Comparison between Addition of Neostigmine and Atropine to Standard Post-Dural Puncture Headache Regimen Versus Standard Regimen Alone

Qaim Ali Bhatty; Sami  Wahid; Mobeen  Ikram; Khan Muhammad  Yaqub; Bilal Humayon Khan  Durrani; Hassan Nasir  Minhas

doi:10.51253/pafmj.v76i3.11444

Authors

Qaim Ali Bhatty Department of Anesthesiology, Combined Military Hospital Kharian/National University of Medical Sciences (NUMS) Pakistan
Sami Wahid Department of Anesthesiology, Combined Military Hospital Kharian/National University of Medical Sciences (NUMS) Pakistan
Mobeen Ikram Department of Anesthesiology, Combined Military Hospital Kharian/National University of Medical Sciences (NUMS) Pakistan
Khan Muhammad Yaqub Department of Anesthesiology, Combined Military Hospital Kharian/National University of Medical Sciences (NUMS) Pakistan
Bilal Humayon Khan Durrani Department of Anesthesiology, Combined Military Hospital Kharian/National University of Medical Sciences (NUMS) Pakistan
Hassan Nasir Minhas Department of Anesthesiology, Combined Military Hospital Kharian/National University of Medical Sciences (NUMS) Pakistan

DOI:

https://doi.org/10.51253/pafmj.v76i3.11444

Keywords:

Atropine, Caesarian, Neostigmine, Post-dural Puncture Headache

Abstract

Objective: To compare the treatment efficacy of adding neostigmine and atropine to standard treatment regimen versus standard regimen alone for post-dural puncture headache (PDPH) in patients after caesarian section delivery.

Study Design: Randomized controlled trial (IRCT: 72737).

Place and Duration of Study: Anesthesia Department, Combined Military Hospital, Kharian Pakistan, from Jun to Nov 2023.

Methodology: Patients in the standard regimen received the institute followed conservative management. Patients in the modified regimen (Group-A) received the same protocol and drugs of the standard regimen (Group-B) as well as IV neostigmine 20 mcg/kg and atropine 10 mcg/kg in 20 ml.

Results: Median pain scores 6 hours post-intervention were 3.00 (IQR=0.00) in Group-A versus 6.00 (IQR=0.00) in Group-B (p<0.001). Re-assessment of pain scores at 12 hours post-intervention showed median scores of 2.00 (IQR=0.00) in Group-A versus 5.00 (IQR=1.00) in Group-B (p<0.001). At 24 hours post-procedure, median scores were 2.00 (IQR=0.00) in Group-A versus 5.00 (IQR=0.00) in Group-B (p<0.001). Median scores at 48- and 72-hours post-intervention were 1.00 (IQR=0.00) and 1.00 (IQR=0.00) in Group-A versus 4.00 (IQR=0.00) and 3.00 (IQR=0.00) in Group-B (p<0.001).

Conclusion: We conclude that neostigmine/atropine as adjunct to standard therapy of post-dural puncture headache (PDPH) offer superior pain relief and early resolution of associated symptoms of neck stiffness and nausea.

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References

1. Boerma T, Ronsmans C, Melesse DY, Barros AJ, Barros FC, Juan L, et al. Global epidemiology of use of and disparities in caesarean sections. Lancet 2018; 392(10155): 1341-1348.

https://doi.org/10.1016/S0140-6736(18)31928-7

2. Xue R-H. Towards to a lower rate of cesarean delivery on maternal request: stick to indication. Authorea prep 2022.

https://doi.org/10.22541/au.165090446.68822946/v1

3. Rafiei M, Ghare MS, Akbari M, Kiani F, Sayehmiri F, Sayehmiri K, et al. Prevalence, causes, and complications of cesarean delivery in Iran: A systematic review and meta-analysis. Int J Reprod Biomed 2018; 16(4): 221.

https://doi.org/10.29252/ijrm.16.4.221

4. Schyns-Van den Berg AM, Gupta A. Postdural puncture headache: revisited. Best Pract Res Clin Anaesthesiol 2023; 37(2): 171-187.

https://doi.org/10.1016/j.bpa.2023.02.006

5. Ljubisavljevic S. Postdural puncture headache as a complication of lumbar puncture: clinical manifestations, pathophysiology, and treatment. Neurol Sci 2020; 41(12): 3563-3568.

