Thread by @OBsleepmerchant

@euklaas from @asznl presents on PDPH: new perspectives at #OAA3dc2022. (As promised by teaser) August Bier = father of PDPH, a surgeon started it not #OBAnes 😉

Current perspective on PDPH. ICHD-3 definition, tied to CSF pressure & volume as is pathophysiology. #OAA3dc2022

New anatomical perspectives challenge the classic CSF hypothesis. Choroid plexus not main site of production, CSF doesn’t circulate unidirectionally.

Bulat-Kiarica-Orešković hypothesis: osmotic & hydrostatic forces are main determinants of CSF movement, pulsates

#OAA3dc2022

PDPH presentation: EPiMAP1 (@BJAJournals ) - signs and symptoms (100% headache not too surprising) #OAA3dc2022

NB PDPH is NOT always postural (another poll for @antonchau1 or @emilysharpe or @OAAinfo or @SOAPHQ: how many #OBAnes/ institutional protocols exclude PDPH on basis of postural component?), 39% get headaches postpartum (only 4% PDPH), No CSF. Beware changing picture
#OAA3dc2022

Complications of PDPH (neurological): increased SDH rate associated with PDPH (@JAMA_current) postpartum depression, PTSD, chronic headache, chronic backache (@EJA_Journal) #OAA3dc2022

Can #OBAnes prevent PDPH? Lots about needle type and size. (@Anaes_Journal) Sadly probability of PDPH & probability of block failure are “inversely” related; least PDPH: 26A>27A>29C etc, lowest failure: 26A>25C>22C etc. 26G atraumatic = perfect? The std 25G middling?
#OAA3dc2022

Pencil point better (except perhaps 29G, how long would you have to wait to CSF return?), 26G seem ideal. If we’re to massively reduce the morbidity burden should 26G pencil point be everywhere? Achieving that worldwide = expensive! Ultrasound has no effect on ADP?
#OAA3dc2022

What do you do if you recognize an ADP? Sharon Orbach-zinger et al (incl @noolslucas @MarcVandeVelde6) in @Anaes_Journal - low level evidence for recommendations on intrathecal catheter. Multiple options, variable effficacy. #OAA3dc2022

@NarouzeMD favourite! Fluoroscopically guided vs intranasal LA?
Jespersen et al (@BJAJournals) no significant effect on pain intensity > 30 min vs. placebo. But, pain was reduced & EBP was avoided in 50% patients of both groups, suggesting position NB? #OAA3dc2022

A little history of EBP (@robin_russell1 in @IJOA_Journal). When, where, how much? When to mobilize after? Gupta et al (incl. @euklaas @roshanagf @MarcVandeVelde6) looked at PDPH management.

EPiMAP group then proceeded to look at factors associated with failed EBP. Using p<0.01 for significance: migraine Hx, ADP level, time from ADP to EBP. If p<0.05 had been chosen, interesting. No effect volume or level EBP, position during EBP or operator experience! #OAA3dc2022

Factors p<0.01: migraine, timing and ADP level. Relationship between level ADP & level EBP - food for thought, but considering how inaccurately #OBAnes assess level (even with US), either ADP or EBP level may be out? @euklaas how was level assessed? #OAA3dc2022

Summary from @euklaas with QR email code to join research (in fullness of time, don’t flood her inbox [yet]). Prominent QR code for references on first slide (repeated here enlarged) #OAA3dc2022

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