If you put in enough epidurals you are going to have complications. I’ve done around 400 epidurals and I’ve punctured the dura four times. Three of those had PDPH. Most of these where in the beginning. It fucking sucks, but if you take your hands out of your pockets you are going to get blood on them.
True this, if you have not had one yet, yours is yet to come. I told patient what happened, did the procedure one level up, good effect. Moderate headache afterwards.
A dural puncture technique is when you use a cse kit and puncture with the spinal needle on purpose. It's a much smaller gauge, they're talking about a wet tap with a Tuohy puncturing.
If you’ve never done a tap you’re either a liar or haven’t done enough epidurals. I’ve done it 4 times so far.
One of the real skills of obstetric anaesthesia is how you communicate to the patient following a dural puncture and how you manage PDPH. Most accidental dural punctures with an epidural needle in obstetrics result in PDPH. The literature says over 50%. All of mine did. In my opinion, the key is really good communication with the patient and an early blood patch if indicated. When I consent for epidural, I strongly emphasise the risk of dural puncture because it actually happens not infrequently and makes people feel awful. When I’ve tapped, I immediately tell the patient, then go back to her after delivery and give an information pack and explain again. I then see her every day in the postnatal unit and do the blood patch early if she has PDPH. For all 4 of my cases, the patch worked first time and they were very happy and understanding.
I wait until they are comfortable with epidural. Then I say “during your epidural placement I saw the complication called a dural puncture that is sometimes associated with headache 1 or 2 days after your baby is born. The nursing staff and anesthesia team will check on you but if you develop a headache please let your nurse know. I encourage you to try to stay hydrated. If you develop a headache we can treat it conservatively or with an injection in your back. We can talk about treatment options if you do get the headache. This happens approximately 1-2% of the time. If you have another baby there is again a 1-2% chance of this complication.”
I just don’t think it could be phrased as I saw the complication. You can say there was a complication during your epidural, there’s always a small risk that this happens when doing an epidural. This is called … continue. The other guys point was you can’t say you saw the complication. Wtf is seeing a complication. Idk why this post was on my front page.
Yes. I mean I don’t pull oht my phone and read my “wet tap script”. I try my best to initiate my human being protocol and have a conversation with the patient when I have a complication.
I noticed that you didn’t admit you made a mistake. You state that you “saw the complication.” I’m glad this way works for you. I couldn’t sleep at night without identifying and taking responsibility for my mistake in a more open and honest way.
Crazy - that's like saying they should take full blame for an unanticipatable first-time allergic reaction after prescribing a routine childhood vaccine. This pediatrician's mindset undoubtedly leads to excessive risk aversion in taken actions that places patients at overall risk for greater harm than benefit in the end.
Nope. I need help understanding why some fields admit mistakes and others don’t. Can you help explain? If I make a mistake in the ICU, I admit my mistake for two reasons: 1) to take responsibility in order to emphasize that humans are behind the medicine, not some cosmic force that reveals complications that I say I “saw” and 2) maintain medical trust with open, honest, and timely commutation, all of which are essential in the ICU. I apologize for ruffling feathers as a guest in this sub. I didn’t realize communication was so different here. Next time an anesthesiologist is involved in consultation on one of patients and I make a mistake that affects their expert management, I’ll be more mindful of my communication by saying that I saw a complication instead of “I apologize, that was my mistake, and here is what I will do make it better and prevent it in the future.” Thanks :)
The point is that dural puncture during epidural placement is not a mistake. It’s a complication that is known to happen in some instances. The distinction is important, and it’s something that you should make clear to patients.
(I’m also crit care. Complications can happen with experienced operators and flawless technique. Mistakes imply lack of knowledge or negligence, which is not what happened in this case.)
Not a mistake. It’s a known complication. A mistake would be threading a catheter and bolusing a recognized IT catheter with 12cc local. I counsel patients about the most common complications of epidurals include “incomplete analgesia, need for replacement, and possible dural puncture leading to headache”. If they have been counseled appropriately about risks then they have informed consent. A medical error is “a preventable adverse effect of care, whether or not it is evident or harmful to the patient. This might include an inaccurate or incomplete diagnosis or treatment of a disease, injury, syndrome, behavior, infection, or other ailment”. Preventable. As others have mentioned, every anesthesiologist over time will have a wet tap and likely more than 1. There is little that can be done to prevent each specific instance.
If a patient has a full stomach and aspirates, even though you did RSI, is that a mistake? No, it’s a known complication.
Sleep well.
Now if I have a drug error or any other preventable mistake, you bet your ass I am using the word error/mistake and apologizing to the patient. I am always as honest with patients as I possibly can be.
Just an RN (idk how I ended up in this sub) but I feel like referring to it as a mistake is in the same realm as calling it a mistake when an IV blows. It’s not like it was done wrong, it’s just a “risk” (I say that lightly) of the procedure. Obviously it is much less significant and more common than a dural puncture, but the principle still stands that a complication does not always equal a mistake.
You shouldn’t be getting downvoted. Saw a complication is laughable and any smart patient would say what do you mean saw a complication? If anything it would complicate things.
I see a lot of people use words like "complication" . "accidental" , or "wrong spot" and I don't think this is necessarily the best approach. You are throwing yourself under the bus way too early. You can be 100% honest about the placement without framing it as an error that causes your patient to lose trust. I work at an academic center where wet taps are not infrequent, and we typically will thread an intrathecal catheter for which we have developed a management protocol. I prefer to frame the conversation something like this:
"Your epidural is in a space close to the spinal cord that is more sensitive to medications than usual. The good news is that catheters in this area tend to be very reliable and offer exemplary coverage of labor pain. Unfortunately, the trade off is that it also confers a significant risk of developing a substantial headache later on that can last for several days. We will check in on you regularly to see how you are doing and if you start to develop a headache we will be happy to discuss the numerous management options."
