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Case Reports Epidural Gelatin (Gelfoam®) Patch Treatment for Post Dural Puncture Headache s. P. AMBESH,t A. KUMAR* AND A. BAJAJ* Department of Anaesthesiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India Key Words: ANAESTHESIA, ANALGESIA: obstetric, epidural; COMPLICATIONS: dural puncture, lumbar puncture, headache; TREATMENT: epidural gelatin patch

Epidural gelatin patch in autologous plasma was used to treat post dural puncture headache after two cases of inadvertent dural puncture. Ten millilitres of gel was used, the patients obtaining complete relief of their headache forty minutes after the patch. No untoward effect such as neck stiffness, backache or rise in body temperature was observed. The gelatin patch was found to be a safe and effective method in treating severe post dural puncture headache. However, much more needs to be known about the use of Gelfoam® in this situation, especially in regard to its effectiveness and recurrence rates of post dural puncture headache in a larger series. The incidence of inadvertent dural puncture during epidural block has been reported by various authors as 2.9,1 1.72 and 0.6 3 per cent and subsequent post dural puncture headache (PDPH) as 76.5 per cent.4 The accepted cause ofPDPH is continuous leakage of cerebrospinal fluid (CSF).5 PDPH following inadvertent dural puncture during epidural block can be prolonged, refractory and incapacitating, causing a financial, physical and psychological burden to the patient and a source of worry to the anaesthesiologist and obstetrician. Several prophylactic and therapeutic regimens have been recommended following accidental puncture, and it is apparent that a wide range of practice exists from a conservative expectant approach to more vigorous management. Initially, attempts to plug the dural rent with pieces of catgut °M.D., Registrar. tM.D., Registrar. tM.D., Assistant Professor. Address for Reprints: Dr. Ani! Bajaj, Assistant Professor, Department of Anaesthesio1ogy, Post Graduate Institute of Medical Education and Research, Chandigarh - 1600 12, India. Accepted for publication March 14, 1991

to prevent CSF leakage were made by Nelson 6 however, the procedure was difficult and caused serious neurological complications. In 1960, Gormley7 reported that the epidural injection of autologous blood at the site of dural puncture relieved PDPH by sealing the dural opening. Since that time this therapy has been widely employed and has been reviewed by Brownridge2 and Okell and Sprigge. 3 In our two case reports, sterile gelatin powder Gelfoam® (The Upjohn Co., Kalamazoo, Michigan) was used to seal the dural rent and found to be effective in the treatment of severe PDPH after inadvertent dural puncture. CASE 1 A twenty-six-year-old full-term primigravida who was known to have pulmonary tuberculosis presented for caesarean section under epidural anaesthesia. During the introduction of an 18 gauge Tuohy needle, the patient started coughing, contributing to an inadvertent dural puncture which was detected immediately. Lignocaine 5% 1.2 ml was injected into the subarachnoid space via the same needle, the patient positioned and the surgery undertaken uneventfully. On completion of surgery the patient was transferred to the ward, advised to stay in bed in a comfortable lateral or semiprone position and encouraged to drink sufficiently to satisfy her thirst. Oral analgesics were prescribed and she was assessed at least twice daily. Headache was first reported by the patient 28 hours following dural puncture. It was quite unlike any previous headache, was bifrontal and aggravated by upright position, coughing and movements of head and relieved by lying down. Associated symptoms included nausea, but there was no photophobia or change in hearing or tinnitus. The patient was reassured and oral analgesics were increased. On the fourth Anaesthesia and Intensive Care, Vol. 19, No. 3, August, 1991

