the incidence of postdural puncture headache (spinal 72% vs. epidural 62%, P=0.2) or blood patch (spinal 50% vs. epidural 55%, P=0.6). Binary logistic analysis revealed the relative risk of headache increased with 16-gauge vs. 18-gauge epidural needles (RR=2.21, 95% CI 1.4-2.6, P=0.005); anaesthetist inexperience (RR=1.02 per year difference in experience, 95% CI 1.001-1.05, P=0.043), and spontaneous vaginal compared to caesarean delivery (RR=1.58, 95% CI 1.14-1.79, P=0.02). These same factors also increased the risk of a blood patch: 16-gauge vs. 18-gauge needles (RR=2.92, 95% CI 1.37-3.87, P=0.01), anaesthetist inexperience (RR=1.06 per year difference in experience, 95% CI 1.02-1.09, P=0.006), spontaneous vaginal versus caesarean delivery (RR=2.22, 95% CI 1.47-2.63, P=0.002). When all patients were included for analysis of complications, there was a significantly greater requirement for two or more additional attempts to establish neuraxial analgesia associated with repeating the epidural (41% vs. 12%, P=0.0004) and a 9% risk of second dural puncture.
Converting to spinal analgesia after accidental dural puncture did not reduce the incidence of headache or blood patch, but was associated with easier establishment of neuraxial analgesia for labour. The most significant factor increasing headache and blood patch rates was the use of a 16-gauge compared to an 18-gauge epidural needle.
在分娩时发生意外硬脊膜穿刺后，建议插入鞘内导管并转为脊髓镇痛，以降低硬脊膜穿刺后头痛和硬膜外血补丁的发生率。这种治疗方法从未经过对照试验验证。
将 34 家医院随机分为两组，分别采用两种方案管理分娩时硬脊膜穿刺后意外：重复硬膜外操作或通过将硬膜外导管插入鞘内来转为脊髓镇痛。医院每隔六个月更改一次方案，共进行两年。
共招募了 115 名妇女，但由于潜在的并发症，有 18 名妇女在初步分析时被排除在外，这些并发症有可能影响头痛和血补丁的发生率。在剩余的 97 名妇女中，47 名被分配到重复硬膜外组，50 名被分配到脊髓镇痛组。转为脊髓镇痛并未降低硬脊膜穿刺后头痛的发生率（脊髓组 72% vs. 硬膜外组 62%，P=0.2）或血补丁的发生率（脊髓组 50% vs. 硬膜外组 55%，P=0.6）。二项逻辑分析显示，头痛的相对风险随 16 号 vs. 18 号硬膜外针而增加（RR=2.21，95%CI 1.4-2.6，P=0.005）；麻醉师经验不足（RR=每年经验差异 1.02，95%CI 1.001-1.05，P=0.043），以及自然阴道分娩与剖宫产（RR=1.58，95%CI 1.14-1.79，P=0.02）。这些相同的因素也增加了血补丁的风险：16 号 vs. 18 号针（RR=2.92，95%CI 1.37-3.87，P=0.01），麻醉师经验不足（RR=每年经验差异 1.06，95%CI 1.02-1.09，P=0.006），自然阴道分娩与剖宫产（RR=2.22，95%CI 1.47-2.63，P=0.002）。当所有患者都被纳入并发症分析时，与重复硬膜外操作相比，建立神经轴镇痛需要进行两次或更多次额外尝试的情况明显更多（41% vs. 12%，P=0.0004），而且第二次硬脊膜穿刺的风险增加了 9%。
在意外硬脊膜穿刺后转为脊髓镇痛并不能降低头痛或血补丁的发生率，但与分娩时更容易建立神经轴镇痛相关。增加头痛和血补丁发生率的最重要因素是使用 16 号针而不是 18 号针。