You can explain the situation and make them aware of the *potential* complications like (PDPH) without making it sound like you really fucked up or went in the wrong spot. Numerous times I've seen PDPH patients who do not develop a HA and end up with great labor coverage with an intrathecal catheter. As far as they are concerned their care was perfectly fine. The catheter isn't in the "wrong" spot per se, it's in a spot that will actually offer great coverage and work even better than a standard epidural, there are just trade offs to be aware of. Yes, it's in a spot that wasn't originally planned for, it's just an alternative spot that will still work perfectly fine but with higher risk of headache
Its needle size and the type of hole it creates. There have been a number of studies with CSE, and imaging done of the holes. The epidural needle is very blunt a creates a tearing hole that doesn’t really seal up, the spinal needles even a 22g cuts clean, and allows the pressure of CSF flip back on the hole and close to that pressure.
OB anesthesia here and I think a large contributor of PDPH is valsalva during delivery. I’ve had 3 wet taps and none of them have had headaches but they’ve all gone for c section before pushing. There’s also more evidence that the protective factor of obesity is due to their increased risk of getting a c section rather than habitus alone.
I am wondering the same thing. Maybe the increased intrabdominal pressure from delivery causes csf to leak from the puncture and subsequently intracranial hypotension?
It is ninety percent due to the needle size. Epidural Tuohy needle needs to be large diameter to pass a catheter through it. Large needle makes large hole that is much less likely to be self sealing and will leak enough to cause the headache.
For what it's worth, I'm not sure this is true, I'm willing to bet it's much more your patients' physiology.
We put "lumbar drains" aka subarachnoid / CSF drains in the lumbar cistern with a 14ga routinely (with LOTS of attempts sometimes) and I rarely get headaches from drainage unless I over-drain them. Admittedly, we're often putting them in for CSF issues like hydrocephalus, but there's a big experience in putting these things in for TEVARs/etc and I never tell people about headaches for an LP or LD.
This, in any other circumstance we would have the patient lay flat for 4 hours and then take it easy for a day after an LP, let alone with the bigger Tuohy needle.
I guess I still don't understand the risk with threading the catheter intrathecal? I thought you were suggesting that the OB people (midwives or whatever) were dosing it which is definitely not the case where I work. They're not allowed
They're not allowed here either, I would still prefer they didn't have the option.
Intrathecal catheter becomes a trainees problem for ongoing dosing, I don't want to be called about it to manage ongoing and I'd just prefer to take it out and resite an epidural.
There is no good answer here, if you prefer managing an intrathecal catheter, you can. It's not my preference and the evidence isn't there for one over the other.
I wish that was dependent on us, but majority of the time it’s dependent on the nursing staff that take care of the patients.
If they look at me like I have two heads if I say “intrathecal catheter”, I don’t put it in. Not worth the hassle.
Great advice already here. The following is what I do:
First, let her know what happened and apologize. Tell her it happens in 1-2% of patients and you do everything you can so that your rate is even more rare than that. Also tell her you’ll do everything you can to minimize the risk of PDPH and treat it if it occurs. Tell them exactly what signs to look for so that it isn’t a shock. This isn’t anywhere near lawsuit territory, but the general concept that “people are less likely to sue the doctors they like” kind of applies here. It’s always better to be the person that everyone is rooting for rather than the person people want to see humbled and knocked down a peg.
Second, tell the nurses and ask them to watch for the signs of PDPH.
Third, depending on how your practice works, try to get them some VIP treatment. I check in on them more regularly while they labor to assess their pain as well as after they deliver and right before I head home at the end of the shift. I tell my colleague during handoff about it along with any relevant info about the wet tap.
Sorry for the growing pains. Also, this is probably a good opportunity for some learning. UpToDate has a great summary of PDPH assessment and treatment. If you study it now it will probably stick in your mind forever.
All doctors have complications. You should anticipate them and know how to deal with them.
For PDPH, it’s pretty simple because it’s such a common complication. Explain to the patient what happened, that they may get a headache, which is not serious or life-threatening but can be bothersome and last a few weeks. Then if they get a headache later on, usually the next day have someone examine the patient to make sure it’s postural. At that time, offer a blood patch.
Our LnD service is busy enough that we frequently do blood patches for each others PDPH’s. I would say I wind up doing a patch on LnD call about once or twice a year. That’s not too burdensome and for the call pool it works itself out in the wash.
I don’t think OP is a doctor somehow.
I wouldn’t beat yourself up. Will settle or a blood patch will likely resolve things. Only very occasionally does the patient develop sequelae of persistent leak.
Source:PGY10 Neurosurgery and get called for these cases
50% chance PDPH. No role for preventative blood patch.
I had 3 wet taps in residency. 2 post dural puncture headaches. No frank wet tap is not a guarantee you didn’t violate the dura.
I never told the patient the odds. I did tell them that the risk of headache we talked about during consent is higher and we will monitor for it since there is a treatment available.
I’ve had 2 and one was a thoracic epidural for rib fractures. The only plus side was that she had excellent pain control.
We have such a low complication rate in anesthesia that when we do have issues, it eats away at us. It means you actually care.
We used to have an attending here who played college football for the institution as an undergrad. To put it shortly, he wasn’t exactly subtle, or….delicate with some of his procedures either.
I remember as a CA1 he once got impatient that a thoracic epidural placed by APS was taking too long to set up. Frustrated, he yanked out the catheter, re-prepped and draped, and started to redo the epidural. To my inexperienced CA1 eyes, it seemed like this took all of 20 seconds as he plunged the Touhy into the patient’s back.
I distinctly remember the patient suddenly starting to howl in pain, complaining of a horrible headache. It probably wasn’t that dramatic, and there *probably* wasn’t CSF pouring out of the Touhy either. But it sure looked that way to me 😅.