https://doi.org/10.1007/s10072-020-04757-z

6. Russell R, Laxton C, Lucas D, Niewiarowski J, Scrutton M, Stocks G. Treatment of obstetric post-dural puncture headache. Part 1: conservative and pharmacological management. Int J Obstet Anesth 2019; 38: 93-103.

https://doi.org/10.1016/j.ijoa.2018.12.006

7. Russell R, Laxton C, Lucas D, Niewiarowski J, Scrutton M, Stocks G. Treatment of obstetric post-dural puncture headache. Part 2: epidural blood patch. Int J Obstet Anesth 2019; 38: 104-118.

https://doi.org/10.1016/j.ijoa.2018.12.005

8. Urits I, Cai V, Aner M, Simopoulos T, Orhurhu V, Nagda J, et al. Post dural puncture headache, managed with epidural blood patch, is associated with subsequent chronic low back pain in patients: a pilot study. Curr Pain Headache Rep 2020; 24(1): 1-5.

https://doi.org/10.1007/s11916-020-0834-5

9. Ibrahim SF, Talaat SM, AbdElrahman TN. Comparison between Adding Intravenous Neostigmine and Atropine versus Intravenous Hydrocortisone for Conservative Treatment of Postdural Puncture Headache After spinal Anaesthesia For Elective Caesarean Section. QJM Int J Med 2021; 114(Supplement_1): hcab086-050.

https://doi.org/10.1093/qjmed/hcab086.050

10. Saafan AAE, Mahmoud MS, Ghaly SI, Ahmed AM. A comparative study between the effect of Aminophylline, Neostigmine and Gabapentin on prevention of post dural puncture headache after cesarean section. QJM Int J Med 2021; 114(Supplement_1): hcab086-018.

https://doi.org/10.1093/qjmed/hcab086.050

11. Mahmoud AAA, Mansour AZ, Yassin HM, Hussein HA, Kamal AM, Elayashy M, et al. Addition of neostigmine and atropine to conventional management of postdural puncture headache: a randomized controlled trial. Anesth Analg 2018; 127(6): 1434-1439. https://doi.org/10.1213/ANE.0000000000003734

12. Gaiser RR. Postdural puncture headache: a headache for the patient and a headache for the anesthesiologist. Curr Opin Anesthesiol 2013; 26(3): 296-303.

https://doi.org/10.1097/ACO.0b013e328360b015

13. Bodian CA, Freedman G, Hossain S, Eisenkraft JB, Beilin Y. The visual analog scale for pain: clinical significance in postoperative patients. J Am Soc Anesthesiol 2001; 95(6): 1356-1361.

https://doi.org/10.1097/00000542-200112000-00013

14. Patel R, Urits I, Orhurhu V, Orhurhu MS, Peck J, Ohuabunwa E, et al. A comprehensive update on the treatment and management of postdural puncture headache. Curr Pain Headache Rep 2020; 24(6): 1-9.

https://doi.org/10.1007/s11916-020-00860-0

15. Li H, Wang Y, Oprea AD, Li J. Postdural Puncture Headache—Risks and Current Treatment. Curr Pain Headache Rep 2022: 1-12. https://doi.org/10.1007/s11916-022-01041-x

16. Girma T, Mergia G, Tadesse M, Assen S. Incidence and associated factors of post dural puncture headache in cesarean section done under spinal anesthesia 2021 institutional based prospective single-armed cohort study. Ann Med Surg 2022; 78.

https://doi.org/10.1016/j.amsu.2022.103729

17. Turai A, Prabha P. A Clinical Study to Evaluate the Effect of Intrathecal Atropine on Post Operative Nausea and Vomiting in Patients Receiving Intrathecal Morphine and Hyperbaric Bupivacaine for Spinal Anaesthesia: Prospective Randomized Trial. Karnataka Anaesth J 2021; 17(1-2): 23-31.

https://doi.org/10.4103/jdmimsu.jdmimsu_378_21

18. Nair AS. Questions regarding the use of neostigmine–atropine to treat postdural puncture headache. Anesth Analg 2019; 128(6): e126-e127.

https://doi.org/10.1213/ANE.0000000000004156

19. Makram E, Khashaba M, Mohamed N. Recent recommendations for prevention of post dural puncture headache in pregnant females undergoing cesarean section. Benha J Appl Sci 2021; 6(4): 150-155.

https://dx.doi.org/10.21608/bjas.2021.189900