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Effectiveness of Single Dose Intravenous Aminophylline Administration on Prevention of Post Dural Puncture Headache in Patients Who Received Spinal Anesthesia for Elective Cesarean Section

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Abstract

Post dural puncture headache is a relatively common complication in spinal anesthesia, so several kinds of regimens has been suggested for treatment of this problem. The aim was to determine whether single dose of intravenous aminophylline (1-1.5-mg/kg) can decrease the incidence of this complication in cesarean section or not. So in a double blind randomized study, 120 patients undergoing spinal anesthesia for the elective cesarean section, participated. After cord clamping, 1mg/ kg aminophylline injected intravenously in 60 patient but others didnt receive it. At 1 , 4 , 24 and 48 hours after operation, these 120 patients evaluated ' st th th th for Post dural puncture headache. Data was analyzed statistically by independent T-test and chi-square between two groups. Results showed that the incidence rate of post dural puncture headache is significantly lower than control one (5% vs 23.3%, P<0.001) and severe headache after 48 hours was 3 and 11% respectively. It seems that the incidence of post dural puncture headache decreases in those patients who received single dose intravenous aminophylline after cord clamping. The article can potentially help clinicians to use different combinations of effective drugs for preventing pains instead of curing them. INTRODUCTION fluid administration are among other therapies. For the
World Journal of Medical Sciences 7 (1): 13-16, 2012
ISSN 1817-3055
© IDOSI Publications, 2012
Corresponding Author: Ali Reza Safarpour, MD & MPH, Head of Colorectal Research Center, Shiraz University of Medical
Sciences, Shiraz, Iran. Tel: +989171114597, Fax: +987112336758.
13
Effectiveness of Single Dose Intravenous Aminophylline
Administration on Prevention of Post Dural Puncture Headache
in Patients Who Received Spinal Anesthesia for Elective Cesarean Section
Seyed Ebrahim Sadeghi, Gholamreza Abdollahifard, Narjes Alsadat Nasabi,
Manoosh Mehrabi and Ali Reza Safarpour
Shiraz University of Medical Sciences, Shiraz, Iran
Abstract: Post dural puncture headache is a relatively common complication in spinal anesthesia, so several
kinds of regimens has been suggested for treatment of this problem. The aim was to determine whether single
dose of intravenous aminophylline (1-1.5-mg/kg) can decrease the incidence of this complication in cesarean
section or not. So in a double blind randomized study, 120 patients undergoing spinal anesthesia for the
elective cesarean section, participated. After cord clamping, 1mg/ kg aminophylline injected intravenously in
60 patient but others didnt receive it. At 1 , 4 , 24 and 48 hours after operation, these 120 patients evaluated
' st th th th
for Post dural puncture headache. Data was analyzed statistically by independent T-test and chi- square
between two groups. Results showed that the incidence rate of post dural puncture headache is significantly
lower than control one (5% vs 23.3%, P<0.001) and severe headache after 48 hours was 3 and 11% respectively.
It seems that the incidence of post dural puncture headache decreases in those patients who received single
dose intravenous aminophylline after cord clamping. The article can potentially help clinicians to use different
combinations of effective drugs for preventing pains instead of curing them.
Key words: Spinal Anesthesia % Cesarean Section % Aminophylline % Post Dural Puncture Headache
INTRODUCTION fluid administration are among other therapies. For the
One of the relatively common complications of spinal relieving agents and methylxantines are also effective.
anesthesia is post dural puncture headache that its
incidence has been reported up to 70% [1]. Post dural
puncture headache (PDPH) is a kind of headache that
worsens by standing up and dwindles with recumbency.
methods are used for the headache treatment such as
Methylxantines (e.g caffeine and theophylline). Probably
vascular expansion caused by returning the lost
cerebrospinal fluid (CSF) can be the main cause of the
headache. It seems that Methylxantines’ derivations lead
to vascular contraction and can reduce the headache.