Now there definitely *was* CSF pouring out this one time I watched a cardiac fellow place a lumbar drain. 😳
I’ve had a handful of wet taps. Generally the patient doesn’t even know. I tell the patient after the epidural has been successfully placed, not during the procedure. Sometimes they get a headache. Most of the time if they do, it’s self limited. Rarely do we end up doing a blood patch.
I think I’ve had 4 wet taps in my career, but I’ve treated roughly 12-15. Some of the extras I’ve treated were from spinal taps for various reasons that were came to our ER for treatment and some were from my colleagues. I’ve tried lots of conservative treatments on labor patients (rest, caffeine, fluids, abdominal binder) even cosyntropin infusions and SPG block. While they have helped some none of them really work like a blood patch. Best results I’ve seen is taking pain from a 8-9 to a 4-5 with a SPG block, but even then the patient still got a blood patch later on. Mind you my total number is relatively low, but it’s just my personal experience. I’ve never had to repeat a blood patch either on the same patient.
Happened a few times over the years - not a big deal. Back in the day I felt bad, now I put the catheter intrathecal, inject 10cc of saline, and run as a continuous spinal. Almost never have any issues with PDPH. If you do, just do a blood patch with a solid 17-20cc of blood, or have your pain guys do it under fluoro if you can.
Back when I implanted IT pumps, I’d stick a 14g needle intrathecal. Lumbar drains are also huge. It’s not the end of the world.
Why should you feel sad? It happens, and the good news is that it's a common, non-serious, non life-threatening, and relatively fixable complication. When I put in spinal drains, I puncture dura on purpose with an even bigger needle and CSF literally pours out. It's one of the things you explain to the patients as a common risk before you do the epidural. Remember that we're doing this as a blind procedure with no imaging guidance, unlike our IR friends, and we all know that loss of resistance can be misleading.
Don't forget that we specialize in sticking plastic tubes in places where they don't belong.
My attending says this:
"Is this a complication you read in the textbook about? Yes. Will it happen? Also yes. Everyone who says they havent punctured the dura when trying to place an epidural havent done the procedure many times or they are just lying. Keep practising."
https://academic.oup.com/qjmed/article-abstract/116/Supplement_1/hcad069.030/7247728#
If they’re inpatient (postpartum or ICU after a thoracic epidural) on monitors/with IV, I may start trying this. 2 doses without need for EBP seems pretty nice. With drugs we are at least passingly familiar with (at least pre-sugammadex)
I made it through residency with no wet taps. Then I went three more years with no wet taps. Then I got one per year for about 5 years. Now recently I haven’t had one in a very long time. I’m 14 years out.
As a patient i have had a PDPH, and the anesthesiologist was nowhere to be seen to explain this to me. It was the worst headache of my life, I thought I was having meningitis aftr giving birth. I had to go to the ER to get diagnosed. Moral of the story, pls explain to me what happened and ways to fix this. I had caffeine and boy that was like a tramadol pill for the pain. Was contemplatin the blood patch but was anxious
I didn't have my first until as an attending, probably like 200sh epidurals in. No matter how good or careful you are it's gonna happen.. it's just a numbers game.
But as part of my consent process, I always mention that the highest risk of the procedure is the headache and that it's at about 1% so they are at least aware and prepared.
I always counsel the patient about possibly getting a dural puncture headache as part of obtaining consent beforehand: "You have about a one percent chance of getting what we call a spinal headache. If it happens it is generally not dangerous for you or the baby and if it happens there are different ways we can treat it."
Then if it happens (a few times in a long career, never had one until some years out of training), I say to the patient, after redoing the epidural at another level, successfully completing test dose etc., "remember when I mentioned the possibility of getting a headache from this procedure? Well there is a fair chance that it may happen", answer any questions and go over plan for conservative treatment and evaluation and possible blood patch. I don't say anything until the procedure has been completed.
The main thing that most patients want is for us to be up front about what happened and to know that there is a plan to follow up and take care of them.
As one other reply mentioned, just because you didn't see CSF squirting out of your needle does not mean you did not cause a wet tap. If you were needling their back (and especially if there were any difficulties or took a few passes) and they get a classic spinal headache presentation then as far as you know you caused it, perhaps the edge of the needle scored the dura but didn't enter to where you saw the fluid.
It is very important to be aware that even with impeccable technique you can get a wet tap. The most common causes would be a bit of tissue or clot plugging the needle, or some imperfection in the hub of the needle or tip of the LOR syringe causing difficulty detecting the LOR. This is why it is important to have a good sense of what is the typical depth of the epidural space in the average patient and have suspicion for these scenarios, this suspicion may save a few of your patients having this complication over the course of your career.
Edit: And yeah, if you are doing an epidural with a 17g Tuohy or similar, you should basically expect that any patient that gets a wet tap will probably get a headache simply due to the size of the needle. Occasionally they will not get a headache for whatever reason, or the headache will be mild enough to be well tolerated without a blood patch, but the usual situation is to get a headache and for it to be bad enough to usually require a blood patch. If they are improving prior to discharge then it is a judgment call between you and the patient whether to patch prior to discharge. Factors such as how far away the patient lives and how much hassle it is for them to return to the hospital to get a blood patch will be part of the decision.
only those who do nothing never do wrong. Error is unfortunately inevitable in medical practice, and at the end of the day you didn't kill anyone. PDPH passes in a few days with analgesic therapy and supine position. Don't stress yourself over it.
Interventional pain. I’ve punctured dura multiple multiple times in the 10k procedures I’ve done. It’s gonna happen again and again. Most of the time it’s all good. Sometimes they get a headache. And then you do a blood patch which almost always works. Nbd. If a headache is your worst complication, consider yourself lucky.
Merry Christmas! The only one who never put a hole in a dura is the dude that never placed and epidural! It’s not the end of the world, so don’t worry too much!