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postoperative day the patient complained that the Headache was getting worse and had become intolerable. She became tearful, bedridden and dependent. After obtaining informed written consent, the patient had an epidural blood patch at the site of dural puncture using 10 ml of autologous blood injected via a Tuohy needle under sterile conditions. By two hours after the epidural blood patch the patient experienced substantial relief of headache, but complained of slight neck and back stiffness. She could walk without difficulty. Twenty-four hours later she again complained of having the same type of headache which made her restless and irritable. This time a thin gel of sterile surgical Gelfoam powder was made in 10 ml of autologous plasma under sterile conditions. After preparing the antecubital area of the patient using iodine and spirit, 25 ml of blood was withdrawn from the antecubital vein of the patient using a sterile heparinised syringe and was collected in a sterile container. Ten ml of supematent plasma was taken and little more than half the contents of Gelfoam powder packet (of one gram) was added to this plasma in another sterile container. Thus a thin gel was prepared by mixing 600-700 mg of the Gelfoam powder to 10 ml of plasma. Written informed consent of the patient was obtained. The patient was then positioned, epidural space identified using a 10 ml glass syringe and this gel was injected into the epidural space at the site of dural puncture. The gel so prepared is viscous and, if a glass syringe is used, the plunger of the syringe tends to stick. We used a plastic disposable syringe in which the area of contact of plunger with the barrel is minimal. Obviously due to the viscous nature of the gel, resistance was encountered and pressure was needed to inject the gel. No discomfort was felt by the patient during or after the injection of the gel. After thirty minutes she had obtained substantial relief Qf her headache. No increase in neck or back stiffness was noticed. She was asked to lie in bed for about two hours and then she was allowed to move about in the ward. The patient was discharged on the fourth day following the epidural gelatin patch and advised to attend for follow-up. After twenty months the patient has remained asymptomatic. CASE

2

A twenty-nine-year-old gravida 2 woman in active labour underwent epidural anaesthesia for a caesarean and had an inadvertent dural puncture with an 18 gauge Tuohy needle. On the second day she developed PDPH which was occipital and involved the neck and upper shoulders. Again the pain was quite unlike any previous headache and Anaesthesia and Intensive Care, Vol. 19, No. 3, August, 1991

postural in nature. This was accompanied by decrease in hearing acuity but no tinnitus, photophobia, diplopia or nausea. The patient became depressed and miserable due to pain. Bed rest, copious oral fluids and liberal use of analgesics were prescribed but she did not get much relief. On the fourth day, after obtaining written informed consent, sterile surgical Gelfoam 'Powder in 10 ml autologous plasma was injected into the epidural space at the site of dural puncture as in Case 1. After forty minutes her headache was relieved substantially. She was asked to lie in the bed for about two hours and then she was allowed to move about in the ward. No increase in upper shoulder pain was noticed. She was discharged on the eighth day free of headache and with no neck, back or shoulder stiffness. Throughout fourteen months of follow-up she remains asymptomatic. DISCUSSION

Absorbable gelatin (Gelfoam) is a sterile, absorbable material prepared from a specially treated gelatin solution that was first introduced by Correll and Wise in 1945. 8 It is available as a white, soft pliable sponge, as well as in a powder form which is insoluable in water but which can absorb approximately 45 times its weight ofblood. 9 Its use to seal spinal fluid leaks and to bridge defects in the dura mater was suggested by Light and Prentice in 1945. 10 Once the gelatin is in place and is left undisturbed, adhesion to the wound will be preserved by precipitation of fibrin and the glueing effect of blood platelets between it and the wound surface. 9 There have been several studies that examined the histological reaction of tissue to implanted gelatin sponge. One of the first was by Light and Prentice lO whose results showed tissue reaction beginning at approximately day six post implant with a leukocytic infiltrate and reaching a maximum by day 12 when lymphocytes and giant cells predominated. They observed complete absorption of the material sometime between day 20 and 45. Correll and Wise 8 also reported that gelatin sponge had visually disappeared from the implantation sites within ten days, had maximal tissue reaction within 10-25 days and was completely absorbed by 30 days. The cellular reaction described is no greater than that which occurs naturally during resorption of a blood clot. 9 A more recent study by Rafteryll indicated that gelatin sponge is not associated with an increased incidence of post surgical adhesions. Despite being made from animal skin gelatin, gelatin sponge has been proven to be nonantigenic. 8 This is probably due to its structural lack of aromatic radicals which is the part of the molecule responsible for sensitization

