Epidural blood patch for patients with COVID-19 infection

Labor epidural analgesia can be performed safely in patients with confirmed or suspected COVID-19 infection. Epidural blood patch (EBP) remains today the most effective technique to relieve post-dural puncture headache (PDPH) symptoms after a dural tap. We present five cases of patients with confirmed COVID-19 infection retrieved through the SOS-Regional Anesthesia hotline service [1].

1. Report

1.1. Case 1

A 38-year-old healthy G2P2 female patient complained of headache on Day 1 after a labor epidural analgesia complicated by a dural tap. The headache was non-positional, associated with nuchal rigidity and a positive Kernig sign but no fever. A cerebral magnetic resonance imaging (MRI) showed non-specific meningeal contrast uptake. The patient was diagnosed with COVID-19 with an antigenic/auto-test performed because of new-onset isolated cough. Her headache was refractory to medical treatment and an EBP with 30 mL of autologous blood was performed on Day 2. The symptoms rapidly improved and the patient was observed for 5 days before being discharged. No complications were noted on discharge. The patient was lost to follow-up afterward.

1.2. Case 2

A 32-year-old female patient had a history of ankylosing spondylitis, depression, anorexia, and residual motor deficit of the right upper limb after open-reduction and internal fixation of a fracture. She complained of positional headache with nausea and vomiting which appeared after a diagnostic lumbar puncture for febrile confusion and vomiting to rule out meningitis on day 7 of COVID-19 infection. The patient had been diagnosed with COVID-19 infection (positive PCR test) 10 days before and conservative treatment was ineffective. A sphenopalatine ganglion block was performed bilaterally with no improvement. Consequently, an EBP was performed using 30 mL of autologous blood with rapid relief. She was discharged the same day and was followed up for 10 days with no complications.

1.3. Case 3

A 30-year-old healthy female patient complained of a severe positional headache without sensory-motor deficit following a diagnostic lumbar puncture for severe headache with a cerebral CT scan normal. The CSF from the lumbar puncture was also normal. Asymptomatic COVID-19 infection was diagnosed on admission. Medical treatment for 3 days was ineffective and an EBP with 30 mL of autologous blood effectively improved the symptoms. The patient was discharged 4 days later and followed up for 6 additional days with no reported complications.

1.4. Case 4

A 21-year-old healthy female patient with asymptomatic COVID-19 infection diagnosed on admission complained of bifrontal positional headache on Day 1 after labor epidural analgesia complicated by a dural tap. Initial medical treatment was unsuccessful. An EBP with 23 mL of hydroxyethyl starch was performed on Day 2 with no improvement. On Day 4, she presented with left sided upper and lower limb weakness and ataxia. A cerebral MRI was performed showing a superior sagittal sinus thrombophlebitis complicated by a frontal venous infarct and signs of pachymeningitis. A therapeutic heparin infusion was started with progressive resolution of the weakness but persistent ataxia. A lumbar MRI was performed on day 5 showing no sign of CSF leak. A cerebral CT scan on Day 6 showed similar results. Since the headache persisted on Day 8, after withholding heparin infusion an EBP with 6 mL of autologous blood was performed with subsequent improvement; the volume was low because the patient had difficulty maintaining a sitting position. The patient was observed for 8 additional days before being discharged. After 1 month of follow-up, her ataxia had resolved, and her clinical examination was normal.

1.5. Case 5

A 38-year-old healthy G3P0 female patient was scheduled for a cesarean section due to the lack of progress in labor. She complained of headache on Day 1 after a labor epidural with 4 punctures. Her headache was refractory to medical treatment. The patient had been diagnosed with asymptomatic COVID-19 infection (positive PCR test) 9 days before. An EBP with 18 mL of autologous blood was performed on day 2. The symptoms rapidly improved and the patient was observed for 2 days before being discharged. No complications were noted on discharge and on Day 8.

2. Discussion

In patients with COVID-19, the administration of autologous blood in the epidural space can potentially predispose to viral introduction into the central nervous system (CNS) with unpredictable consequences. This concern was expressed in the joint statement of the European and American Societies of Regional Anesthesia, recommending postponing an EBP until recovery from the infection and carefully weighing the risk and benefits before performing this procedure in patients with active illness [2].

To our knowledge, there are currently two separate cases of uneventful EBP in COVID-19 patients, and no complications were reported [3], [4]. We present here five additional cases of PDPH refractory to conservative management and treated with EBP with no complications on short-term follow-up. Three of these patients were asymptomatic for COVID infection, theoretically reducing the risk of viremia. The risk of viremia was likely higher in the remaining two symptomatic patients. The absence of complications and the rapid improvement of symptoms after the EBP was performed suggest that CNS spread did not occur.

Given the present uncertainty, we believe that the previously defined algorithm (Fig. 1 ) is adequate, with the epidural blood patch positioned after all other strategies have failed, but the limited available literature and our case series suggest that it can be performed effectively and safely.

Fig. 1.

Algorithm applied to determine the use of Epidural Blood Patch.

Informed consent and patient details

The Institutional Review Board of the French Society of Anesthesia and Intensive Care Medicine (IRB 00010254 - 2022 – 098, September 11, 2022) waived ethical approval.

The authors declare that this report does not contain any personal information that could lead to the identification of the patient(s).

The authors declare that they obtained a written informed consent from the patients included in the article. The authors also confirm that the personal details of the patients have been removed.

Disclosure of interest

All authors declare no conflicts of interest.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author contributions

All authors attest that they meet the current International Committee of Medical Journal Editors (ICMJE) criteria for Authorship.