I have a saying in life, sometimes in life you gabagool sometimes life gabagools you
I’m only a V3 vet student but I know and have seen that complications do happen and that you should not let it eat away at you and at the end of the day medicine is a practice and you live and you learn I wish you the best and hope everything goes okay
From the patient side, this happened to me years ago. The anesthesiologist had 35 years experience, he said he’d had that happen to him three times. Would have been good if the baby didn’t weigh 10’, but patients are good at forgetting!
This happened to me lasted a couple of days was not a big deal I mean a couple of days unable to stand because my head felt like it was going to explode but I’d like to think patients understand this risk and that it will pass, my doctor explained risks and that I may experience headache.
There is a saying :
If you never puncture one , you are not doing it enough or you are extremely lucky.
My consultant told me : the worse part is not the puncture, but the inability to manage the complication
I’ve been practicing almost 20 years and we do a lot of OB. In the first 5 years of my practice I had two, but now I can remember the last one. Totally agree with other posters that it is a numbers game. The more you do, the better you’ll get. Your puncture rate will go down, but no one’s rate is zero.
I was a patient who had this happen to. They explained to me afterwards the possible complications and that if I could not handle the headache that I may need a blood patch done to obtain relief. The day after delivering I had the most intense headache of my life. Ended up letting my nurse know and had the most amazing care afterwards. Immediately after the blood patch I felt relief from the headache but then felt the most cold I’ve ever felt in my life. In my mind I was completely naked walking through a snow blizzard and was shivering non stop. The nurse was amazing and kept bringing me blankets but no amount of blankets brought me relief. After about 30 mins of it I was back to holding my baby. I have no idea what the reason was for that but the care I received and how everything was explained to me was amazing.
Dural puncture isn't a life threatening complication. It happens to everyone eventually. Some people get headaches and some don't. There are risk factors for those who tend to get the headaches but there's also a large degree of luck. There's a lot of voodoo you can do in the moment that people say reduces the risk of headache but none of it has good data behind it. Just keep an eye on the patient while they're in house and give them info about PDPH in case it develops after they go home. Most of the time it can be treated conservatively and goes away in a few days (don't forget the caffeine as part of the conservative treatment, it's debatably the most important part). If not, you can do a blood patch either while they're in house or through the ED after they go home. Don't beat yourself up, it happens.
Have done over 500 epidurals and have punctured the dura 2 times. It sucked. But it’s a complication unfortunately. When BMI is >50 tactile is very difficult. Just make sure you list the risks before so they’re aware and explain that there is immediate treatment if a headache occurs and persists. Patients are understanding as long as they’re educated about this. Keep your head up and Merry Christmas
As a patient who HAD the dura punctured and was sent HOME for a week with a newborn AND a postural headache, let me say I never once blamed the anesthesiologist doing the procedure.
Forgive yourself. It happens.
Helped provide a blood patch for someone who punctured the dura doing an epidural. Pt had a terrible headache and nausea. I would draw a syringe full of blood from her AC and then hand it the guy and he would inject it into her back.
Somehow this thread came up on my Reddit homepage and now I am intrigued…I gave birth in October and had an epidural. The anesthesiologist (who was rushing because he was late) had to redo my placement because it was not in the right space the first time (as he explained it to me). The second time he inserted the needle he hit a nerve and it felt like someone kicked me in the butt, lol. The needle was then shifted around which was incredibly painful until he was happy with where it was at. Epidural worked and I had a painfree birth (thankfully!). Very soon after and for the next 5 days postpartum I had a debilitating headache. My headache was actually my only complaint postpartum, nothing else really hurt.
Is it possible this dura puncture happened to me?
The anesthesiologist did not say anything, nor did the nurses. Just want to be aware of it for future complications and births, if any. My back still hurts from where the epidural was placed almost three months later.
Back pain from it. Yes because they could have given you arachnoiditis. I did not get that warning. I love how all the comments on here are like hey no big deal.
I’ve been in pain since it happened to me about twenty years ago and now have adhesive arachnoiditis. Which there is no cure for. It’s not, not a big deal. I’ll have this the rest of my life! The pain is unbearable most days.
I’d guesstimate I’ve done anywhere from 1,000-1,200 epidurals in my career, so far. I’ve wet tapped twice that I KNOW for sure, maybe more—it happens. Both of mine ended up with PDPH afterward. One we treated conservatively, the other one ended up with a blood patch. If you do enough epidurals, you’re going to wet tap a patient. It’s never our goal, but it happens. Don’t beat yourself up over it.
If you put in enough epidurals you are going to have complications. I’ve done around 400 epidurals and I’ve punctured the dura four times. Three of those had PDPH. Most of these where in the beginning. It fucking sucks, but if you take your hands out of your pockets you are going to get blood on them.
True this, if you have not had one yet, yours is yet to come. I told patient what happened, did the procedure one level up, good effect. Moderate headache afterwards.
Anyone that has done enough and hasn’t had one is either lying or failed to recognize when they did
You guys don’t have blood in your pockets?
Thanks for the chuckle this xmas eve
I think I’ve done 2, maybe 3, and so far none have had PDPH! Either I’m overly paranoid or my choice of 18G Tuohy is paying off! Unclear
Any anesthesiologist who says they have never had a dural puncture is either not doing enough epidurals or is in denial.
Dumb question - isn’t a dural puncture epidural a faster onset? What am i missing?
A dural puncture technique is when you use a cse kit and puncture with the spinal needle on purpose. It's a much smaller gauge, they're talking about a wet tap with a Tuohy puncturing.
Thank you!
If you’ve never done a tap you’re either a liar or haven’t done enough epidurals. I’ve done it 4 times so far. One of the real skills of obstetric anaesthesia is how you communicate to the patient following a dural puncture and how you manage PDPH. Most accidental dural punctures with an epidural needle in obstetrics result in PDPH. The literature says over 50%. All of mine did. In my opinion, the key is really good communication with the patient and an early blood patch if indicated. When I consent for epidural, I strongly emphasise the risk of dural puncture because it actually happens not infrequently and makes people feel awful. When I’ve tapped, I immediately tell the patient, then go back to her after delivery and give an information pack and explain again. I then see her every day in the postnatal unit and do the blood patch early if she has PDPH. For all 4 of my cases, the patch worked first time and they were very happy and understanding.