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anaphylaxis. 9 It has been used successfully in various neurosurgical and other surgical procedures. S. 12 Headache following accidental dural puncture can be of excruciating severity. The onset of headache occurs several hours after the puncture and usually within the first two days.2,5,13 The headache is invariably bifrontal and occipital and frequently involves the neck and upper shoulders. Severity varies from mild to incapacitating, and is invariably described by the patient as 'quite unlike previous headache'. The upright position, coughing and sudden movements of head all typically make headaches more severe while lying down produces varying degrees of relief. Nausea and loss of appetite is common. 2,5,13 Auditory symptoms can often be elicited - particularly changes in hearing acuity and tinnitus, and is thought to be due to a lowering of intralabyrinthine pressure. 2 Photophobia is unusual. The patient can be depressed, miserable, tearful, bedridden and dependent. 2 Aggravation of headache by jugular vein compression and passive neck flex ion has been described. 2 Diplopia and cranial nerve palsies have also been reported. 2, 13 It is generally but not universally accepted that the size of the dural tear is a major factor in both the incidence and severity of headache. The incidence of headache in patients managed conservatively with bed rest, systemic analgesics and high fluid intake can be 85% and in 58% it can be severe. 2 It is generally agreed that PDPH is caused by CSF leakage from the subarachnoid space at a greater rate than CSF production. 2The leakage rate is determined by the pressure differential across the dura and the dimensions and characteristics of the puncture hole. The vertical position not only increases this pressure differential but causes d~scent of the brain. Resulting traction on the intracranial sinuses, cerebral vessels, the tentorium and falx cerebri produces position-sensitive referred pain to the head and neck, depending on the structure stimulated. Above the tentorium pain is referred via the trigeminal nerve to the frontal region. Below the tentorium referral is to the occiput and neck via the glossopharyngeal, vagus and the upper three cervical nerves. 2 Innervation is unilateral. 2 Several prophylactic and therapeutic regimens including surgical repair have been described following accidental dural puncture. 2.4 ,6,7,13.16 Many are of doubtful value as the headache is usually self-limiting despite 'treatment'. Nevertheless the epidural blood patch using 10-20 ml autologous blood is considered a major therapeutic advance with its indisputable and often dramatic efficacy. A success rate of 97% within 24 hours has been quoted. 15 The success rate is better

if greater volume of blood is used. The ultimate test of success, however, is whether the symptoms are permanently relieved in the upright position. Applying that definition, only three quarters of patients could be regarded as cured following an epidural blood patch. 2,16 A repeat blood patch may be required in 25% of the patients. Although no permanent sequelae of therapeutic blood patch have been reported, back and neck stiffness and/or pain is common. 2,13 Moderately severe radicular pain,2,17 paraesthesia in the legs, rise in body temperature and subdural haematoma requiring surgical evacuation have also been described. 2,13,17,IS In one case moderately severe pain radiating into the buttock for three days afterwards and restricted straight-leg raising was attributed to nerve root irritation. 2 In one study19 a patch performed within 24 hours of dural puncture had a 71 % failure rate. The recurrence of PDPH after epidural blood patch could be attributed to either dislodgement of blood clot from the site of dural puncture or to early clot lysis. In our two cases no recurrence of headache after epidural gelatin patch was noticed. By forming absorbable adhesion that is preserved by precipitation of fibrin and the glueing effect of blood platelets,9 gelatin in place seals the dural rent effectively without any dural irritation. In conclusion, epidural patch with gelatin in plasma can be an alternative choice in cases of severe PDPH. In addition the Gelfoam-plasma patch may be acceptable to those patients who refuse traditional blood patching for religious or other reasons. The gel must be freshly prepared and sufficiently thin so that it can be injected epidurally via a Tuohy needle. However, aseptic precautions are mandatory and more needs to be known about the use of Gelfoam in this situation - especially its effectiveness and recurrence rates in a larger series before it could be recommended routinely over the time tested blood patch.

REFERENCES

I. Dawkins ClM. An analysis of the complications of epidural and caudal block. Anaesthesia 1969; 24:554-563. 2. Brownridge P. The management of headache following accidental dural puncture in obstetric patients. Anaesth Intens Care 1983; 1I :4-16. 3. Okell RW, Sprigge lS. Unintentional dural puncture. A survey of recognition and management. Anaesthesia 1987; 42:1110-1113. 4. Craft lB, Epstein BS, Coak1ey CS. Prophylaxis of dural-puncture headache with epidural saline. Anesth Analg 1973; 52:228-231. 5. Vandam LD, Dripps RD. Long term follow up of patients who received 10,098 spinal anaesthetics: Syndrome of decreased intracranial pressure Anaesthesia and Intensive Care, Vol. 19, No. 3, August, 1991

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6. 7. 8. 9. 10. 11. 12. 13.

