Kakde Avinash, Chia Pamela, Tan Hon Sen, Sultana Rehena, Tan Chin Wen, Sng Ban Leong
Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore.
Anaesthesiology and Perioperative Sciences Academic Clinical Program, Duke-NUS Medical School, Singapore.
Heliyon. 2024 Mar 4;10(6):e27511. doi: 10.1016/j.heliyon.2024.e27511. eCollection 2024 Mar 30.
Inadvertent dural puncture and post-dural puncture headache are complications of labour epidural analgesia and may result in acute and chronic morbidity. Identification of risk factors may enable pre-emptive management and reduce associated morbidity. In this retrospective cohort study, we aimed to identify factors associated with an inadvertent dural puncture or post-dural puncture headache by identifying parturients who received labour epidural analgesia from January 2017 to December 2021. The primary outcome was any witnessed inadvertent dural puncture, inadvertent placement of an intrathecal catheter, clinical diagnosis of post-dural puncture headache, or headache that was assessed to have characteristic post-dural puncture headache features. A wide range of demographic, obstetric, and anaesthetic factors were analysed using univariate and multivariable analyses to identify independent associations with the primary outcome. Data from 26,395 parturients were analysed, of whom 94 (0.36%) had the primary outcome. Within these 94 parturients, 26 (27.7%) had inadvertent dural puncture, 30 (31.9%) had inadvertent intrathecal catheter, and 38 (40.4%) had post-dural puncture headache without documented inadvertent dural puncture or intrathecal catheter insertion. Increased number of procedure attempts (adjusted odds ratio 1.39, 95% confidence interval 1.19 to 1.63), longer procedure duration adjusted odds ratio 1.03, 95% confidence interval 1.01 to 1.05), increased depth of epidural space (adjusted odds ratio 1.10, 95% confidence interval 1.04 to 1.18), greater post-procedure Bromage score (adjusted odds ratio 7.70, 95% confidence interval 4.22 to 14.05), and breakthrough pain (adjusted odds ratio 3.97, 95% confidence interval 2.59 to 6.08) were independently associated with increased odds of the primary outcome, while the use of standard patient-controlled epidural analgesia (PCEA) regimen (adjusted odds ratio 0.50, 95%confidence interval 0.31 to 0.81), increased concentration of ropivacaine (adjusted odds ratio 0.08 per 0.1%, 95% confidence interval 0.02 to 0.46), and greater satisfaction score (adjusted odds ratio 0.96, 95% confidence interval 0.95 to 0.97) were associated with reduced odds. The area under curve of this multivariable model was 0.83. We identified independent association factors suggesting that greater epidural depth and procedure difficulty may increase the odds of inadvertent dural puncture or post-dural puncture headache.
意外硬膜穿破和硬膜穿破后头痛是分娩硬膜外镇痛的并发症，可能导致急慢性发病。识别风险因素有助于进行预防性处理并降低相关发病率。在这项回顾性队列研究中，我们旨在通过识别2017年1月至2021年12月期间接受分娩硬膜外镇痛的产妇，来确定与意外硬膜穿破或硬膜穿破后头痛相关的因素。主要结局是任何有记录的意外硬膜穿破、鞘内导管误置、硬膜穿破后头痛的临床诊断，或经评估具有典型硬膜穿破后头痛特征的头痛。使用单因素和多因素分析对广泛的人口统计学、产科和麻醉因素进行分析，以确定与主要结局的独立关联。对26395名产妇的数据进行了分析，其中94名（0.36%）出现了主要结局。在这94名产妇中，26名（27.7%）发生了意外硬膜穿破，30名（31.9%）出现了鞘内导管误置，38名（40.4%）出现了硬膜穿破后头痛但无意外硬膜穿破或鞘内导管置入的记录。操作尝试次数增加（调整后的优势比为1.39，95%置信区间为1.19至1.63）、操作持续时间延长（调整后的优势比为1.03，95%置信区间为1.01至1.05）、硬膜外间隙深度增加（调整后的优势比为1.10，95%置信区间为1.04至1.18）、术后布罗玛杰评分更高（调整后的优势比为7.70，95%置信区间为4.22至14.05）以及爆发痛（调整后的优势比为3.97，95%置信区间为2.59至6.08）与主要结局发生几率增加独立相关，而使用标准的患者自控硬膜外镇痛（PCEA）方案（调整后的优势比为0.50，95%置信区间为0.31至0.81）、罗哌卡因浓度增加（每增加0.1%调整后的优势比为0.08，95%置信区间为0.02至0.46）以及更高的满意度评分（调整后的优势比为0.96，95%置信区间为0.95至0.97）与发生几率降低相关。该多因素模型的曲线下面积为0.83。我们确定了独立的关联因素，表明更大的硬膜外深度和操作难度可能会增加意外硬膜穿破或硬膜穿破后头痛的几率。