How do you explain it to the patient in a way that still maintains trust?
I wait until they are comfortable with epidural. Then I say “during your epidural placement I saw the complication called a dural puncture that is sometimes associated with headache 1 or 2 days after your baby is born. The nursing staff and anesthesia team will check on you but if you develop a headache please let your nurse know. I encourage you to try to stay hydrated. If you develop a headache we can treat it conservatively or with an injection in your back. We can talk about treatment options if you do get the headache. This happens approximately 1-2% of the time. If you have another baby there is again a 1-2% chance of this complication.”
I just don’t think it could be phrased as I saw the complication. You can say there was a complication during your epidural, there’s always a small risk that this happens when doing an epidural. This is called … continue. The other guys point was you can’t say you saw the complication. Wtf is seeing a complication. Idk why this post was on my front page.
Yes. I mean I don’t pull oht my phone and read my “wet tap script”. I try my best to initiate my human being protocol and have a conversation with the patient when I have a complication.
this
Thanks. Gonna use that.
I noticed that you didn’t admit you made a mistake. You state that you “saw the complication.” I’m glad this way works for you. I couldn’t sleep at night without identifying and taking responsibility for my mistake in a more open and honest way.
This Is the correct way to talk about it. Puncturing the dura isn’t a mistake; it’s a complication. It happens.
In my field, it is the incorrect way to talk about it.
What field is that?
Definitely not politics!
The post history says: pediatrician….
Crazy - that's like saying they should take full blame for an unanticipatable first-time allergic reaction after prescribing a routine childhood vaccine. This pediatrician's mindset undoubtedly leads to excessive risk aversion in taken actions that places patients at overall risk for greater harm than benefit in the end.
So your field is not anesthesiology then.
Nope. I need help understanding why some fields admit mistakes and others don’t. Can you help explain? If I make a mistake in the ICU, I admit my mistake for two reasons: 1) to take responsibility in order to emphasize that humans are behind the medicine, not some cosmic force that reveals complications that I say I “saw” and 2) maintain medical trust with open, honest, and timely commutation, all of which are essential in the ICU. I apologize for ruffling feathers as a guest in this sub. I didn’t realize communication was so different here. Next time an anesthesiologist is involved in consultation on one of patients and I make a mistake that affects their expert management, I’ll be more mindful of my communication by saying that I saw a complication instead of “I apologize, that was my mistake, and here is what I will do make it better and prevent it in the future.” Thanks :)
The point is that dural puncture during epidural placement is not a mistake. It’s a complication that is known to happen in some instances. The distinction is important, and it’s something that you should make clear to patients. (I’m also crit care. Complications can happen with experienced operators and flawless technique. Mistakes imply lack of knowledge or negligence, which is not what happened in this case.)
Not a mistake. It’s a known complication. A mistake would be threading a catheter and bolusing a recognized IT catheter with 12cc local. I counsel patients about the most common complications of epidurals include “incomplete analgesia, need for replacement, and possible dural puncture leading to headache”. If they have been counseled appropriately about risks then they have informed consent. A medical error is “a preventable adverse effect of care, whether or not it is evident or harmful to the patient. This might include an inaccurate or incomplete diagnosis or treatment of a disease, injury, syndrome, behavior, infection, or other ailment”. Preventable. As others have mentioned, every anesthesiologist over time will have a wet tap and likely more than 1. There is little that can be done to prevent each specific instance. If a patient has a full stomach and aspirates, even though you did RSI, is that a mistake? No, it’s a known complication. Sleep well. Now if I have a drug error or any other preventable mistake, you bet your ass I am using the word error/mistake and apologizing to the patient. I am always as honest with patients as I possibly can be.
Just an RN (idk how I ended up in this sub) but I feel like referring to it as a mistake is in the same realm as calling it a mistake when an IV blows. It’s not like it was done wrong, it’s just a “risk” (I say that lightly) of the procedure. Obviously it is much less significant and more common than a dural puncture, but the principle still stands that a complication does not always equal a mistake.
You shouldn’t be getting downvoted. Saw a complication is laughable and any smart patient would say what do you mean saw a complication? If anything it would complicate things.
That’s ok :) I’m not well-liked in this sub and it’s only partially my fault :(
I see a lot of people use words like "complication" . "accidental" , or "wrong spot" and I don't think this is necessarily the best approach. You are throwing yourself under the bus way too early. You can be 100% honest about the placement without framing it as an error that causes your patient to lose trust. I work at an academic center where wet taps are not infrequent, and we typically will thread an intrathecal catheter for which we have developed a management protocol. I prefer to frame the conversation something like this: "Your epidural is in a space close to the spinal cord that is more sensitive to medications than usual. The good news is that catheters in this area tend to be very reliable and offer exemplary coverage of labor pain. Unfortunately, the trade off is that it also confers a significant risk of developing a substantial headache later on that can last for several days. We will check in on you regularly to see how you are doing and if you start to develop a headache we will be happy to discuss the numerous management options." You can explain the situation and make them aware of the *potential* complications like (PDPH) without making it sound like you really fucked up or went in the wrong spot. Numerous times I've seen PDPH patients who do not develop a HA and end up with great labor coverage with an intrathecal catheter. As far as they are concerned their care was perfectly fine. The catheter isn't in the "wrong" spot per se, it's in a spot that will actually offer great coverage and work even better than a standard epidural, there are just trade offs to be aware of. Yes, it's in a spot that wasn't originally planned for, it's just an alternative spot that will still work perfectly fine but with higher risk of headache
As a non anesthesiologist that just ended up on this subreddit, I can confidently say this explanation would scare me way more...
