1. Loss of CSF should be minimized by replacing the stylet of the Tuohy needle or by immediate, complete withdrawal of the needle.
2. Partial withdrawal of the Tuohy needle through the dura until CSF flow stops is not recommended because the subdural space, rather than the epidural space, may be entered (1).
3. If a subsequent subarachnoid block is undertaken (Chapter 63), there may be an increased risk of a high block, particularly if any fluid has been injected into the epidural space (2). It is thought possible that an increased hydrostatic pressure in the epidural space may encourage spread of local anaesthetic in the subarachnoid space.
4. Epidural puncture may be repeated in an adjacent interspace, although there is an increased risk of a second dural puncture. The local anaesthetic dose should be decreased by 25% and given in small increments because of the potential for leakage of local anaesthetic through the dural hole into the subarachnoid space (3) (Chapter 114).
5. A normal vaginal delivery with bearing-down is to be permitted. This is in contrast to earlier recommendations that delivery be forceps-assisted so as to avoid straining and increased CSF loss.
6. The epidural catheter may be left in position for prophylactic saline infusion or blood injection through the catheter but these techniques have met with little success (4).
7. Bedrest post-puncture is not effective in the prevention of headache although it will relieve symptoms once they occur. A temporary abducent (Vlth cranial) nerve palsy and diplopia may follow early, energetic ambulation.
8. The management of post-dural puncture headache by blood patching and other means is discussed in Chapter 110 and Chapter 85.
References:
1. COLLIER CB. Collapse after epidural injection following inadvertent dural perforation. Anesthesiology 1982 57:427-428.
2. BECK GN, GRIFFITHS AG. Failed extradural anaesthesia for caesarean section: Complication of subsequent spinal block. Anaesthesia 1992 47:690-692.
3. LEACH A, SMITH GB. Subarachnoid spread of epidural local anaesthetic following dural puncture. Anaesthesia 1986 43:671-674.
4. GUTSCHE BB. Lumbar epidural analgesia in obstetrics: taps and patches. In: Reynolds F, Editor. Epidural and spinal blockade in obstetrics. London: Balliere Tindall,1990: 95-106.