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Anesth Analg 2004;98:629-631 © 2004 International Anesthesia Research Society doi: 10.1213/01.ANE.0000100661.31566.43
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Abstract |
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 Top Abstract IntroductionCase ReportDiscussionReferences |
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A 3-yr-old with B-cell lymphoma presented with a 5-wk history of 400 mL/day cerebrospinal fluid (CSF) leak, which precluded chemotherapy, after placement of an Omaya reservoir and drain. Surgical repair was unsuccessful. Symptoms included irritability, failure to eat and noncommunication. After lumbar epidural blood patch with 7 mL the symptoms resolved immediately, allowing recommencement of chemotherapy. Epidural blood patch should be considered as possible early treatment for CSF leaks.
IMPLICATIONS: An epidural blood patch successfully treated a large cerebrospinal fluid leak of long duration in a 3-yr-old. Considering the distress of such a leak to the patient, staff, and parents, epidural blood patch may be considered as an early treatment option.
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Introduction |
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TopAbstractIntroductionCase ReportDiscussionReferences |
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Cerebrospinal fluid (CSF) leakage and postdural puncture headache have been reported after placement of CSF drains in adults (1) and children (2). Other symptoms, such as low back pain (3) and nausea (4), have also been reported. Epidural blood patch has been used in children as young as 5-yr-old to control postdural puncture symptoms (4). We present a case of a large, persistent CSF leak after placement of an Omaya Reservoir and intrathecal catheter in a 3-yr-old with Stage IV lymphoma that precluded further intrathecal therapy and resulted in irritability, loss of communication, and failure to feed. All symptoms related to the leak of CSF resolved immediately upon placement of a lumbar epidural blood patch.
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Case Report |
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TopAbstractIntroductionCase ReportDiscussionReferences |
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A 3-yr-old, 13.4-kg girl presented with Stage IV B-cell lymphoma. After numerous lumbar punctures for intrathecal injection of chemotherapeutic agents and disease monitoring, which resulted in increasingly difficult CSF aspiration, an Omaya Reservoir and intrathecal catheter (external diameter, 2.1 mm) were placed at L3-4 by a neurosurgeon to facilitate CSF access and allow continued intrathecal chemotherapy. CSF leakage began from the wound site on the day after surgery. Repeated attempts were made over 4 wk to control the leak using staples, sutures, and collodion glue. Because of pneumothoraces and ventilatory problems the patient had suffered previously during surgery under general anesthesia, the neurosurgeons and pediatricians decided not to repair the leak by dural suturing. The catheter and reservoir were removed at 4 wk in a final attempt to stop the leak, reduce the chance of infection, and allow recommencement of chemotherapy. Leakage increased to 300–400 mL/day, based on the weight of gauze sponges, after removal of the catheter. A normal 3-yr-old produces 20 mL/h of CSF (5). The child became increasingly irritable, refused food, and was unable to communicate with her parents. Five days after removal of the reservoir and drain, the Department of Pediatric Anesthesiology was contacted to assess her for an epidural blood patch, 5 wk after the leak had been detected.
On examination the child was irritable, listless, and noncommunicative with staff and parents. She was afebrile but slightly tachycardic and tachypneic. She was receiving supplemental oxygen 2 L/min by nasal cannulae and had oxygen saturation in the low 90s with frequent desaturations to the 70s. Her most recent arterial blood gas showed pH of 7.34, PO2 of 68, PCO2 of 55, and bicarbonate of 36. Her complete blood count was as follows: hemoglobin, 10.6; hematocrit, 34; white cell count (WCC), 19.3; platelets, 245. No preoperative coagulation studies were done. Her chest radiograph showed complete opacification of the left lung with numerous blebs in the right upper lobe and a large pneumatocele in the left upper lobe. She had a history of multiple emergent intubations because of respiratory failure. She had scars from chest tubes inserted emergently during her surgery for placement of a subcutaneous venous access port. She had an occasional systolic murmur and echocardiography showed mild biventricular hypertrophy. Her abdomen was greatly distended. She was receiving caloric supplementation and maintenance fluids plus 400 mL/day crystalloid to replace her CSF losses. She was sedated with IV lorazepam (0.1125 mg · kg-1 · h-1 infusion) and fentanyl (2.5 µg · kg-1 · h-1 infusion). Inspection of her back showed completely drenched gauze sponges which, when removed, revealed CSF flowing from the incision site. She was scheduled to have an epidural blood patch the following morning.
Three anesthesiologists were assigned to the case—one to manage the anesthesia, one to draw the blood, and one to place the epidural. After full monitoring, anesthesia was induced and maintained with sevoflurane with intermittent assistance of ventilation by mask. She was placed in the right lateral decubitus position and her back prepared with povidone-iodine solution and draped. Her right ankle at the site of the saphenous vein was prepared with povidone-iodine solution and draped. The surgical incision on her back extended from L3-5. Using loss of resistance to saline through an 18-gauge, 12-cm Tuohy needle, the epidural space was located at L4-5. Blood drawn from the saphenous vein was injected until resistance was felt (a total of 7 mL). The visible drainage of CSF stopped immediately. Recovery from anesthesia was prompt and uneventful.
Over the course of the day her symptoms of irritability and noncommunication resolved. Chemotherapy was recommenced 3 days later. Her CSF leak did not reappear, nor did the symptoms associated with it. She remained in hospital until she died from her lymphoma 4 wk later.