On the other hand, these drugs may decrease the
headache by blocking the purine receptors. Vasopressin,
Sumatriptan and ACTH were used in the treatment of
such headache [2-6]. Continuous injection of pain
relieving agents through spinal catheter and keeping the
catheter for 12-20 hours can decrease the incidence of
PDPH [7-8].One of the preventive methods for reducing
PDPH is to use small gauge needles (#25) or pencil-point
needles. Bed rest, pain relieving agents and intravenous
treatment of mild headaches, reducing activity, pain
Furthermore Methylxantine and Epidural Blood Patch
(EBP) are promising agents for the treatment of PDPH.
Although Epidural Blood Patch is one of the most
effective treatment methods for PDPH [6, 9],
pharmacologic management is less invasive method in
comparison with EBP. Epidural injection of NaCL 0.9% or
dextran is used as an alternative when the EBP is
unsuccessful or contraindicated [10].
This was demonstrated that intravenous tiapride-
which is a dopamine antagonist drug with anti psychosis
activity -can decrease PDPH incidence in comparison with
the placebo group [11].
In the other hand, Theophylline which causes the
contraction in cerebral veins has beneficial effects on
PDPH treatment [12]. The present study was designed to
evaluate the effectiveness of single dose intravenous
aminophylline administration on prevention of Post Dural
Puncture Headache in patients who received spinal
anesthesia for elective cesarean section.
World J. Med. Sci., 7 (1): 13-16, 2012
14
MATERIALS AND METHODS variables in both groups were collected in a questionnaire
In this double-blind randomized study (patient andand chi-square were used for data analysis in the study.
researcher), there were 120 patients undergoing elective
cesarean section as participants. The purpose and designRESULTS
of the trial was explained to all the patients when they
were alert before they gave informed written consent.There were 60 patients in the case group with the age
After performing the spinal anesthesia, the patients wereof 18-36 years, weight 65-110 kg, height 150-170 cm and
randomly divided into two groups with an accidental60 patients in control group with the age of 18-36 years,
allocation. The age range of participants was betweenweight 56-110 kg and height 145-170 cm as the study
18-36 years. The patients who have headache, psychiatric participants. The demographic characteristics of the
problems, back pain, preeclampsia, coagulation disorders, patients are shown in Table 1. In 1 and 4 hours after
convulsion background, spinal anesthesia history andoperation, 1 and 2 cases of headache were reported
those who used any kinds of opiates were excluded fromrespectively which were not statistically significant. The
the study. headache disappeared after few hours. In case group
Needle No.23 used for the spinal anesthesia. Thewhich used intravenous aminophylline, 3 of patients (5%)
selected location for spinal anesthesia was intervertebraldeveloped headache in 24 hours after operation. In
space at L3-L4. Then 2cc Lidocaine 1% used for skincontrol group that was not received aminophylline, 19
anesthesia. After this, a combination of 55 mg lidocaine(31%) patients were reported with the headache which is
5% and 5 mg mepridine were used for spinal anesthesia.statistically significant (P <0.001). The headache incidence
The cesarean section was performed after the fixation ofin the case and control groups was respectively 3 patients
anesthesia in T4 level. After the child birth and umbilical (5%) and 14 patients (23.3%).This was statistically
cord clamping, 1mg/kg aminophylline injectedsignificant (P<0.004). Table 2 shows the headache
intravenously with cardiac monitoring in the patients ofincidence in the case and control group during 24 and 48
the case group. hours after operation.
