Treatment of Post-Dural Puncture Headache After Accidental Dural Puncture in Obstetrics

Abstract

Objective: The purpose of this scholarly project was to develop an evidenced-based clinical practice guideline (CPG), a simplified differential diagnosis decision tree and a patient education handbook to guide identification, diagnosis and treatment of post-dural puncture headache (PDPH). The goal was to decrease hospital length of stay, decrease re-admission rates, decrease emergency room visits after discharge, improve patient outcomes, and improve patient satisfaction in the obstetrical patients at a tertiary care hospital in Maryland. Background: The most common type of postpartum headache is PDPH. The absence of a definitive guidelines or recommendations led to: (1) inconsistent identification, evaluation, diagnosis of PDPH (2) apprehension regarding treatment options which delayed treatment and (3) procedural errors (i.e. treatment initiation, volume of administration, follow-up evaluations, etc). Main ideas/ Methods: A literature search was conducted to identify current strategies in the treatment and management of PDPH. A total of 50 studies were initially identified, but 8 met all inclusion criteria. The 8 studies included for review. The 8 studies included: 3 randomized control trials, 4 retrospective chart reviews and 1 systematic review of meta-analysis and RCT. A CPG was developed based on these results of the 8 studies. An expert panel (n=3) used the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool to rate the quality of the contents within the CPG on the 23-item Likert scale.. The anesthesia department members evaluated the CPG using a 23-item Likert scale called a practitioner feedback questionnaire (PFQ) after implementation. All data was analyzed using descriptive statistics. Results: The AGREE II tool revealed ratings of 96-100% in agreement with the CPG for all 7 domains and overall. Fifteen of the 20 item PFQ, 80-100% respondents marked “Strongly Agree” for “… should be approved as a CPG…,” “… I would use this in my own practice…”, “… will result in better outcomes…”, etc. For 2 items the 70-85% of respondents marked “Strongly Disagree” for “… the guideline is too rigid…” and “… the guideline is too expensive…” Most importantly, 83-95% of respondents marked “Strongly Agree” for “…the CPG should be approved…”, “… would use in my own practice…” and “… would apply the recommendations in my own practice…” Conclusion: The expert panel, administrators and anesthesia department staff all accepted the CPG and attest to the use in clinical practice. An indepth review of the evidence demonstrated the efficacy of EBP in PDPH treatment. EBP provided complete resolution of PDPH in up to 98% of patients. When EBP was compared to conservative management options or other invasive treatment modalities the results of the EBP were superior.