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Discussion |
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TopAbstractIntroductionCase ReportDiscussionReferences |
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Epidural blood patch has been used to treat postdural puncture headache in children as young as 6 years (6) and to treat vomiting in a 5-year-old (4). Its use to treat a large (400 mL/day), persistent (5 weeks), symptomatic leak in a child has not been described. The use of epidural blood patch to treat a CSF leak of such duration has not been described in adults. Apart from being distressing to the child, symptoms of irritability, listlessness, food refusal, and noncommunication are distressing to parents and staff. A large, persistent CSF leak increases the risk of infection, especially in an immune-compromised child, and precludes intrathecal chemotherapy. A leak of 400 mL/day, approximately 30% of blood volume, makes fluid and electrolyte balance difficult. Although not without risks, especially in such a severely ill patient, epidural blood patch seemed the best potential solution after repeated attempts by neurosurgeons to stop the leak.
Persistent CSF leak after surgical placement of an intrathecal catheter is an uncommon complication, although postdural puncture headache has been reported in 17 (3.2%) of 530 adults after placement of lumbar drains (7). The definitive treatment is removal of the implanted catheter and suture of the dural tear. In this case, conservative measures of superficial and subdermal sutures and glues failed to stop the leak; removal of the catheter increased the leakage.
Epidural blood patches can be injected at lumbar and caudal sites (4). Injection of the blood at the site of the leak or one space below has been recommended in adults because injected blood has a greater tendency for rostral spread (8). The volume of blood to inject in children has not been determined. Adults are injected with up to 20 mL, but 0.3 mL/kg has been recommended for children (9). We injected 7 mL (0.52 mL/kg). Injection was stopped when resistance was felt, but we decided to inject as large a volume as possible because the leak was so large and persistent and we did not want to further endanger the patient by having to repeat the procedure. When symptoms, such as headache, appear soon after dural puncture, it is recommended to wait 24–48 h in adults and 3 days in children before epidural blood patch (9). Postdural puncture headache has been treated in a 12-year-old 6 weeks after dural puncture (10), but it is not known how the duration of symptoms, or in this case a visible leak, affects the efficacy of epidural blood patch.
A patient with Stage IV B-cell lymphoma is at particular risk from an epidural blood patch. Apart from the usual complications of failure of treatment, backache, and dural puncture, there are enhanced risks of infection, bleeding, and possibly seeding tumor into the epidural space. Risks of infection were decreased by the use of strict sterile technique and the fact the patient was afebrile and on antibiotics even though she had a WCC of 19.3. The risk of bleeding was judged to be small because the platelet count was 245 and there were no signs or symptoms of spontaneous bleeding or altered coagulation. Consultation with the oncologists reassured us that her tumor had a very small risk for seeding. In view of her delayed chemotherapy and severe persistent symptoms it was determined that the potential benefits outweighed the risks.
In this case, lumbar epidural blood patch in a volume of 7 mL (0.52 mL/kg) relieved symptoms and stopped a large persistent CSF leak in a 3-yr-old. Considering the distress to child and parents caused by the duration of symptoms, delay of chemotherapy, and likely failure of conservative surgical management, epidural blood patch should be considered as possible early treatment for CSF leaks.
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References |
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TopAbstractIntroductionCase ReportDiscussionReferences |
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- Huch K, Kunz U, Kluger P, Puhl W. Epidural blood patch under fluoroscopic control: non-surgical treatment of lumbar cerebrospinal fluid fistula following implantation of an intrathecal pump system. Spinal Cord 1999; 37: 648–52.[Medline]
- Kumar V, Maves T, Barcellos W. Epidural blood patch for treatment of subarachnoid fistula in children. Anaesthesia 1991; 46: 117–8.[Web of Science][Medline]
- Kokki H, Hendolin H, Turunen M. Postdural puncture headache and transient neurologic symptoms in children after spinal anaesthesia using cutting and pencil point paediatric spinal needles. Acta Anesthesiol Scand 1998; 42: 1076–82.[Web of Science][Medline]
- Robins B, Boggs DP. Caudal epidural blood patch for treating intractable vomiting in a child after placement of a permanent intrathecal catheter. Anesth Analg 2001; 92: 1169–70.
[Free Full Text] - Pleasure D, De Vito DC. The nervous system. In: Rudolph CD, Rudolph AM, Hostetter MK, et al., eds. Rudolph’s pediatrics 21st ed. New York: McGraw Hill, 2002: 2165–351.
- Ylonen P, Kokki H. Management of postdural puncture headache with epidural blood patch in children. Paediatr Anaesth 2002; 12: 526–9.[Medline]
- Grady RE, Horlocker TT, Brown RD, et al. Neurological complications after placement of cerebrospinal fluid drainage catheters and needles in anesthetized patients: implications for regional anesthesia. Anesth Analg 1999; 88: 388–92.
[Abstract/Free Full Text] - Szeinfeld M, Ihmeidan IH, Moser MM, et al. Epidural blood patch: evaluation of the volume and spread of blood injected into the epidural space. Anesthesiology 1986; 64: 820–2.[Web of Science][Medline]
- Oliver A. Dural punctures in children: what should we do? Paediatr Anaesth 2002; 12: 473–7.[Medline]
- Robbins KB, Prentiss JE. Prolonged headache after lumbar puncture successful treatment with an epidural blood patch in a 12-year-old boy. Clin Pediatr (Phila) 1990; 29: 350–2.
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