Optimising management strategies for intrathecal catheters after accidental dural puncture

We commend Griffiths et al. [1] for their work on managing intrathecal catheters after inadvertent dural puncture in obstetric patients. These evidence-based recommendations complement and enhance previous guidelines published in Anaesthesia [2]. The recommendation for early removal of intrathecal catheters is particularly noteworthy, as it corresponds with recent findings in the field. We previously recommended leaving the intrathecal catheter for 24 h, but subsequent research has indeed shown no benefit in prolonged catheterisation. In a recent study of 550 cases of accidental dural puncture, we found no advantage in leaving the intrathecal catheter in for 24 h postpartum (postdural puncture headache, adjusted odds ratio (aOR) (95%CI) 1.01 (1.00–1.02), p = 0.015; epidural blood patch, aOR (95%CI) 1.00 (0.99–1.01), p = 0.40) [3]. This aligns well with the Obstetric Anaesthetists' Association current recommendation and supports the trend towards earlier catheter removal. Injecting intrathecal saline through the catheter was associated with decreased odds of developing postdural puncture headache (aOR (95%CI) 0.85 (0.73–0.99), p = 0.04) and reduced need for epidural blood patch (aOR (95%CI) 0.75 (0.64–0.87), p < 0.001) [3]. Moreover, there is some evidence suggesting that a combined approach, such as prophylactic cosyntropin administration with intrathecal 0.9% saline injection, may offer additional benefits in managing postdural puncture headache [4]. This area warrants further investigation and consideration in future updates.

We agree with the authors on the importance of long-term follow-up. However, we suggest extending the follow-up period and explicitly including screening for chronic pain and postpartum depression. Recent studies have shown that women who experience accidental dural puncture are at increased risk of both these complications [5].

We hope that ongoing research in intrathecal 0.9% saline injection, prophylactic treatments and the importance of extended follow-up with screening for chronic pain and postpartum depression can further optimise care for these patients.