(Headache and ocular and auditory difficulties) lAMA 1956; 586-591. Nelson MO. Post puncture headaches, a clinical and experimental study of the cause and prevention. Arch Derm Syph 1930; 21:615-627. Gormley lB. Treatment of post spinal headache. Anesthesiology 1960; 21 :565-566. Correll IT, Wise EC. Certain properties of a new physiologically absorbable sponge. Proc Soc Exp Bioi Med 1945; 58:233-235. Arand AG, Sawaya R. Intraoperative chemical hemostasis in neurosurgery. Neurosurgery 1986; 18:223-233. Light RV, Prentice HR. Surgical investigation of a new absorbable sponge derived from gelatin for use in hemostasis. 1. Neurosurg 1945; 2:435-455. Raftery AT. Absorbable hemostatic materials and intra peritoneal adhesion formation. Br 1 Surg 1980; 67:57-58. Fincher EF. Further use of gelatin foam in neurosurgery. 1. Neurosurg 1947; 4:97-104. Abouleish E, Vega De La s, BlendingerI, Tio T. Long term follow up of epidural blood patch. Anesth Analg 1975; 54:459-463.

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14. Brown BA, 10nes OW. Prolonged headache following spinal puncture. Response to surgical treatment. 1 Neurosurg 1962; 19:349-350. 15. Ostheimer GW. Headache in the postpartum period. From Clinical Management of Mother and Newborn. ed Marx GF. Springer-Verlag, New York, 1979; 27-41. 16. Bart Al. Scott Wheeler A. Comparison of epidural saline placement and epidural blood placement in the treatment of post-lumbar-puncture headache. Anesthesiology 1978; 48:221-223. 17. Cornwall RD, Dolan WM. Radicular back pain following lumbar epidural blood patch. Anesthesiology 1975; 43:692-693. 18. Reynolds AF, Hameroff SR, Blitt CD, Roberts WL. Spinal subdural epiarachnoid hematoma: a complication of a novel epidural blood patch technique. Anesth Analg 1980; 59:702-703. 19. Loeser RA, Hill GE, Bennett GM, Sederberg lH. Time vs success rate for epidural blood patch. Anesthesiology 1978; 49:147-148.

Massive Adrenaline Doses in Labetalol Overdose P. R. HICKS* AND A. P. N. RANKINt Department of Anaesthesia, Auckland Hospital, Auckland, New Zealand Key Words: INTENSIVE CARE: self-poisoning, overdose, labetalol

Overdoses of beta-adrenergic blocking drugs are not uncommon. Some have been life-threatening and have required high-dose isoprenaline and glucagon,l adrenaline, 2 intra-aortic balloon pumping3 or external cardiac pacing. 4 Labetalol, an alpha- and beta-adrenergic blocking drug, has been reported twice in overdose and has responded to dopamine 5 and high-dose isoprenaline/dopamine combined. 6 We wish to report a case of a labetalol self-poisoning which presented as an unknown overdose and required massive doses of adrenaline in the resuscitation. CASE REPORT A 43-year-old woman presented to the Emergency Department of Middlemore Hospital, Auckland at 1545 hours on 22 September, 1988. 'M.B.Ch.B., Registrar. tF.F.A.R.A.C.S., Consultant Intensivist. Address for Reprints: Dr. Peter Hicks, Department of Anaesthesia, Auckland Hospital, Private Bag, Grafton, Auckland, New Zealand. Accepted for publication July 10, 1990

Anaesthesia and Intensive Care. Vol. 19, No. 3. August, 1991

She was unconscious with a Glascow Coma Score 5/15. She had shallow breaths, systolic BP 60 mmHg, heart rate 80/min and cool peripheries. The history was of self-poisoning but the drug or drugs and time of ingestion were unknown. Her general practitioner had prescribed her seven doxepin 75 mg tablets and fourteen temazepam 10 mg tablets two days before for acute depression. She was not taking any other medication. Oxygen by mask and intravenous fluids were commenced. Her heart rate fell quickly to 30/minute and atropine 0.6 mg, plus twn doses of adrenaline 250 micrograms increased it only to 40/minute. Intubation then became necessary. By 1600 hours, two litres of 0.9% saline and 500 ml of Haemaccel had been given, and this improved her peripheral perfusion. She had a systolic BP 70 mmHg and pulse 60/min with nodal rhythm. Two doses of adrenaline 1 mg were given and a dopamine infusion at 1000 ~g/min (60 mg/hr) was started via a central venous line. Arterial blood gas