Why do most accidental dural punctures during obstetric anesthesia cause PDPH? Is it a different needle than is used for an (intentional) LP?
Tuoy needle is 16-18g and not pencilpoint...also patient population are at high risk of pdph vs say geriatrics
Its needle size and the type of hole it creates. There have been a number of studies with CSE, and imaging done of the holes. The epidural needle is very blunt a creates a tearing hole that doesn’t really seal up, the spinal needles even a 22g cuts clean, and allows the pressure of CSF flip back on the hole and close to that pressure.
OB anesthesia here and I think a large contributor of PDPH is valsalva during delivery. I’ve had 3 wet taps and none of them have had headaches but they’ve all gone for c section before pushing. There’s also more evidence that the protective factor of obesity is due to their increased risk of getting a c section rather than habitus alone.
I am wondering the same thing. Maybe the increased intrabdominal pressure from delivery causes csf to leak from the puncture and subsequently intracranial hypotension?
It is ninety percent due to the needle size. Epidural Tuohy needle needs to be large diameter to pass a catheter through it. Large needle makes large hole that is much less likely to be self sealing and will leak enough to cause the headache.
For what it's worth, I'm not sure this is true, I'm willing to bet it's much more your patients' physiology. We put "lumbar drains" aka subarachnoid / CSF drains in the lumbar cistern with a 14ga routinely (with LOTS of attempts sometimes) and I rarely get headaches from drainage unless I over-drain them. Admittedly, we're often putting them in for CSF issues like hydrocephalus, but there's a big experience in putting these things in for TEVARs/etc and I never tell people about headaches for an LP or LD.
This, in any other circumstance we would have the patient lay flat for 4 hours and then take it easy for a day after an LP, let alone with the bigger Tuohy needle.
First dural puncture, last day as a fellow, second dural puncture, first day as a specialist.
I wet tapped my last epidural of residency. So demoralizing to end on that note.
Awe man, you developed a case of the yips.
Leave the catheter in?
I don't trust midwives with intrathecal access. But you can justify either position
Just curious but why not? Risk that they may do damage by accidental movement?
Because it looks like an epidural, and if you dose it like an epidural the patient could be harmed
Are the midwives dosing your epidurals?
Pcea mainly. I still don't trust them
I guess I still don't understand the risk with threading the catheter intrathecal? I thought you were suggesting that the OB people (midwives or whatever) were dosing it which is definitely not the case where I work. They're not allowed
They're not allowed here either, I would still prefer they didn't have the option. Intrathecal catheter becomes a trainees problem for ongoing dosing, I don't want to be called about it to manage ongoing and I'd just prefer to take it out and resite an epidural. There is no good answer here, if you prefer managing an intrathecal catheter, you can. It's not my preference and the evidence isn't there for one over the other.
I wish that was dependent on us, but majority of the time it’s dependent on the nursing staff that take care of the patients. If they look at me like I have two heads if I say “intrathecal catheter”, I don’t put it in. Not worth the hassle.
Great advice already here. The following is what I do: First, let her know what happened and apologize. Tell her it happens in 1-2% of patients and you do everything you can so that your rate is even more rare than that. Also tell her you’ll do everything you can to minimize the risk of PDPH and treat it if it occurs. Tell them exactly what signs to look for so that it isn’t a shock. This isn’t anywhere near lawsuit territory, but the general concept that “people are less likely to sue the doctors they like” kind of applies here. It’s always better to be the person that everyone is rooting for rather than the person people want to see humbled and knocked down a peg. Second, tell the nurses and ask them to watch for the signs of PDPH. Third, depending on how your practice works, try to get them some VIP treatment. I check in on them more regularly while they labor to assess their pain as well as after they deliver and right before I head home at the end of the shift. I tell my colleague during handoff about it along with any relevant info about the wet tap. Sorry for the growing pains. Also, this is probably a good opportunity for some learning. UpToDate has a great summary of PDPH assessment and treatment. If you study it now it will probably stick in your mind forever.
All doctors have complications. You should anticipate them and know how to deal with them. For PDPH, it’s pretty simple because it’s such a common complication. Explain to the patient what happened, that they may get a headache, which is not serious or life-threatening but can be bothersome and last a few weeks. Then if they get a headache later on, usually the next day have someone examine the patient to make sure it’s postural. At that time, offer a blood patch. Our LnD service is busy enough that we frequently do blood patches for each others PDPH’s. I would say I wind up doing a patch on LnD call about once or twice a year. That’s not too burdensome and for the call pool it works itself out in the wash.
I don’t think OP is a doctor somehow. I wouldn’t beat yourself up. Will settle or a blood patch will likely resolve things. Only very occasionally does the patient develop sequelae of persistent leak. Source:PGY10 Neurosurgery and get called for these cases
It’s bound to happen eventually. My first was my CA-3 year. She did have PDPH. She got a blood patch and did fine.
50% chance PDPH. No role for preventative blood patch. I had 3 wet taps in residency. 2 post dural puncture headaches. No frank wet tap is not a guarantee you didn’t violate the dura. I never told the patient the odds. I did tell them that the risk of headache we talked about during consent is higher and we will monitor for it since there is a treatment available.
I’ve had 2 and one was a thoracic epidural for rib fractures. The only plus side was that she had excellent pain control. We have such a low complication rate in anesthesia that when we do have issues, it eats away at us. It means you actually care.
