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IntroductionPostdural puncture headache (PDPH) can follow unintentional dural puncture during epidural techniques or intentional dural puncture during neuraxial procedures such as a lumbar puncture or spinal anesthesia. Evidence-based guidance on the prevention, diagnosis or management of this condition is, however, currently lacking. This multisociety guidance aims to fill this void and provide practitioners with comprehensive information and patient-centric recommendations to prevent, diagnose and manage patients with PDPH.MethodsBased on input from committee members and stakeholders, the committee cochairs developed 10 review questions deemed important for the prevention, diagnosis and management of PDPH. A literature search for each question was performed in MEDLINE (Ovid) on 2 March 2022. The results from each search were imported into separate Covidence projects for deduplication and screening, followed by data extraction. Additional relevant clinical trials, systematic reviews and research studies published through March 2022 were also considered for the development of guidelines and shared with contributors. Each group submitted a structured narrative review along with recommendations graded according to the US Preventative Services Task Force grading of evidence. The interim draft was shared electronically, with each collaborator requested to vote anonymously on each recommendation using two rounds of a modified Delphi approach.ResultsBased on contemporary evidence and consensus, the multidisciplinary panel generated 50 recommendations to provide guidance regarding risk factors, prevention, diagnosis and management of PDPH, along with their strength and certainty of evidence. After two rounds of voting, we achieved a high level of consensus for all statements and recommendations. Several recommendations had moderate-to-low certainty of evidence.ConclusionsThese clinical practice guidelines for PDPH provide a framework to improve identification, evaluation and delivery of evidence-based care by physicians performing neuraxial procedures to improve the quality of care and align with patients’ interests. Uncertainty remains regarding best practice for the majority of management approaches for PDPH due to the paucity of evidence. Additionally, opportunities for future research are identified.

Background Axillary vein/subclavian vein (AxV/SCV) and Internal jugular vein (IJV) are commonly used for implantable venous access port (IVAP) implantation in breast cancer patients for chemotherapy. Previous research focused on comparison of complications while patient comfort was ignored. This study aims to compare patient comfort, surgery duration and complications of IVAP implantation between IJV and AxV/SCV approaches. Methods Two hundred forty-eight breast cancer patients were enrolled in this randomized controlled study from August 2020 to June 2021. Patients scheduled to undergo IVAP implantation were randomly and equally assigned to receive central venous catheters with either AxV /SCV or IJV approaches. All patients received comfort assessment using a comfort scale table at day 1, day 2 and day 7 after implantation. Patient comfort, procedure time of operation as well as early complications were compared. Results Patient comfort was significantly better in the AxV/SCV group than that of IJV group in day 1 ( P  < 0.001), day 2 ( P  < 0.001) and day 7( P  = 0.023). Procedure duration in AxV/SCV group was slightly but significantly shorter than IJV group (27.14 ± 3.29 mins vs 28.92 ± 2.54 mins, P  < 0.001). More early complications occurred in AxV/SCV group than IJV group (11/124 vs 2/124, P  = 0.019). No difference of complications of artery puncture, pneumothorax or subcutaneous hematoma between these two groups but significantly more catheter misplacement in AxV/SCV group than IJV group (6/124 vs 0/124, P  = 0.029). Absolutely total risk of complications was rather low in both groups (8.87% in AxV/SCV group and 1.61% in IJV group). Conclusions Our study indicates that patients with AxV/SCV puncture have higher comfort levels than IJV puncture. AxV/SCV puncture has shorter procedure duration but higher risk of early complications, especially catheter misplacement. Both these two approaches have rather low risk of complications. Consequently, our study provides an alternative choice for breast cancer patients to reach better comfort.

