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Correspondence |
Riyadh, Saudi Arabia
To the Editor:
I read with interest an informative review article by P.J. Duffy and E.T. Crosby (The epidural blood patch. Resolving the controversies).1 I would like to comment on the issue of septic complication of EBP. In a North American survey of the management of dural puncture, 18 of 36 centres mention sepsis in the informed consent discussion as the complication of EBP.2 The incidence of bacteremia has been estimated as up to 7.3% after normal vaginal delivery and higher with prolonged labour, chorioamnionitis and retained placenta.3 The statement by the authors that pyrexia may reflect concurrent bacteremia and therefore EBP should be delayed until the patient becomes apyrexial, raises some questions. For how long the patient should remain apyrexial before EBP?
In a patient with bacteremia, EBP is contraindicated4 but the bacteremic patient may be apyrexial. Cases have been reported, where after delivery, patients have developed meningitis after EBP, while they were apyrexial at the time of EBP.5 An important, but less widely appreciated, cause of aseptic meningitis is systemic drug administration. Drug- induced aseptic meningitis has been reported after non-steroidal anti-inflammatory agents, ranitidine and cabamazepine, which may be difficult to differentiate from bacterial meningitis.6
There is no controversy that EBP should not be done in pyrexic patients, but in apyrexial patients, should we (while performing EBP) send blood for culture & sensitivity? A negative blood culture result would also prove that blood was aseptically collected and in the case of a positive result, a specific antibiotic can be commenced early.
References
1
Duffy PJ, Crosby ET. The epidural blood patch. Resolving the controversies. Can J Anesth 1999; 46: 878–86.
2
Berger CW, Crosby ET, Grodecki W. North American survey of the management of dural puncture occurring during labour analgesia. Can J Anaesth 1998; 45: 110–4.
3 Redleaf PD, Fadell EJ. Bacteraemia during parturition. JAMA 1959; 169: 1248–85.
4 Reynolds F. Dural puncture and headache. BMJ 1993; 306: 874–6.
5 Sprigge JS. Epidural blood patch. Anaesthesia 1999; 54: 300–1.
6 Marinac JS. Drug and chemical induced meningitis: a review of the literature. Ann Pharmacother 1992; 26: 813–22.[Abstract]
Ottawa, Ontario
We thank Dr. Anwari for his interest and comments concerning the potential for septic complications following epidural blood patch. Unfortunately, this facet of care has not been well studied and we have limited data to inform clinical decision-making.
Transient bacteremia is common, resulting from seemingly trivial events such as dental cleaning, brushing and flossing of teeth, and chewing hard candy.1 These bacteremias are typically both short-lived, lasting less than 15 min, and benign, posing little threat to patients save perhaps those with cardiac structural abnormalities.1,2 Crawford reported a 1% incidence of positive cultures in women when blood was drawn within 30 min of delivery.3 Presumably, positivity would occur at even a lower rate at times more distant to delivery.
Persistent, more clinically threatening (pathogenic) bacteremia is unlikely to occur without pyrexia and other evidence of sepsis. The presence of fever should lead one to seek a diagnosis and if sepsis is diagnosed, appropriate antibiotic therapy should be commenced. Common sense dictates that an epidural blood patch should not be performed in a febrile patient. The etiology of the fever should be sought and treated appropriately. It is prudent to proceed with an epidural blood patch only after the clinical situation is clarified and resolved.
We do not think that routine blood cultures are indicated in otherwise well patients at the time of epidural blood patch. The likelihood of a true positive result is low, and a false positive result is more likely in this low risk population. Moreover, in the absence of other evidence of sepsis, antibiotic therapy would not be indicated solely on the basis of a single positive blood culture. In Berger et al.'s survey of the management of dural puncture headache in North America, only one centre (1/36) routinely submitted blood for culture at time of patching, suggesting that it is an uncommon practice to do so.4 In our exhaustive search of the literature, only partly referenced in our recent review, we could find no data which would prompt or support a change in this pattern of practice.
References
1 Hupp JR. Changing method of preventing infective endocarditis following dental procedures: 1943 to 1993. J Oral Maxillofac Surg 1993; 51: 616–23.[Medline]
2
Durack DT. Prevention of infective endocarditis. N Engl J Med 1995; 332: 38–44.
3 Crawford JS. Experiences with epidural blood patch. Anaesthesia 1980; 35: 513–5.[Medline]
4 Berger CW, Crosby ET, Grodecki W. North American survey of the management of dural puncture occurring during labour epidural analgesia. Can J Anaesth 1998; 45: 110–4.
This article has been cited by other articles:
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  D. P. Martin, B. D. Bergman, and I. H. Berger Epidural Blood Patch and Acute Varicella Anesth. Analg., December 1, 2004; 99(6): 1760 - 1762. [Abstract] [Full Text] [PDF]
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 R. Sharma, A. Bailey, J. Bamber, and D. K. Turnbull Post-dural puncture headache Br. J. Anaesth., March 1, 2004; 92(3): 449 - 450. [Full Text] [PDF]
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