In case of hypotension in both groups, 5 mg
ephedrine was intravenously utilized. In both groups, theDISSCUSSION
patients rested 24 hours after operation and then started
walking. The patients were asked about having headacheThe results of the study indicated that, although
1, 4 and 24 hours after their exit of the operation room and methyxantines is effective in treatment of PDPH, it may
48 hours after operation. The questioner did not knoweffectively use in prevention and reduction of the
anything about the intervention and just trained toheadache too. Further investigations are needed to
examine the headache existence in the patients. All the generalize the results of this study to different conditions.
and analyzed by SPSS version 17. Independent T- test
Table 1: Frequency of patients in relation to age, height and weight in the control and case group
Group Case Control
-------------------------------------------------------------- --------------------------------------------------------------
Variable Mean Standard deviation Mean Standard deviation
Age (year) 26.11 4.493 26.35 5.33
Height (cm) 164.34 8.210 158.31 8.78
Weight (kg) 75.80 11.940 70.58 13.81
Table 2: Frequency and percentage of headache in 24 and 48 hours after operation in case and control groups
Case Control
------------------------------------------------- ------------------------------------------------
Frequency Percentage Frequency Percentage P
24 h after operation 3 5 19 31.7 <0.001
48 h after operation 3 5 14 23.3 <0.004
World J. Med. Sci., 7 (1): 13-16, 2012
15
CONCLUSION height in case group is 6cm more than control group. Also
There are few researches on the methylxantinesgroup. These background differences may cause changes
effectiveness on Post Dural Puncture Headache (PDPH)into our conclusion. Although the data collection
management. In one study, the effect of theophylline inperformed by a trained nurse that did not know anything
the treatment (not prevention) of PDPH was examinedabout the intervention, the other stages of the study were
(abstract published) [13]. Feuerstein et al. reported theperformed by the doctors who knew the whole project and
positive impact of theophylline on headache reduction.it may cause bias in the study.
Their results showed that from 11 patients with PDPH, the
headache in 6 patients received oral theophylline reduced ACKNOWLEDGEMENT
more in comparison with other 5 patients that was taken
placebo [14]. The authors would like to thank the colleagues of
Another study showed that using 500 mgAnesthesia, Operation Room and Surgery Department of
intravenous caffeine sodium benzoate resulted inShaeed Motahari Hospital, Marvdasht and
improvement of headache to%90 of the patients, on theConsultation Research Center of Shiraz University of
contrary, only %63 of those received placebo got betterMedical Sciences.
[15].
The results gained from other researches on theREFRENCES
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Questionnaire of evaluation of the single dose effect of intravenous aminophylline administration on prevention of PDPH in patients who received spinal
anesthesia for elective cesarean section Hour Day after Operation
Frequency Frequency ---------------------------- -------------------------
No Name Age Weight Height of Pregnancy Needle size of Devour Group 1 4 24 48 4 5 6 7 Other points
st th th th th th th th
... The results of this study showed that aminophylline, a methylxanthine drug that is an active metabolite of theophylline, could decrease the number of patients with PDPH in comparison with the control group among women experiencing elective cesarean sections (6). Along with this finding, Sadeghi et al., in a double-blinded randomized study reported the clinical effectiveness of a single dose of intravenous aminophylline for preventing PDPH in cesarean section (25). ...
... Based on several studies, PDPH can be relieved by bed rest, the prone position, hydration, caffeine, analgesics, and the invasive technique of epidural blood patch (18,26). There is also some research that has investigated the efficacy of therapeutic drugs on relieving PDPH; for example, the effectiveness of methylxanthine derivatives for treating PDPH has been assessed in several studies (25). Ona et al. designed a systematic review to examine the safety and effectiveness of pharmacological drugs administered for the treatment of PDPH; studies until 2014 were evaluated in this systematic review. ...