Background Dural puncture epidural (DPE) improves labor analgesia by reducing numeric rating scale (NRS) score, accelerating onset, and enhancing sacral blockade. Although larger-gauge needles may potentiate local anesthetic diffusion and improve analgesic quality, current clinical practice favors smaller-gauge needles (25-gauge to 27-gauge) to mitigate post-dural puncture headache (PDPH) risks. This randomized trial specifically evaluates the differential impacts of 23-gauge, 25-gauge, and 27-gauge needles on both analgesic efficacy and procedure-related complications. Methods In this randomized trial, 200 parturients requesting labor analgesia received DPE (23-gauge, 25-gauge, 27-gauge subgroups) or standard epidural (EP), followed by programmed intermittent epidural boluses (PIEB) of 12 mL with ropivacaine 0.08% and sufentanil 0.33 µg/mL every 50 min. Primary outcome was NRS score 10 min after the initial epidural bolus; secondary outcomes included time to NRS score ≤ 1, block characteristics at 20 min, number of top-up boluses, Apgar scores, and adverse events. Results Among 198 analyzed participants, all DPE groups exhibited lower 10-minute NRS scores versus EP groups ( P  < 0.001). The 23-gauge and 25-gauge subgroups had lower NRS scores than 27-gauge ( P  < 0.05), with no difference between 23-gauge and 25-gauge ( P  > 0.05). The 23-gauge group achieved NRS score ≤ 1 fastest ( P  < 0.001). DPE groups demonstrated higher bilateral sacral (S2) blockade rates versus EP groups ( P  < 0.001), with no inter-subgroup differences. No significant difference were observed in procedure duration, top-up requirements, catheter adjustments/replacement, complications (PDPH, hypotension, nausea), or neonatal Apgar scores at 1 and 5 min. Conclusion Compared to conventional epidural analgesia, the combined application of DPE and PIEB techniques demonstrated superior quality. The utilization of 25-gauge pencil-point spinal needles achieves the optimal balance between analgesic efficacy and safety, while the 23-gauge needle may be suitable for specific scenarios requiring rapid onset of action.

Background Acute lymphoblastic leukemia (ALL) is the most common malignancy diagnosed in children. At present, the long-term survival from pediatric ALL is well over 90%. However, the probability of event-free survival is reduced if the lumbar puncture (LP) procedures at the beginning of the patient’s intrathecal therapy cause blood leakage into the spinal canal and blast cells contaminate the cerebrospinal fluid. According to the literature, such traumatic LP procedures concern one out of five pediatric patients with ALL. Recently, a novel medical device measuring the tissue bioimpedance at the tip of a spinal needle was found feasible in pediatric patients with ALL. The LP procedure was successful at the first attempt in 80% of procedures, and the incidence of traumatic LPs was then 11%. The purpose of the present study is to compare the bioimpedance spinal needle system with the standard clinical practice resting on a conventional spinal needle and investigate its efficacy in clinical practice. Methods The study is a multicenter, randomized, two-arm crossover noninferiority trial of pediatric hemato-oncology patients that will be conducted within the usual clinical workflow. Patients’ LP procedures will be performed alternately either with the IQ-Tip system (study arm A) or a conventional Quincke-type 22G spinal needle (study arm B). For each enrolled patient, the order of procedures is randomly assigned either as ABAB or BABA. The total number of LP procedures will be at least 300, and the number of procedures per patient between two and four. After each study LP procedure, the performance will be recorded immediately, and 1-week diary-based and 4-week record-based follow-ups on symptoms, complications, and adverse events will be conducted thereafter. The main outcomes are the incidence of traumatic LP, first puncture success rate, and incidence of post-dural puncture headache. Discussion The present study will provide sound scientific evidence on the clinical benefit, performance, and safety of the novel bioimpedance spinal needle compared with the standard clinical practice of using conventional spinal needles in the LP procedures of pediatric patients with leukemia. Trial registration ISRCTN ISRCTN16161453. Registered on 8 July 2022.

Purpose of Review This paper reviews the complications of lumbar puncture with a focus on post-dural puncture headache including pathophysiology, risk factors, prevention, and treatment. Recent Findings Recent research has focused on understanding the multifactorial mechanisms of post-dural puncture headache and improving prevention and treatment strategies. Small caliber, pencil-point type needles are encouraged to minimize the risk of post-dural puncture headaches, especially in populations that are at higher risk for complication. While new medications and procedures show promise in small cohorts, conservative medical management and epidural blood patch are still the first and second-line treatments for PDPH. Summary Post-dural puncture headache is the most frequent complication of lumbar puncture. There are both modifiable and nonmodifiable risk factors to consider when performing this procedure. Conservative medical management and procedure-based therapies exist for when complications of lumbar puncture arise.

To investigate the impact of the absence of specific advice for oral fluid intake, compared to supplementation water intake on the occurrence of post-dural puncture headache. A prospective, open-label, non-inferiority, multicenter trial including hospitalized patients requiring a diagnostic lumbar puncture in seven hospitals in France. Patients were randomly allocated (1:1) either to receive no specific advice on oral fluid intake (FREE-FLUID), or to be encouraged to drink 2 liters of water (CONTROL) within the 2 hours after lumbar puncture. The primary outcome was the post-dural puncture headache rate within the 5 days after lumbar puncture, with a non-inferiority margin of 10%. The secondary outcome was the time-to-post-dural puncture headache onset between Day 0 and Day 5. From November 2016 and July 2019, we have included 554 participants. The primary outcomes occurs in 33.1% patients in the FREE-FLUID group, versus 38.0% in the CONTROL group with adjusted difference of 3.7%. Among patients who had lumbar puncture, our study shows the noninferiority of the absence of specific advice on water intake after a lumbar puncture, compared with advice to increase oral fluid to prevent a post-dural puncture headache. The value of questioning the appropriateness of non-evidence-based nursing care may allow time to be devoted to more relational and comforting care. The study adheres to the CONSORT reporting guidelines. No patient or public contribution. Clinical Trials.gov (NCT02859233, August 9, 2016).

