부산대학교 도서관

Post-dural puncture headaches ( PDPHs) present an important clinical problem. We assessed methods to decrease accidental dural punctures ( ADPs) and interventions to reduce PDPH following ADP. Multiple electronic databases were searched for randomised clinical trials ( RCTs) of parturients having labour epidurals, in which the studied intervention could plausibly affect ADP or PDPH, and the incidence of at least one of these was recorded. Forty RCTs ( n = 11,536 epidural insertions) were included, studying combined spinal-epidurals ( CSEs), loss of resistance medium, prophylactic epidural blood patches, needle bevel orientation, ultrasound-guided insertion, epidural morphine, Special Sprotte needles, acoustic-guided insertion, administration of cosyntropin, and continuous spinal analgesia. The RCTs for CSE, loss of resistance medium, and prophylactic epidural blood patches were meta-analysed. Five methods reduced PDPH: prophylactic epidural blood patch {four trials, median quality score = 2, risk difference = −0.48 [95% confidence interval ( CI): −0.88 to −0.086]}, lateral positioning of the epidural needle bevel upon insertion (one trial, quality score = 1), Special Sprotte needles [one trial, quality score = 5, risk difference = −0.44 (95% CI: −0.67 to −0.21)], epidural morphine [one trial, quality score = 4, risk difference = −0.36 (95% CI −0.59 to −0.13)], and cosyntropin [one trial, quality score = 5, risk difference = −0.36 (95% CI −0.55 to −0.16)]. Several methods potentially reduce PDPH. Special Sprotte needles, epidural morphine, and cosyntropin are thus far each supported by a single, albeit good quality trial. Prophylactic blood patches are supported by three trials, but these had flawed methodology. Mostly, trials were of limited quality, and further well-conducted, large studies are needed. [ABSTRACT FROM AUTHOR]