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LETTERS TO THE EDITOR

Treatment of Postdural Puncture Headaches with Colloid Solutions: An Alternative to Epidural Blood Patch

Department of Anesthesiology Cochin Port-Royal Hospital Paris, France

J. Hamza, MD

Department of Anesthesiology Saint-Vincent de Paul Hospital Paris, France

We read with interest the case report of Bucklin et al. (1) regarding a difficult clinical dilemma: a patient with post dural puncture headaches (PDPH) and acute leukemia. The authors provide a very interesting discussion about the risks induced by the injection of autologous blood in the epidural space in such a patient (infectious complications, central nervous system leukemia). They also discuss the best conservative treatments if autologous epidural blood patch (EBP) is contraindicated. Despite the administration of ibuprofen and caffeinated beverages, the complete resolution of these severe and incapaciting headaches occured 10 days after the dural puncture in this case.

The authors do not mention an alternative treatment that could have been used in this patient: the injection of a colloid solution instead of autologous blood in the epidural space. In two noncontrolled studies (including 56 and 17 patients), epidural injection of 20–30 mL Dextran 40 has successfully treated PDPH complicating spinal or epidural anesthesia for surgical and obstetrical indications (2,3). As epidural saline infusions, the injection of the colloid increases the epidural pressure and immediately relieves headache (3). Because of its viscosity, reabsorbtion of the colloid from the epidural space is delayed, leading to a greater and longer compression, enabling closure of the dural tap (3). Except for rare dysesthesias at the site of injection (10%), no serious complications have been noted in these two studies. Lander and Korbon (4) studied the histopathologic consequences of epidurally administered Dextran 40 and concluded that no neurotoxic effects were noted, whereas EBP did seem to produce moderate inflammatory reactions.

In 1997, we designed a French postal survey concerning the management of dural taps occuring during the siting of epidural analgesia for pain relief in labor (5). Of the 267 maternity units surveyed, 11.6% routinely used epidural colloid injections with modified fluid gelatine in 30 cases and hydroxyethylstarch in only one case, but none used Dextran 40. In this retrospective study, the anesthetists reported a high success rate for this treatment and no adverse effect. Two surveys in United Kingdom and North America did not report such a practice, in contrast with a larger use of therapeutic and prophylactic epidural saline infusions (6,7). We believe that epidural colloid boluses are a better PDPH treatment than saline boluses or infusions because of the lower risk of failure. However, the absence of neurotoxic effects of colloid injections must be confirmed by experimental studies.

We believe that epidural injection of modified fluid gelatine or hydroxyethylstarch should be more closely investigated, because it provides an effective and prolonged PDPH treatment in the case of an absolute contraindication to EBP. After a dural puncture with a Tuohy needle during labor, prophylactic injection of a colloid solution through the epidural catheter after the complete elimination of the local anesthetics from the epidural space could also be studied as an alternative to EBP.

References

1. Bucklin BA, Tinker JH, Smith CV. Clinical dilemma: a patient with postdural puncture headache and acute leukemia. Anesth Analg 1999;88:166–7.[Free Full Text]
2. Barrios-Alarcon J, Aldrete JA, Paragas-Tapia D. Relief of post-lumbar puncture headache with epidural Dextran 40: a preliminary report. Reg Anesth 1989;14:78–80.[Web of Science][Medline]
3. Salvador L, Carrero E, Castillo J, et al. Prevention of post dural puncture headache with epidural-administered dextran 40 [letter]. Reg Anesth 1992;17:357–8.[Web of Science][Medline]
4. Lander CJ, Korbon GA. Histopathologic consequences of epidural blood patch and epidurally administered Dextran 40 [abstract]. Anesthesiology Suppl 1988;69:A410.
5. Souron V, Simon L, Sacquin P, Hamza J. Current management of inadvertent dural taps occuring during epidural analgesia for pain relief in labour: a French postal survey [abstract]. Br J Anaesth Suppl 1998;80:A523.
6. Sajjad T. Current management of inadvertent dural taps occuring during the siting of the epidurals for pain relief in labour: a survey of maternity in the United kingdom. Anesthesia 1995;50:156–61.[Web of Science][Medline]
7. Berger CW, Crosby ET, Grodecki W. North American survey of dural puncture occurring during labour epidural anagesia. Can J Anaesth 1998;45:110–4.[Web of Science][Medline]

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