Chronic headaches related to post-dural puncture headaches: a scoping review.

Post-dural puncture headache (PDPH) is a well-recognised complication of neuraxial procedures. Although it is generally considered to be self-limiting, there is mounting evidence suggesting an association between PDPH and chronic headaches. In this review, chronic headache after dural puncture was defined as the reporting of persistent headaches more than 1 month after the index dural puncture. This scoping review aims to: (1) review the relationship between PDPH and chronic headaches, (2) explore the pathophysiology of chronic headache arising from a dural puncture, and (3) make recommendations about the follow-up and treatment of these patients. The pooled relative risk of chronic headache from 15 863 patients reported in 12 cohort studies in patients with an accidental dural puncture compared with those without accidental dural puncture were 1.9 (95% confidence interval [CI], 1.2-2.9), 2.5 (95% CI, 2.0-3.2), and 3.6 (95% CI, 1.9-7.1) at 2, 6, and 12 months, respectively. We also identified 20 case reports of 49 patients who developed chronic headache after a dural puncture. Epidural blood patch and fibrin glue injection and surgery have been used to treat chronic postural headaches. Overall, the level of evidence is low for all reported outcomes (aetiology, intervention and outcome) by virtue of the type of studies available (cohort and case reports) and significant risk of bias in the cohort studies. Based on findings from this review, we recommend that the risk of chronic headache is included in the informed consent discussion for all neuraxial procedures. Patients with PDPH should be closely followed up after hospital discharge.

Evaluation of timings and outcomes in category-one caesarean sections: A retrospective cohort study.

BACKGROUND AND AIMS: A decision-to-delivery interval (DDI) of 30 min for category-one caesarean section (CS) deliveries is the standard of practice recommended by clinical guidelines. Our institution established a protocol for category-one ('crash') CS to expedite deliveries. The aim of this study is to evaluate DDI, factors that affect DDI and the mode of anaesthesia for category-one CS. METHODS: This retrospective cohort study evaluated 390 women who underwent category-one CS in a tertiary obstetric centre. We analysed the factors associated with DDI, mode of anaesthesia and perinatal outcomes. Summary statistics were performed for the outcomes. The association factors were considered significant at P < 0.05. RESULTS: The mean (standard deviation) DDI was 9.4 (3.2) min with all deliveries achieved within 30 min. The longest factor in the DDI was time taken to transfer patients. A shorter DDI was not significantly associated with improved perinatal outcomes. The majority (88.9%) of women had general anaesthesia (GA) for category-one CS. Of those who had an epidural catheter already in situ (34.4%), 25.6% had successful epidural extension. GA was associated with shorter DDI, but worse perinatal outcomes than regional anaesthesia (RA). CONCLUSIONS: Our 'crash' CS protocol achieved 100% of deliveries within 30 min. The majority (88.9%) of the patients had GA for category-one CS. GA was found to be associated with shorter anaesthesia and operation times, but poorer perinatal outcomes compared to RA.

Incidence and characteristics of breakthrough pain in parturients using computer-integrated patient-controlled epidural analgesia.

INTRODUCTION: The computer-integrated patient-controlled epidural analgesia (CIPCEA) system can automatically adjust the background infusion rate during combined spinal-epidural analgesia based on the parturient's need, as labor progresses. OBJECTIVES: The objective is to identify risk factors associated with breakthrough pain during labor as well as identify obstetric and fetal outcomes that are affected by breakthrough pain. DESIGN: This is a retrospective review of prospectively collected data. SETTING: The setting is in a delivery room. PARTICIPANTS: The participants are 280 nulliparous women in early labor (≤5 cm cervical dilatation) who received combined spinal-epidural analgesia with CIPCEA. INTERVENTIONS: The intervention is CIPCEA. MEASUREMENTS: The primary outcome is the incidence of breakthrough pain (≥1 episodes of pain or pressure that required supplemental epidural medications) during labor. Relevant demographic, anesthetic, obstetric, and fetal characteristics were also measured. Univariate and multivariate analyses were performed to identify obstetric and anesthetic factors that were associated with increased incidence of breakthrough pain as well as to evaluate the impact of breakthrough pain on obstetric and fetal outcomes. RESULTS: The incidence of breakthrough pain was 9.6%. Independent factors associated with incidence of breakthrough pain are the presence of dysfunctional labor, increased maternal body mass index, and decreased successful-to-total-bolus-demand ratio. The postlabor characteristics independently associated with breakthrough pain were increased duration of labor, decreased duration of effective analgesia, increased total local anesthetic consumption, and decreased maternal satisfaction. CONCLUSIONS: Low successful to total patient demand bolus ratio was the factor with the strongest association with breakthrough pain. Breakthrough pain was also associated with dysfunctional labor and poorer maternal satisfaction.