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REGIONAL ANESTHESIA AND PAIN MANAGEMENT

Clinical Dilemma: A Patient with Postdural Puncture Headache and Acute Leukemia

Brenda A. Bucklin, MD^*, John H. Tinker, MD^*, and Carl V. Smith, MD

Departments of *Anesthesiology and Obstetrics and Gynecology, University of Nebraska Medical Center, Omaha, Nebraska

Address correspondence to Brenda Bucklin, MD, University of Nebraska Medical Center, Department of Anesthesiology, 600 S 42 St., Omaha, NE 68198-4455.

	Introduction

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The incidence of dural puncture varies from 1% to 5% in patients undergoing labor epidural placement (1–3). In severely immunocompromised patients, treatment of postdural puncture headache (PDPH) with epidural blood patch (EBP) is controversial. We report a case of PDPH after accidental dural puncture in a parturient with acute myelogenous leukemia and discuss the management considerations of this bothersome iatrogenic complication.

	Case Report

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A 27-yr-old, 70-kg primigravida was admitted for induction of labor at 34 wk gestation after a relapse of acute myelogenous leukemia (AML). At 20 wk gestation, her pregnancy was complicated by the diagnosis of AML, and she underwent induction chemotherapy with daunorubicin and ara-C. Before admission for induction of labor, bone marrow and skin biopsies again confirmed AML. On admission, her white blood cell count was 11,000/µL, platelet count was 120,000/µL, hemoglobin level was 9.1 g/dL, and temperature was 36.8°C. Serial cervical ripening and IV oxytocin resulted in active labor on the third day. IV fentanyl provided inadequate pain relief, and the obstetricians requested labor epidural analgesia. After evaluation by the anesthesia care team and thorough discussion of risks with the patient, she agreed to labor epidural analgesia. The first epidural attempt resulted in dural puncture at L4-5. Successful epidural placement was achieved at L3-4 with adequate pain relief. Within several hours of uncomplicated vaginal delivery, the patient complained of a severe positional headache. After an initial response to ibuprofen and three 500-mg doses of IV caffeine over 36 h, the patient continued to have a severe positional headache. After consultation with regional anesthesia experts and literature review, EBP was considered but rejected on the grounds that this more invasive treatment could place the patient at increased risk of infectious complications and central nervous system leukemia. After discharge from the labor and delivery ward, the patient was admitted for chemotherapy. Ibuprofen 400 mg was administered at regular intervals, and caffeinated beverages were encouraged. Complete resolution of the headache occurred 10 days after dural puncture.

	Discussion

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Labor epidural anesthesia and PDPH unresponsive to conservative therapy in immunocompromised patients raise several relevant clinical questions. Is EBP contraindicated in an immunocompromised patient with acute leukemia and severe PDPH? What are the treatment options when EBP may increase the risk of infection or tumor?

Although Vandam and Dripps (4) found that 80% of PDPHs resolve within 2 wk, some reports indicate that symptoms can last months or years (5). In addition, postpartum patients frequently desire early definitive therapy so that they can care for the newborn and avoid immobility (6). The severity of our patient's symptoms and her desire for ambulation before the intended intense chemotherapy and necessary isolation prompted our search for treatment options beyond conservative therapy. Treatment options included autologous EBP, donor EBP, and epidural saline infusion.

Autologous EBP is generally accepted as the definitive treatment for PDPH (7). In most patients, it is effective and safe. Tom et al. (8) reported no increased central nervous system morbidity related to EBP in a series of human immunodeficiency virus seropositive patients after a 24-mo follow-up. Immunocompromised patients and those with cancer present different dilemmas regarding a blood patch, especially a potential risk of neoplastic seeding of the central nervous system (9,10). Introduction of autologous blast-laden blood into the epidural space could place patients with AML at risk of neoplastic seeding, central nervous system leukemia, and increased mortality. Although irradiation would destroy blasts before a blood patch, irradiation of autologous blood seemed awkward and was complicated by an increased risk of contamination.

Whether infectious complications of EBP are increased in immunocompromised patients is unknown. Epidural abscess or vertebral osteomyelitis is potentially disastrous after neuraxial anesthesia (11–13). Because organisms frequently remain on skin surfaces after skin antisepsis before epidural placement (14) and are a known source of epidural abscesses (12,15), these organisms could serve as a significant source of infection in immunocompromised patients, especially when blood is introduced into the epidural space.

An alternative to the autologous blood patch might be cross-matched blood obtained from a suitable directed donor. Nondirected donor whole blood is generally not available from the blood bank, and units of packed red blood cells do not contain clotting factors. The headache would likely resolve before completion of antiviral processing and identification of a directed donor. Nonirradiated donor blood injected into the epidural space could result in graft-versus-host disease in an immunocompromised patient. After consideration of EBP, we concluded that the risk of central nervous system leukemia and other risks outweighed the benefits of the procedure.

Another treatment alternative was epidural saline infusion. Despite some studies that suggest a benefit of prolonged epidural saline infusions in patients with PDPH (16–18), Bart and Wheeler (19) reported success rates of 60% for 25-gauge dural punctures and 0% for 17-gauge dural punctures. Unfortunately, these infusions would require extended epidural catheter maintenance. Although the particular infection risk of epidural maintenance in immunocompromised patients is unknown, Holt et al. (20) suggested a high incidence of catheter infections in patients with a median catheter duration of 12 days. Because 24–48 h of catheter maintenance would be anticipated, the risk of epidural-related infection may parallel the low risk of epidural infection in patients with short-term epidural catheters. Although Darchy et al. (21) reported a low risk of infections during short-term epidural catheterization, the benefits of epidural infusions seemed minimal considering the potential risk of catheter-related complications.

In this case report, we examine treatment limitations and considerations in a patient with acute leukemia and PDPH. In our case, the PDPH did resolve spontaneously within the expected time period. In the absence of spontaneous resolution, consultation with the chronic pain service may have provided other treatment alternatives for this iatrogenic complication.

	References

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