Epidural blood patch

Epidural Blood Patch.

1. CONFIRM CONFIRM CONFIRM   that headache is PDPH and NO NEUROLOGY
2. Religiously rule out other causes of headache
3. Do it after 24 hours
4. contraindication-routine like fever/coagulopathy/infection etc etc
5. Indication: Pt who has  received a 'wet tap' epidural or subarachnoid injection, and who has a headache which  is sufficiently incapacitating ,the characteristics of a PDPH, and not relieved by conservative management (bed rest in the supine position, hydration, caffeine or caffeine-containing drinks, oral simple analgesics, non-steroidal anti-inflammatory agents),
6.Techique
 Explaining the technique, hazards and anticipated success rate
 Informed consent (imp part is possibility of getting bigger hole with Tuohys needle !!!!!!!!!!!!!!!!!)
 Starting an intravenous drip
Position: left lateral, fully-flexed position. Two-operator technique.
Both operators should scrub, gown and glove as is standard in the particular institution.
Operator 1.Cleans and drapes the patient's back using a standard epidural kit and technique, Identifies the site of original puncture(or one below) and locates the epidural space using a standard technique . At the same time as operator 1 is prepping the back, the second operator cleans and drapes the antecubital area of (usually) the left (downside) arm. A second kit and drapes containing a 20cc syringe with 22G sterile straight or butterfly needle is ideal for the task. Once the epidural space is located by operator 1, the second operator, using a rigidly aseptic technique, performs a venepuncture, withdraws 20-25 mls of blood, removes the needle from the syringe, hands the syringe to the first operator (without breaching the integrity of the sterile fields) and applies pressure and a sterile dressing to the venepuncture site.
blood  injection
Inject the blood slowly until either, the patient complains of tightness in the buttocks, lower back or thighs (usually when 12 to 15ml are injected)  or, until 20 ml is injected. Withdraw the needle, apply a sterile dressing and turn the patient to the supine position. Inject the residual blood through a fresh, sterile needle into a blood culture bottle and send to bacteriology for culture and antibiotic sensitivity.
Post procedure= supine for atleast one  hour
Advise to patient
 report fever, back or radicular pain, PDPH
Results : majority of cases, expect almost instantaneous relief  and in few in  24-48 hours  period. Common feeling  of mild backache for a few days. < 2% will also have mild, transient paraesthesiae, neck pain or radicular pain