Lumbar puncture (LP) to extract cerebral spinal fluid (CSF) to quantify analytes relevant to brain health can lead to post-dural puncture headache (PDPH). Incidences vary across studies. This prospective memory clinic study assessed the incidence and intensity of PDPH after protocolised extraction and post-procedural rest. Patient and procedural risk factors for PDPH were explored. In 724 patients or healthy volunteers we performed 1147 procedures with intravenous infusion of 500 ml of 0.9% saline, LP with 22-gauge non-cutting pencil point needles, CSF collection (13.5–15 ml) without negative pressure, and observed bed and chair rest for 45 min. The overall incidence of PDPH was 9.6% at 24 h and 4.7% at seven days. All PDPHs were mild to moderate and self-limited (no blood patches or hospitalisations required). Patients managed symptoms with low doses of acetaminophen or non-steroidal anti-inflammatory drugs, along with oral caffeine intake . At 24 h PDPH was significantly associated with a low (> 18.5–24.9) or very high (> 40) body mass index ( P  = 0.021), a history of chronic pain ( P  = 0.007), or a lower puncture site ( P  = 0.002). We conclude that protocolised extraction of large volumes of CSF with a medium-gauge non-traumatic needle, controlled fluid loading and short bed rest can lower the incidence of PDPH, favouring safe CSF research.

ObjectiveTo assess the effect of a non-noxious vibratory stimulus on noxious-evoked cortical responses to skin puncture and to determine whether the presence of certain behavioural components may be used to predict such cortical responses.DesignRandomised controlled trial.SettingLevel IV neonatal intensive care unit at a stand-alone children’s hospital.Patients134 hospitalised infants between 36 and 52 weeks’ postmenstrual age and ordered to receive a clinically required laboratory draw.InterventionsInfants randomised to receive the intervention, a vibratory stimulus at the site of skin puncture beginning 10 s prior to a heel stick, or the control, no vibration.Main outcome measuresElectroencephalography and video recording time-locked to the deployment of the lancet for the skin puncture. Noxious-evoked cortical responses were measured by the area under the curve in the somatosensory region contralateral to the skin puncture. Behavioural responses were coded through video analysis.ResultsNoxious-evoked cortical responses were significantly reduced in participants receiving the vibratory stimulus compared with the control (frontal, p<0.0001; central, p=0.0088; central-parietal, p=0.0111). There were no significant differences in behavioural responses between groups (all p>0.05).ConclusionsA non-noxious vibratory stimulus presented prior to and continuing simultaneously with skin puncture significantly mitigates nociception in hospitalised infants. The presence or absence of facial expression components is inadequate to reliably predict pain signalling in the brain.Trial registration number NCT04050384.

Background Lumbar puncture (LP) procedure can be challenging, creating stress for both patients and students. This study assesses the effectiveness of augmented reality (AR) and haptic feedback simulation training compared to traditional bedside teaching. Method We conducted a prospective, single center, randomized controlled clinical trial with two parallel groups of medical students inexperienced in LP. Students were randomized to either the simulation group or the control group receiving traditional bedside teaching. Patients requiring LPs as part of their routine care were randomized. The primary outcome was LP success rate. Secondary outcomes included procedure duration, complication rates and patient and student perceptions. Results The study included 55 patients (AR group: n  = 29; control group: n  = 26). LP success rates were similar between groups (AR: 46.4%, control: 40.0%; p  = 0.9). Median procedure duration was shorter in the AR group (138 s [IQR 37–454]) compared to the control group (695 s [IQR 15–900]), though not statistically significant ( p  = 0.67). Patient pain and anxiety scores did not differ significantly, but patients reported greater ease and higher satisfaction with simulator-trained students. Students in the AR group expressed greater comfort performing the procedure (7/10 vs. 6/10; p  = 0.04). Complication rates were low and comparable across groups. Conclusion Although augmented reality simulation training did not improve LP success rate, it improved the procedural speed and student ease without compromising technical performance. Patients preferred to be handled by simulator-trained students. These findings support the integration of AR technologies in medical training to improve efficiency and relational skills. ClinicalTrials.gov ID NCT05269238, Registration Date 2022-01-14.