Intravenous Cosyntropin in the Management of a Post-Dural Puncture Headache

Intravenous Cosyntropin in the Management of a Post-Dural Puncture Headache

Ann-Marie Surette, MD1, Robert Herreria, MD2,  Laura Morello, MDUniversity of Connecticut School of Medicine, Farmington, CT  2St. Francis Hospital and Medical Center, Hartford, CT

INTRODUCTION

Post-dural puncture headache (PDPH) is the most common complication following labor neuraxial anesthesia. While epidural blood patch (EBP) is the most effective treatment, a subset of patients will refuse or have an absolute contraindication.

It is important to provide alternative treatment options for patients with PDPH. One pharmacologic treatment option is cosyntropin, a synthetic adrenocorticotropic hormone (ACTH).

 

CASE DESCRIPTION

31 yo G1 P0000 at 41 weeks for induction of labor due to late-term pregnancy.

 

Labor course:

  • dinoprostone
  • oxytocin

 

Epidural placement:

  • multiple attempts by resident and attending
  • successful placement at L3-L4 with adequate pain relief
    ● no accidental dural puncture
  • multiple boluses with poor pain control

 

Cesarean section:

  • multiple attempts to perform spinal
  • multiple attempts to place epidural
  • clear fluid obtained from Tuohy needle at L3-L4 → injected 1.8ml of 0.75% hyperbaric bupivacaine
  • no surgical anesthesia obtained
  • general anesthesia required

POD1:

  • severe 10/10, positional headache (HA)→ occipital with radiation to the neck
  • IV hydration, oral analgesics, and oral Fioricet
  • refused EBP due to prior neuraxial difficulty
  • 750mcg IV cosyntropin in 1L normal saline over 1 hour
  • within 4 hours, visual analogue scale (VAS) score 5/10 with improved functional status

POD2:

  • increase in HA, VAS scores 6-7/10
  • no change in functional status

POD3:

  • improvement in HA, VAS scores 5/10
    POD4:
  • discharged home, no subsequent ED visits/treatment

 

DISCUSSION

Cosyntropin: analog of the first 24 amino acids of ACTH

  • same hormonal activity, less antigenicity

Mechanism of action:

  • increased aldosterone secretion
  • promotion of dural edema→ overlap of puncture site
  • increased CSF production through active Na+ transport
  • release of brain B-endorphins

 

Multiple case reports have been published showing a benefit of cosyntropin in PDPH management. RCTs are inconclusive.

 

Rucklidge 2004: 18 women with PDPH, IM ACTH vs. IM saline.

VAS scores: pre-treatment and at 6, 12, 24, 48 hrs.

  • Results: No difference in VAS scores or rescue EBP

eger 2012: 33 patients with PDPH, IV cosyntropin vs. IV caffeine. VAS scores: pre-treatment and at 60 and 120 minutes.

  • Results: No difference in efficacy rates or VAS scores

 

Hanling 2016: 28 patients with PDPH, IV cosyntropin vs. EBP.

VAS/function scores: pre-treatment and Days 0, 1, 3, 7.

  • Results: EBP superior on Day 1

Cosyntropin = EBP on Days 0, 3, 7

Hakim, 2010. Kaplan–Meier curves for the occurrence of postdural puncture headache (PDPH) in cosyntropin and control groups.

Hakim 2010:  90 women with accidental dural puncture, IV cosyntropin vs. placebo 30 minutes after vaginal delivery.  Assessed for HA and VAS scores every 8 hours.

  • Results: Significantly fewer patients in the cosyntropin group developed a PDPH or required an EBP

CONCLUSIONS

Additional research needs to be done before ACTH can be routinely recommended as a pharmacologic treatment of PDPH. RCTs:

  • small with overall high risk of bias
  • heterogenous data
  • different measured outcomes

Zeger 2012: no difference between cosyntropin and caffeine

  • risk of attrition bias
  • short followup times

Hanling 2016:

  • bimodal response to cosyntropin
  • multiple types of responders: early, late, non-responders
  • immediate response with later effect natural course

Hakim 2010:

  • largest RCT
  • cosyntropin is more effective as prophylaxis for PDPH

Questions: best delivery route, total dose, number of doses, and length of infusion.

 

REFERENCES

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