Cosyntropin for use in treatment of post-dural puncture headaches in pediatric patients
Post-dural puncture headache (PDPH) is the most common complication after a lumbar puncture (LP) (Ona X 2013). Treatment for PDPH consists of both conservative and invasive modalities. Conservative treatment includes hydration, nonsteroidal anti-inflammatory drugs (NSAIDS), caffeine, and anti-emetics. PDPH is partly a result of cerebral vasodilation as a compensatory attempt to restore intracranial volume (Frank 2006). Caffeine induces vasoconstriction of these vessels, thus alleviating the pain with an efficacy rate of 70% (Frank 2006, Zeger 2012).
While invasive, autologous EBP (blood patch) is considered the definitive treatment for PDPH. Complications include radicular pain from nerve root irritation or displacement, cranial nerve palsies, meningeal irritation, elevated intracranial pressure, paresthesias, cauda equine syndrome, infection, back pain, and subdural hematomas. Contraindications include patient refusal, fever or suspected bacteremia, and anticoagulation (Frank 2006).
Another option involves administration of cosyntropin, an ACTH analog. Cosyntropinincreases the production of CSF by stimulating the release of aldosterone, thus decreasing the amount of traction and producing mild beta-endorphin effects (Zeger 2012). While an adult study demonstrated reduction of PDPH with cosyntropin prophylaxis (Hakim), there are no pediatric studies that examine its efficacy. The purpose of this study is to compare the efficacy of cosyntropin versus invasive treatment in the pediatric population at a tertiary hospital.
Materials and Methods:
This study was an IRB-approved retrospective cohort review. Patients who experienced PDPH at our tertiary care academic medical center were retrospectively identified from the EMR system for a time period of seven years, October 2010 – June 2017. Patient groups included subjects that received a conservative treatment regimen for PDPH, patients who received EBP, and patients who received cosyntropin. Data collected for each groups included: patient age, weight, ASA status (coded by a board certified pediatric anesthesiologist), medications and dose administered, fluid administration, if EBP performed, and medical history. Minitab software (version 17; Minitab Inc, State College, PA) was used to calculate descriptive statistics. Patient characteristics across treatment groups were compared using the Students t-test.
A total of 63 patient’s presented with PDPH (41 females and 22 males) during the study timeframe (age range: 5 years – 21 years, mean: 14 years). Patient characteristics by group were analyzed to assess for differences. ASA status was the only variable that differed between groups. All patients included in the study received conservative treatment of IVFs and caffeine. Of these, 52.4% (n=33/63) of these patients experienced resolution with conservative treatment alone, while 6.3% (n=4/63) received a blood patch after conservative treatment failed to provide full resolution of symptoms.
41.3% (n=26/63) received cosyntropin after conservative treatment failed to provide resolution of symptoms of which 81% (n=21/26) experienced resolved symptoms. Only 19% (n=5/26) continued on to EBP after receiving cosyntropin. Cosyntropin was administered at a dose of 1 mg in 22/26 patients, and 4/26 patients were administered a dose of 0.5 mg.
Our study demonstrates that cosyntropin is an effective alternative for epidural blood patch for treating PDPH. Cosyntropin can be used as a secondary treatment option after conservative treatment fails to avoid an invasive epidural blood patch procedure. Cosyntropin also has an added benefit of avoiding an anesthetic for patients undergoing performance of a blood patch.
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