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Objectives: Post-dural Puncture Headache (PDPH) is prevalent among individuals undergoing lumbar punctures. The non-invasive effect of some drugs, such as aminophylline on PDPH has been investigated in several clinical studies. As there is no comprehensive systematic review and meta-analysis about the preventive and therapeutic effects of aminophylline on PDPH in the literature, the clinical effectiveness of this drug on the prevention and/or treatment of PDPH will be assessed in this study. Methods: PubMed/MEDLINE, Embase, WoS (Clarivate Analytics), the Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL Complete, Scopus, and Google Scholar as electronic databases will be precisely searched for clinical studies that assessed the effect of aminophylline on PDPH. Studies between 01-01-1980 and 30-06-2020 will be evaluated in this study, and there will not be any language restrictions. Contradictions between the reviewers within any phase of the study (screening, selecting, quality assessment, and data extraction) will be resolved by consensus; in case of unsolved disagreements, a third reviewer will eventually decide. The combination method will be applied according to the methodological resemblance in the selected articles using the Random Effect Model or the Fixed Effect Model. Also, for the included articles, forest plots will be drawn. For assessing statistical heterogeneity, the I2 statistic and the Q-statistic test will be applied. In addition, funnel plots will be used for assessing non-significant study effects and potential reporting bias. Furthermore, Egger's and Begg's tests will be done, and publication bias will be indicated by significant findings (P < 0.05). Conclusions: It is expected that the results of this study will be of benefit to researchers and clinicians for managing PDPH, and will be reported in conferences and publications.
... On the contrary, in a study conducted by Sadeghi et al. (24) a single dose of intravenous aminophylline 1 mg/kg significantly decreased the incidence of PDPH in the parturients undergoing elective cesarean section compared to control group. Our study was different because they used meperidine as an adjuvant to the local anesthetic lidocaine which could play a role in decreasing the incidence of PDPH, and the duration of the follow up period was only 48 hours in their study. ...
... [11] Vascular expansion can be the main cause of PDPH. [12] Theophylline, a methylxanthine derivative, can reduce intracranial blood flow and venous enlargement [13] by two mechanisms: first; it interferes with calcium uptake by the sarcoplasmic reticulum, inhibits phosphodiesterase enzymes, and blocks adenosine receptors, which all result in cerebral vasoconstriction, second; it stimulates sodium/potassium pump in the choroid plexus, which increases CSF production. [14] Also, it may decrease the headache by blocking the transmission of pain perception. ...
Article
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Objectives: To compare the safety and efficacy of oral theophylline versus oral sumatriptan in the treatment of post-dural puncture headache (PDPH).Background: PDPH is the most frequent complication of procedures associated with a dural puncture for spinal anaesthesia, cerebrospinal fluid (CSF) sampling, or following inadvertent dural puncture during epidural anaesthesia. Since invasive treatments have known complications, pharmacologic management may be preferable.Patients and Methods: This was a prospective, randomized, double-blind, phase four, comparative clinical trial; carried out on 60 patients presented with PDPH at Damanhour Teaching Hospital, El Beheira, Egypt; between February 2020 and May 2021. Patients were randomly allocated into two equal groups; group T, which received oral theophylline, and group S, which received oral sumatriptan.Results: There were no statistically significant differences between both groups as regards: demographic data, American Society of Anesthesiologists (ASA) physical status, type of operation, type, and size of the spinal needle. PDPH duration and length of hospital stay were significantly shorter in group T than in group S. Numerical pain rating scale (NPRS) scores were significantly lower in group T than in group S. Palpitation, dizziness, gastric irritation, and nausea/vomiting occurred in both groups with no statistically significant differences. No patient in either group needed an epidural blood patch.Conclusion: Oral theophylline is more effective and safer than oral sumatriptan in the treatment of PDPH. It lowered NPRS scores, shortened the duration of PDPH, and length of hospital stay, and was associated with minimal side effects.
... At 1 st , 4 th , 24 th and 48 th hours after operation, these 120 patients evaluated for PDPH. They found that the incidence of PDPH decreases in those patients who received single dose intravenous aminophylline after cord clamping (19). ...
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Background: Post-dural puncture headache (PDPH) is one of the most common complications of lumbar punctures performed for spinal anaesthesia, neurologic investigation or inadvertent Dural puncture during Epidural anaesthesia. Despite acceptance of the postulated cause of CSF leakage and intracranial hypotension, the exact mechanism of developing PDPH is not clear. Many pharmacological options have been advocated as a therapy for PDPH with a varying degree of success, but problem in choosing main drug therapy is the lack of large randomized controlled trials proving efficacy and safety.
