Clinical Indications for the Dural Puncture Epidural Technique

By May 28, 2019Uncategorized

Neuraxial Anesthesia, and more specifically epidural anesthesia, is the most common method of pain control for laboring obstetric patients. Its popularity stems from the fact that it is extremely effective, has a relatively low risk profile, and has few absolute contraindications. In addition, the American College of Obstetricians and Gynecologists (ACOG) and the American Society of Anesthesiologists (ASA) agree that a patient without contraindications (blood-thinning medication, for example) can request an epidural at any stage of labor and safely receive one.

Modifications to the standard epidural have grown in popularity in recent years. For example, combined spinal-epidurals (CSE) are sometimes used in place of a standard epidural for both laboring patients as well as patients going to Cesarean section whose procedures may take an extended amount of time. To perform a CSE, the practitioner obtains loss of resistance (similar to an epidural), and then inserts a spinal needle through the epidural needle that pierces through the dura. Once the practitioner confirms CSF return, they will inject local anesthetic into the intrathecal space. This is followed by placement of an epidural catheter into the epidural space, which can be used to infuse local anesthesia.  Compared to an epidural, multiple studies show that a CSE provides more rapid onset of pain relief, and more reliable, symmetrical, and improved sacral pain control than a standard epidural. In addition, patients with CSE’s require fewer physician boluses to “top off” the epidural. Because of these benefits, CSE’s have become very popular, and are standard of care for low risk patients on many labor and delivery floors.

While CSE’s do not cause an increase in post dural puncture headache risk, some studies show they may have an increased incidence of fetal bradycardia, hypotension, and maternal pruritus. In patients who are at risk for any of these complications, a dural puncture epidural (DPE) technique has emerged as a hybrid of the standard epidural and a CSE.  A DPE is performed much like a CSE; after obtaining loss of resistance, the practitioner punctures the dura with a spinal needle. After confirming CSF return, the epidural catheter is threaded into the epidural space without injecting any medication directly into the intrathecal space. Similar to CSE’s, DPE’s have been shown to provide more reliable and symmetric analgesia and more caudal spread when compared to a standard epidural. In addition, one study found that when compared to a CSE, DPE’s have a lower incidence of maternal pruritus, maternal hypotension, and uterine/fetal distress. As a result, a DPE is most often indicated for patients with whom you’d like to optimize pain control without placing them at addition risk of any of these complications. In addition, DPE’s (along with CSEs) offer an additional benefit in that they help confirm placement of the epidural catheter. The flow of CSF seen once the spinal needle pierces the dura is a confirmation that you are just beyond the epidural space. Presently, standard epidurals are being used less for laboring patients, and CSE’s (for low risk patients) and DPEs (for all other patients) are becoming standard of care.

References:

Cappiello E, O’Rourke N, Segal S, Tsen LC. A randomized trial of dural puncture epidural technique compared with the standard epidural technique for labor analgesia. Anesth Analg 2008; 107:1646.

Simmons SW, Taghizadeh N, Dennis AT, et al. Combined spinal-epidural versus epidural analgesia in labour. Cochrane Database Syst Rev 2012; 10:CD003401.

Chau A, Bibbo C, Huang CC, et al. Dural Puncture Epidural Technique Improves Labor Analgesia Quality with Fewer Side Effects Compared with Epidural and Combined Spinal Epidural Techniques: A Randomized Clinical Trial. Anesth Analg 2017; 124:560.

Heesen M, Van de Velde M, Klöhr S, Lehberger J, Rossaint R, Straube S. Meta-analysis of the success of block following combined spinal-epidural vs epidural analgesia during labour. (PMID:24164577). Anaesthesia [2014].

ACOG Committee Opinion No. 295, Pain Relief During Labor, July 2004 (replaces No. 231, February 2000; reaffirmed 2015).