BLOODY EPIDURAL & DURAL TAP

Describe the management of an epidural catheter aspirating fresh blood shortly after placement

Bleeding via Tuohy needle – abandon the attempt and try a different space (preferably above).

Bleeding via catheter:

• Slight – withdraw the catheter by 1–2cm (not through a needle), flush with 10mL of sterile isotonic saline and wait 2–3 minutes. 
• If no further bleeding on aspiration, proceed with an epidural.
• Use test dose. Frank – withdraw the catheter and attempt a different space (preferably above)

Describe the management of accidental dural puncture in obstetrics

Diagnosis

There is leakage of cerebrospinal fluid (CSF) through a Tuohy needle or catheter. The incidence of accidental dural puncture varies from 0.2% to 4%. The most common adverse event reported after an accidental dural puncture is post-dural puncture headache (PDPH), with a reported incidence of 60–90%.

Puncture of the dura with a Tuohy needle usually results in the obvious flow of CSF through the needle. CSF tests positive for glucose on a reagent strip.

Actions

1. Withdraw the Tuohy needle.
2. Insert an epidural catheter using a different space (preferably above). Observe effects of test dose of local anaesthetic very carefully.
3. In obstetric cases, further labour needs careful management with discussion between the anaesthetist, patient, midwife and obstetrician. Prolonged pushing should be avoided, but instrumental delivery is not always inevitable.
4. At the end of the procedure leave the epidural catheter (with Millipore filter) in situ. The administration of fluid into the epidural space acts as an obstructive pressure gradient against the leakage of CSF from the subarachnoid space. Fluid can be administered as intermittent bolus doses or continuous infusion. Prophylactic administration of 60mL of preservative-free saline has been shown to reduce the severity of headaches associated with accidental dural puncture. Pain on injection of the bolus should be taken as an immediate indication to stop, as it may indicate high pressure around the nerve roots. The second method of administering saline is under gravity feed into the epidural space. Infusions of volumes greater than one litre have not been shown to improve outcomes compared to larger volumes.
5. The patient should lie flat for 24 hours.
6. Ensure high fluid intake – IV or oral (4 litres per 24 hours).
7. Follow up with the patient.
8. Consider an autologous blood patch if symptoms persist beyond 2–3 days. Blood administered into the epidural space forms a clot over the defect in the dural membrane so preventing further leakage. Inject 5–20mL of blood slowly over 2–3 minutes via the Tuohy needle or epidural catheter, into the epidural space. The patient should lie still for several hours after the procedure and avoid excessive straining or heavy lifting in the following week. This reduces the risk of the patch being forced off the dura. History of previous epidural blood patches is not a contraindication to the subsequent central neurological blockade.

Immediate blood patch is not recommended.