Accidental Dural Puncture

Accidental Dural Puncture There is an approximately 80% risk of a headache developing following an accidental dural puncture. There are two alternative management strategies:

1. Re-insertion of Epidural Catheter at Another Interspace The epidural should be resited in an adjacent interspace. Caution must be exercised when the first dose of local anaesthetic is given through the catheter as there is a significant risk of intrathecal diffusion via the dural puncture site. If a normal response is obtained following this dose the epidural should then be conducted as per normal.
2. Deliberate Insertion of the Catheter into the Subarachnoid Space Evidence for a reduced incidence of headache following this technique is equivocal. Furthermore use of intrathecal catheters is associated with a higher rate of failed analgesia. The needle tip is left in the subarachnoid space and the catheter inserted 2 cm only. The catheter must be clearly marked as being in the subarachnoid space. Care should be taken to avoid excessive loss of CSF volume.

If this procedure is used the following guide should be applied:

• The consultant on call must be contacted so that the procedure can be discussed in advance
• Inform the attending midwife, midwife in charge of delivery suite, and obstetrician
• The intravenous infusion should be running well and ephedrine (or phenylephrine) and atropine should be immediately available
• An appropriate allowance for the dead space of a Portex 16G catheter & filter is 1.0 mL
• With the patient in the lateral or supine tilted position, give 1 mL of 0.125% plain levo-bupivacaine, followed by 0.5 mL increments of 0.125% or 0.25% levo-bupivacaine (or 0.1% levo-bupivacaine with fentanyl 2 µg/mL) until satisfactory analgesia is achieved.
• Boluses should not be flushed through the catheter and filter with saline. Each time a top-up is administered careful consideration should be given to the 1 mL of local anaesthetic that is already in the catheter and filter system.
• The anaesthetist must give all top-ups
• It is important to appreciate that plain (i.e. non-heavy) levo-bupivacaine is slightly hypobaric and that sudden movement of the patient may cause displacement of the local anaesthetic in the CSF. Sitting up may result in high blocks.
• For caesarean section, manual removal of placenta and rotational forceps delivery, with the patient in lateral or tilted supine position, 0.5 to 1 mL increments of 0.5% heavy bupivacaine are given, as judged by the level of the existing block, until adequate anaesthesia is achieved. (Usual total dose 3 mL; maximum recommended dose 4 mL as pooling can occur in the sacral curve if the catheter is pointing caudally).
• For outlet forceps delivery, with the patient in the sitting position, use 0.5% heavy bupivacaine 1 to 2 mL to achieve perineal anaesthesia
• Obstetric management: there is no convincing evidence to suggest that a forceps delivery will reduce the incidence of post dural puncture headache

Supporting Evidence/References 

 Jagannathan, D.K., Arriaga, A.F., Elterman, K.G. et al. 2016. Effect of neuraxial technique after inadvertent dural puncture on obstetric outcomes and anesthetic complications. International Journal of Obstetric Anesthesia, 25: 23-29