... Медикаментозна профiлактика головного болю кофеїном, еуфiлiном, магнiєм, iндо-метацином, згiдно результатiв бiльшостi дослiджень, є марною [2]. Однак анестезiологи iз Шираза (Iран), якi вводили внутрiшньовенно еуфiлiн у дозi 1 мг/кг пiсля перетискання пуповини при планових кесаревих розтинах пiд спiнальною анестезiєю (голки G23), отримали зниження частоти головного болю з 23% до 5%, а тяжкого головного болю -з 11% до 3% [14]. ...
... Медикаментозная профилактика головной боли кофеином, эуфиллином, магнием, индометацином согласно результатам большинства исследований бесполезна [2]. Однако анестезиологи из Шираза (Иран), вводившие внутривенно эуфиллин в дозе 1 мг/кг после пережатия пуповины при плановых кесаревых ÏÐÀÊÒÈÊÓÞ×ÎÌÓ ÍÅÂÐÎËÎÃÓ /TO PRACTICING NEUROLOGIST/ сечениях под спинальной анестезией (иглы G23), отметили снижение частоты головных болей с 23 до 5 %, а тяжелых головных болей -с 11 до 3 % [14]. ...
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Background: This meta-analysis aimed at addressing the impact of aminophylline use on risk and severity of post-dural puncture headache (PDPH). Methods: Electronic databases (i.e., Medline, Embase, and the Cochrane controlled trials register) were searched from inception to the 12th of January 2021 for randomised controlled trials (RCTs) that assessed the efficacy of aminophylline for treatment (i.e., primary outcome) or prophylaxis (i.e., secondary outcome) against PDPH in various clinical settings. The study is registered with PROSPERO (CRD42020207713). Results: A total of ten RCTs (n = 976) were included for analysis. Five studies (n = 270) revealed a lower pain score in patients with PDPH receiving aminophylline than that in the placebo group (standardised mean differences = -1.34, 95% confidence interval (CI): -1.76 to -0.91). In contrast, five trials (four on Caesarean sections and one on lower extremity surgeries, n = 706) demonstrated no prophylactic effect of aminophylline against PDPH at 24 [risk ratio (RR) = 0.70, 95% CI: 0.30-1.63, n = 637], 48 (RR = 0.48, 95% CI: 0.22-1.05, n = 506), and 72 (RR = 0.89, 95% CI: 0.54-1.48, n = 317) hours. Nevertheless, sensitivity analysis demonstrated significant prophylactic efficacy after removal of one study adopting a relatively low dose of aminophylline (RR = 0.36, 95% CI: 0.19-0.67). Most studies reported no increase in the incidence of adverse events associated with aminophylline use compared with that in the control group. Conclusion: Our results indicated that aminophylline might be a reasonable alternative for treating PDPH. However, its use for prevention was not established in this meta-analysis and further large-scale studies are warranted to support this option.
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Objective: To investigate the efficacy and safety of IV aminophylline for patients with postdural puncture headache (PDPH). Methods: We randomly assigned patients to groups receiving either 250 mg IV aminophylline or a placebo within 3 hours of symptom onset once daily for 2 consecutive days. The primary endpoint was headache severity 8 hours after treatment. We assessed this using visual analog scale (VAS) scores taken from patients in a standing position. We also recorded posttreatment VAS score changes, Patient Global Impression of Change (PGIC) scores, and adverse events. We performed an intention-to-treat analysis. Results: We enrolled 126 patients with PDPH at 5 centers in China (62 assigned to the aminophylline group and 64 to the placebo group). The median age was 37 years, and 96 (76.2%) patients were women. Compared to the placebo-treated patients, the aminophylline-treated patients had significantly lower mean VAS scores 8 hours after treatment (5.34 vs 2.98,p< 0.001) and were significantly more likely to report improvements on the PGIC (39.1% vs 72.6%,p< 0.01). This therapeutic effect was already evident at the 30-minute time point and persisted for 2 days. There was no significant difference in the incidence of adverse events (4.8% vs 1.6%,p= 0.589). Conclusions: IV aminophylline is an effective and safe early-stage treatment for patients with PDPH. Clinicaltrialsgov identifier: NCT02522013. Classification of evidence: This study provides Class I evidence that for people with PDPH, IV aminophylline reduces headache severity.
