HEREFORD HOSPITALS NHS TRUSTDepartment of Anaesthesia & Critical Care

Obstetric Anaesthesia and Analgesia Guidelines

GUIDELINES FOR OBSTETRIC EPIDURAL BLOOD PATCH

To be considered if post-dural puncture headache (+/- associated symptoms) severe at 24-48 hours post dural puncture and not improving (accidental dural puncture with Tuohy needle or following deliberate spinal anaesthetic). Usually carried out after 48 hours as reduced success rate if performed earlier. Early blood patch via epidural catheter is not recommended as catheter tip position is unknown, success rate is less and procedure may be unnecessary. We do not perform prophylactic blood patching, as this may be an unnecessary procedure.

DO NOT perform if any possibility of local or systemic infection because of risk of epidural abscess or meningitis.Check temperature and white blood cell count a short time before proposed blood patch.

Decision to perform made only by consultant anaesthetist after full consideration of circumstances.

Full explanation of options to patient including purpose and side effects/complications, e.g. backache, failure, further dural puncture and epidural abscess

Written consent from patient Blood patch performed in room on delivery suite Requires two doctors

- anaesthetist performing blood patch- 2nd doctor to perform venepuncture

Full aseptic conditions for epidural insertion and iv cannula insertion/drawing of blood is vital. Both doctors wearing gown, gloves, mask, hat

Insertion of intravenous cannula in large arm vein for drawing of blood Lumbar epidural performed at convenient space The second doctor then draws 30ml blood through the IV cannula (or by direct

venepuncture) Anaesthetist slowly injects approximately 10-20ml blood through Tuohy

needle, retaining 10ml for blood culture (5ml for each of a pair of blood culture bottles)

Stop epidural injection of blood if mother experiences back or leg pain Place dressing over epidural site Patient to lie flat Send blood culture bottles to Microbiology laboratory Patient is allowed to get up after two hours May go home next day if asymptomatic after anaesthetic review and

discussion with consultant anaesthetist, and advised not to lift heavy objects for one week.

Contact patient next day at home, the following day and at one week to check no recurrence of PDPH symptoms or back/leg/sphincter problems. Record consultations in notes.

Mother must be instructed to contact Maternity Unit/Obstetric anaesthetist immediately if any related problems

Follow-up blood culture results to check no growth. If positive culture, results should be treated with caution and immediate Microbiology consultant advice should be sought. Ask patient to return to hospital immediately for consultation and appropriate treatment.

Note: History of previous epidural blood patch is not a contra-indication to subsequent epidural or spinal block.

Microbiological aspects of these Guidelines agreed with Dr. S. Edmondson, Consultant Microbiologist, Hereford Hospitals NHS Trust.

References:Guidelines for Obstetric Anaesthetic Trainees, Cardiff and Vale NHS Trust.

Birmingham Womens Hospital Guidelines for Obstetric Anaesthesia 2005.

Obstetric Anaesthesia Guidelines, King Edward Memorial Hospital, Perth, Western Australia 2005.Sharpe P. Accidental Dural Puncture in Obstetrics. BJA CEPD News 2001;Vol1, No.3, 81-84.

Dr. Nigel Salmon : 05.04.06Review Date: April 2008