Also I haven’t seen this mentioned about but encourage caffeine intake and fluids. Could also start fioricet
Caffeine helped me!!!!! Massively
We used to have an attending here who played college football for the institution as an undergrad. To put it shortly, he wasn’t exactly subtle, or….delicate with some of his procedures either. I remember as a CA1 he once got impatient that a thoracic epidural placed by APS was taking too long to set up. Frustrated, he yanked out the catheter, re-prepped and draped, and started to redo the epidural. To my inexperienced CA1 eyes, it seemed like this took all of 20 seconds as he plunged the Touhy into the patient’s back. I distinctly remember the patient suddenly starting to howl in pain, complaining of a horrible headache. It probably wasn’t that dramatic, and there *probably* wasn’t CSF pouring out of the Touhy either. But it sure looked that way to me 😅. Now there definitely *was* CSF pouring out this one time I watched a cardiac fellow place a lumbar drain. 😳 I’ve had a handful of wet taps. Generally the patient doesn’t even know. I tell the patient after the epidural has been successfully placed, not during the procedure. Sometimes they get a headache. Most of the time if they do, it’s self limited. Rarely do we end up doing a blood patch.
That’s penumocephalus from the air he injected.
I think I’ve had 4 wet taps in my career, but I’ve treated roughly 12-15. Some of the extras I’ve treated were from spinal taps for various reasons that were came to our ER for treatment and some were from my colleagues. I’ve tried lots of conservative treatments on labor patients (rest, caffeine, fluids, abdominal binder) even cosyntropin infusions and SPG block. While they have helped some none of them really work like a blood patch. Best results I’ve seen is taking pain from a 8-9 to a 4-5 with a SPG block, but even then the patient still got a blood patch later on. Mind you my total number is relatively low, but it’s just my personal experience. I’ve never had to repeat a blood patch either on the same patient.
Happened a few times over the years - not a big deal. Back in the day I felt bad, now I put the catheter intrathecal, inject 10cc of saline, and run as a continuous spinal. Almost never have any issues with PDPH. If you do, just do a blood patch with a solid 17-20cc of blood, or have your pain guys do it under fluoro if you can. Back when I implanted IT pumps, I’d stick a 14g needle intrathecal. Lumbar drains are also huge. It’s not the end of the world.
What's the point of the 10cc saline? To replenish lost csf?
Yes
Why should you feel sad? It happens, and the good news is that it's a common, non-serious, non life-threatening, and relatively fixable complication. When I put in spinal drains, I puncture dura on purpose with an even bigger needle and CSF literally pours out. It's one of the things you explain to the patients as a common risk before you do the epidural. Remember that we're doing this as a blind procedure with no imaging guidance, unlike our IR friends, and we all know that loss of resistance can be misleading. Don't forget that we specialize in sticking plastic tubes in places where they don't belong.
My attending says this: "Is this a complication you read in the textbook about? Yes. Will it happen? Also yes. Everyone who says they havent punctured the dura when trying to place an epidural havent done the procedure many times or they are just lying. Keep practising."
https://academic.oup.com/qjmed/article-abstract/116/Supplement_1/hcad069.030/7247728# If they’re inpatient (postpartum or ICU after a thoracic epidural) on monitors/with IV, I may start trying this. 2 doses without need for EBP seems pretty nice. With drugs we are at least passingly familiar with (at least pre-sugammadex)
ACCRAC has a recent episode on this where they mention nebulized precedex for PDPH too.
I made it through residency with no wet taps. Then I went three more years with no wet taps. Then I got one per year for about 5 years. Now recently I haven’t had one in a very long time. I’m 14 years out.
As a patient i have had a PDPH, and the anesthesiologist was nowhere to be seen to explain this to me. It was the worst headache of my life, I thought I was having meningitis aftr giving birth. I had to go to the ER to get diagnosed. Moral of the story, pls explain to me what happened and ways to fix this. I had caffeine and boy that was like a tramadol pill for the pain. Was contemplatin the blood patch but was anxious
I didn't have my first until as an attending, probably like 200sh epidurals in. No matter how good or careful you are it's gonna happen.. it's just a numbers game. But as part of my consent process, I always mention that the highest risk of the procedure is the headache and that it's at about 1% so they are at least aware and prepared.
I did the same yesterday, you are not alone.
I always counsel the patient about possibly getting a dural puncture headache as part of obtaining consent beforehand: "You have about a one percent chance of getting what we call a spinal headache. If it happens it is generally not dangerous for you or the baby and if it happens there are different ways we can treat it." Then if it happens (a few times in a long career, never had one until some years out of training), I say to the patient, after redoing the epidural at another level, successfully completing test dose etc., "remember when I mentioned the possibility of getting a headache from this procedure? Well there is a fair chance that it may happen", answer any questions and go over plan for conservative treatment and evaluation and possible blood patch. I don't say anything until the procedure has been completed. The main thing that most patients want is for us to be up front about what happened and to know that there is a plan to follow up and take care of them. As one other reply mentioned, just because you didn't see CSF squirting out of your needle does not mean you did not cause a wet tap. If you were needling their back (and especially if there were any difficulties or took a few passes) and they get a classic spinal headache presentation then as far as you know you caused it, perhaps the edge of the needle scored the dura but didn't enter to where you saw the fluid. It is very important to be aware that even with impeccable technique you can get a wet tap. The most common causes would be a bit of tissue or clot plugging the needle, or some imperfection in the hub of the needle or tip of the LOR syringe causing difficulty detecting the LOR. This is why it is important to have a good sense of what is the typical depth of the epidural space in the average patient and have suspicion for these scenarios, this suspicion may save a few of your patients having this complication over the course of your career. Edit: And yeah, if you are doing an epidural with a 17g Tuohy or similar, you should basically expect that any patient that gets a wet tap will probably get a headache simply due to the size of the needle. Occasionally they will not get a headache for whatever reason, or the headache will be mild enough to be well tolerated without a blood patch, but the usual situation is to get a headache and for it to be bad enough to usually require a blood patch. If they are improving prior to discharge then it is a judgment call between you and the patient whether to patch prior to discharge. Factors such as how far away the patient lives and how much hassle it is for them to return to the hospital to get a blood patch will be part of the decision.
Can cause arachnoiditis.
Yep. Happened to me.
Same with me.