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Background: Post-dural puncture headache (PDPH) is the most common complication of lumbar puncture. Aminophylline has been reported to be effective in the prevention of PDPH in some clinical studies, but its efficacy for the treatment of PDPH has been unproven. Objective: To evaluate the efficacy and safety of an intravenous (IV) injection of aminophylline on PDPH. Study design: The study was a multicenter, open-label study to assess the effectiveness and safety of aminophylline on PDPH. Setting: The First Affiliated Hospital of Zhengzhou University, The Fifth Affiliated Hospital of Zhengzhou University, and Henan Province Hospital of Traditional Chinese Medicine. Methods: Thirty-two PDPH patients received an IV injection of aminophylline. The primary and secondary endpoints were the degree of headache and the patient's overall response to the treatment, respectively. Treatment safety was evaluated based on the occurrence of adverse reactions. Results: Thirty-one patients completed the study. Before the initial aminophylline administration, the visual analog scale (VAS) score was 7.72 ± 1.65. The VAS scores at 30 minutes, one hour, 8 hours, one day, and 2 days post-treatment were 4.84 ± 2.53, 3.53 ± 2.06, 2.38 ± 1.96, 1.44 ± 1.87, and 0.81 ± 1.79, respectively, and were statistically significantly different (P < 0.05) compared with those before treatment. More than 50% (17/32) of the patients reported that they were "very much improved" or "much improved" 30 minutes after the initial treatment, increasing to 93.8% (30/32) at 2 days post-treatment. One patient experienced mild allergic reaction after treatment. Limitations: Although this study had the largest sample size among current studies on treating PDPH with theophylline drugs, the sample size was still relatively small and the method employed was not compared with a placebo or other current clinical treatments for PDPH. Conclusion: An IV injection of aminophylline may be an effective and safe early-stage treatment for PDPH.
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Postdural puncture headache occurs when leakage of CSF through a dural hole lessens the cushioning effect of the brain, allowing it to sag within the intracranial vault. This situation leads to reflex vasodilatation of and traction on pain-sensitive cerebral vascular structures. The resultant postural headache usually occurs 24 to 72 hours after initial dural puncture and will often persist 5 to 7 days without treatment. The use of smaller spinal needles with tips designed to spread dural fibers will dramatically decrease the incidence of PDPH. Relief of PDPH can be achieved with either epidural saline, or more reliably with intravenous caffeine sodium benzoate therapy. The most immediate and efficacious treatment of PDPH is autologous EBP, a simple technique remarkably free of major permanent complications. The role of prophylactic EBP remains controversial.
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This is a review of literature from 1943 to mid-1989 on the postdural puncture headache. The article looks at the currently held thoughts on the cause, prevention, and treatments of this second most frequent side effect of spinal anesthesia. Postdural puncture headache (PDPH) is caused by vascular distension within the nondistensible cranium following the leakage of cerebral spinal fluid (CSF) into the epidural space. Prevention of PDPH can be accomplished by using small-gauge needles and possibly by using the lateral approach, as opposed to the midline approach. Luck plays a big part, because if the needle punctures a thicker portion of the dura, there is a reduced chance of PDPH. Epidural saline injection is effective only if it is used as a continuous infusion for 24 hours. The usefulness of caffeine sodium benzoate with a 70-80% success rate and epidural blood patching with a 90%-plus success rate are discussed.