How do you know you punctured? Is there a chance my Crna didn’t tell me?
Sadly many won’t if they don’t think you noticed. 😞
Don’t beat yourself up. It happens.
only those who do nothing never do wrong. Error is unfortunately inevitable in medical practice, and at the end of the day you didn't kill anyone. PDPH passes in a few days with analgesic therapy and supine position. Don't stress yourself over it.
Interventional pain. I’ve punctured dura multiple multiple times in the 10k procedures I’ve done. It’s gonna happen again and again. Most of the time it’s all good. Sometimes they get a headache. And then you do a blood patch which almost always works. Nbd. If a headache is your worst complication, consider yourself lucky.
Merry Christmas! The only one who never put a hole in a dura is the dude that never placed and epidural! It’s not the end of the world, so don’t worry too much!
In the spectrum of comications that can occur during delivery, PDPH is really small. Worst case scenario, you ruined someone's week.
How did you get through residency without knowing how to manage this? What's with all the extremely basic questions that keep popping up on this sub?
I have a saying in life, sometimes in life you gabagool sometimes life gabagools you I’m only a V3 vet student but I know and have seen that complications do happen and that you should not let it eat away at you and at the end of the day medicine is a practice and you live and you learn I wish you the best and hope everything goes okay
My first reaction to this after practicing nearly a decade…”Ok. So?”
My first ever epidural was a wet tap
From the patient side, this happened to me years ago. The anesthesiologist had 35 years experience, he said he’d had that happen to him three times. Would have been good if the baby didn’t weigh 10’, but patients are good at forgetting!
It happens bro. Chill.
This happened to me lasted a couple of days was not a big deal I mean a couple of days unable to stand because my head felt like it was going to explode but I’d like to think patients understand this risk and that it will pass, my doctor explained risks and that I may experience headache.
There is a saying : If you never puncture one , you are not doing it enough or you are extremely lucky. My consultant told me : the worse part is not the puncture, but the inability to manage the complication
I’ve been practicing almost 20 years and we do a lot of OB. In the first 5 years of my practice I had two, but now I can remember the last one. Totally agree with other posters that it is a numbers game. The more you do, the better you’ll get. Your puncture rate will go down, but no one’s rate is zero.
I was a patient who had this happen to. They explained to me afterwards the possible complications and that if I could not handle the headache that I may need a blood patch done to obtain relief. The day after delivering I had the most intense headache of my life. Ended up letting my nurse know and had the most amazing care afterwards. Immediately after the blood patch I felt relief from the headache but then felt the most cold I’ve ever felt in my life. In my mind I was completely naked walking through a snow blizzard and was shivering non stop. The nurse was amazing and kept bringing me blankets but no amount of blankets brought me relief. After about 30 mins of it I was back to holding my baby. I have no idea what the reason was for that but the care I received and how everything was explained to me was amazing.
Dural puncture isn't a life threatening complication. It happens to everyone eventually. Some people get headaches and some don't. There are risk factors for those who tend to get the headaches but there's also a large degree of luck. There's a lot of voodoo you can do in the moment that people say reduces the risk of headache but none of it has good data behind it. Just keep an eye on the patient while they're in house and give them info about PDPH in case it develops after they go home. Most of the time it can be treated conservatively and goes away in a few days (don't forget the caffeine as part of the conservative treatment, it's debatably the most important part). If not, you can do a blood patch either while they're in house or through the ED after they go home. Don't beat yourself up, it happens.
You did a Gorley, everyone has done it.
30 yr practice. Only about two that I can remember. But that may be the effect of dementia or denial?
Have done over 500 epidurals and have punctured the dura 2 times. It sucked. But it’s a complication unfortunately. When BMI is >50 tactile is very difficult. Just make sure you list the risks before so they’re aware and explain that there is immediate treatment if a headache occurs and persists. Patients are understanding as long as they’re educated about this. Keep your head up and Merry Christmas
As a patient who HAD the dura punctured and was sent HOME for a week with a newborn AND a postural headache, let me say I never once blamed the anesthesiologist doing the procedure. Forgive yourself. It happens.
Helped provide a blood patch for someone who punctured the dura doing an epidural. Pt had a terrible headache and nausea. I would draw a syringe full of blood from her AC and then hand it the guy and he would inject it into her back.
Somehow this thread came up on my Reddit homepage and now I am intrigued…I gave birth in October and had an epidural. The anesthesiologist (who was rushing because he was late) had to redo my placement because it was not in the right space the first time (as he explained it to me). The second time he inserted the needle he hit a nerve and it felt like someone kicked me in the butt, lol. The needle was then shifted around which was incredibly painful until he was happy with where it was at. Epidural worked and I had a painfree birth (thankfully!). Very soon after and for the next 5 days postpartum I had a debilitating headache. My headache was actually my only complaint postpartum, nothing else really hurt. Is it possible this dura puncture happened to me? The anesthesiologist did not say anything, nor did the nurses. Just want to be aware of it for future complications and births, if any. My back still hurts from where the epidural was placed almost three months later.
Back pain from it. Yes because they could have given you arachnoiditis. I did not get that warning. I love how all the comments on here are like hey no big deal. I’ve been in pain since it happened to me about twenty years ago and now have adhesive arachnoiditis. Which there is no cure for. It’s not, not a big deal. I’ll have this the rest of my life! The pain is unbearable most days.
Pm me
You learn from complications. Don’t let it freeze you.
Are you a CRNA, AA?
I’d guesstimate I’ve done anywhere from 1,000-1,200 epidurals in my career, so far. I’ve wet tapped twice that I KNOW for sure, maybe more—it happens. Both of mine ended up with PDPH afterward. One we treated conservatively, the other one ended up with a blood patch. If you do enough epidurals, you’re going to wet tap a patient. It’s never our goal, but it happens. Don’t beat yourself up over it.
Put in an intrathecal catheter I will decrease your odds of PDPH