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Accidental durai puncture during attempted epidural catheterisation, and headache following spinal blockade, have both attracted attention in the past decade, the former because it is a potent cause of morbidity, the latter because the reintroduction of atraumatic needles has led to a resurgence of spinal anaesthesia in obstetrics.
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To discuss the pathogenesis, incidence, and clinical presentation of postdural puncture headaches (PDPHs) and to provide a comprehensive evaluation on the pharmacologic management of PDPH. A MEDLINE search was used to identify pertinent literature published in English including review articles, case reports, letters, and abstracts. Information was also extracted from textbooks for background purposes. All clinical studies, case reports, abstracts, and letters were included because of the limited amount of literature available on the pharmacologic therapy for PDPH. Related research articles and review articles were also used to provide background information on PDPH. Methodology and results from clinical trials and abstracts were described and evaluated. Case reports and letters were summarized and critically reviewed for the feasibility of the different treatment modalities. Information on the pathophysiology, incidence and severity, and clinical presentation of PDPH was extracted from related research articles, review articles, and textbooks. The epidural blood patch (EBP) is one of the most effective treatments for PDPH. Pharmacologic management of PDPH offers a less invasive treatment modality than the EBP. Numerous drug therapies have been presented in the literature, though few merit clinical application. Caffeine therapy, both oral and parenteral, is the most commonly used pharmacologic treatment modality. Theophylline and sumatriptan are potentially promising agents for the treatment of PDPH. Epidural administration of fluids and drugs is also effective in the treatment of PDPH. Epidural adrenocorticotropic hormone and epidural morphine also demonstrate some potential in the treatment of PDPH. Individual patient characteristics (i.e., HIV, sepsis) need to be considered when deciding on a treatment. More reports, especially clinical studies, are necessary before a definitive statement can be made regarding any one treatment. In the meantime, therapy will be guided by clinical judgement based on the literature reviewed in this article. Intravenous and oral caffeine are effective and noninvasive treatments for PDPH. Epidural NaCl 0.9% or dextran are alternatives when the EBP is unsuccessful or contraindicated. Several methods of pharmacologic management have been cited in the literature, but all require further evaluation.
Article
In two patients, one scheduled for epidural anesthesia and the other for placement of a spinal catheter for operative procedures, severe postdural puncture headache developed and was refractory to conservative therapy. The first patient had several unintentional dural punctures, and the second underwent a planned dural puncture with an 18-gauge needle for insertion of a 20-gauge catheter. When neither patient responded to conservative therapy following development of postdural puncture headache, an infusion of adrenocorticotropic hormone (ACTH) was given prior to consideration of epidural blood patching. Both patients obtained complete and permanent relief from their headaches. A single treatment with ACTH may offer an alternative therapy in the treatment of postdural puncture headache.
Article
In this study, we evaluated the efficacy and safety of prophylactic administration of intravenous caffeine sodium benzoate for postdural puncture headaches (PDPH) on patients administered spinal anesthesia. Sixty ASA I and II patients undergoing lower abdominal or lower extremity surgery were included in this study. Patients were randomized by double-blind, placebo-controlled design to receive either 1,000 mL normal saline with 500 mg caffeine sodium benzoate (group C) or 1,000 mL normal saline (group S) during the first 90 minutes after spinal anesthesia administration. The patient's electrocardiogram, non-invasive blood pressure, and pulse oximetry were monitored and recorded. The patients' headaches were evaluated by using the visual analog scale (VAS). At the end of the fifth day, the severity of the headache was classified as follows: no headache = 0; mild headache = 1; moderate headache = 2; severe headache = 3. Analgesic requirements were recorded for 5 days. Visual analog scale scores were significantly lower in group C than in group S. The incidence of moderate and severe headache was significantly higher in group S (11 patients) when compared with group C (3 patients). Analgesic demand was significantly lower in group C than in group S for 4 days. Intravenous caffeine sodium benzoate administration during spinal anesthesia is a simple and safe way to minimize PDPH.