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Blood Patch in a Jehovah’s Witness: Case Report of a Novel Arterial-to-Epidural Closed-Circuit Technique

Olsen, Kevin, R., MD; Screws, Ashley, L., MD; Vose, Stephen, O., MD

doi: 10.1213/XAA.0000000000000661
Case Reports
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Jehovah’s Witness patients have unique perioperative challenges involving blood products. We describe the use of a novel method to maintain a closed circuit between a Jehovah’s Witness patient’s arterial blood and the epidural space while performing a blood patch for postdural puncture headache. Previously described methods have utilized venous catheters to maintain a closed circuit between the body and the epidural space. This is the first report we are aware of that utilizes a closed-circuit arterial blood supply to create an epidural blood patch in a Jehovah’s Witness patient.

From the Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida.

Accepted for publication September 12, 2017.

Funding: None.

The authors declare no conflicts of interest.

Address correspondence to Kevin R. Olsen, MD, Department of Anesthesiology, University of Florida College of Medicine, 1600 SW Archer Rd, PO Box 100254, Gainesville, FL 32610. Address e-mail to kolsen@anest.ufl.edu.

Postdural puncture headaches (PDPHs) are a recognized complication of intrathecal access, and the use of an epidural blood patch remains the gold standard treatment for moderate to severe PDPH. The mechanism of action is understood to be that the injected blood initially increases the pressure in the spine that compresses the thecal space and translocates cerebrospinal fluid in the cranial direction with maintenance of therapeutic effect by clot formation, resulting in prevention of further cerebrospinal fluid loss.1 Patients who refuse blood products that have been in discontinuity with their vascular system, most notably Jehovah’s Witness patients, pose a clinical challenge in administering this gold standard treatment. Written consent was obtained from the patient for publication of this case report.

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CASE DESCRIPTION

Background

A 46-year-old, American Society of Anesthesiologists III, female Jehovah’s Witness with a history of supermorbid obesity (body mass index, 50), bipolar disorder, chronic migraine, chronic low back pain, and chronic obstructive pulmonary disease presented to the emergency department (ED) with complaints of headache, neck pain, subjective fever, and chills 4 days after receiving a lumbar epidural steroid injection for chronic back pain. On presentation, the patient was afebrile and normotensive, with a white blood cell count of 10.8 × 103/µL. Meningitis was suspected and workup included noncontrast computed tomography (CT) of the cervical spine and head, blood cultures, and lumbar puncture. Multiple attempts at lumbar puncture were performed in the ED with eventual consultation of interventional radiology, who successfully performed a fluoroscopically guided lumbar puncture. Cerebrospinal fluid analysis displayed no xanthochromia, 32 lymphocytes, 44 monocytes/macrocytes, 8300 red blood cells, 15 white blood cells, 24 polymorphonuclear leukocytes protein of 103 mg/dL and glucose of 63 mg/dL, with negative cultures and opening pressure of 16.

The patient remained hospitalized and stable for 7 days, throughout which she was evaluated for the cause of her headaches. Neurosurgery performed a CT angiogram of her head for suspicion of subarachnoid hemorrhage but identified none. Neurology determined that consistent headache was likely a PDPH exacerbated by multiple lumbar puncture attempts in the ED. Anesthesiology was then consulted for placement of a blood patch. On discussion with the patient, her beliefs as a Jehovah’s Witness prevented her from receiving a blood patch in the traditional fashion. She would only accept a blood patch if a closed circuit was established between her circulation and the epidural space. A literature review demonstrated 4 instances in the English literature of venous–epidural blood patch using a closed-circuit technique.

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Technique

Blood pressure, heart rate, electrocardiogram, and end-tidal CO2 were continuously monitored. With the patient in a supine position, an elective left radial arterial line was placed under ultrasound guidance with lidocaine for local skin anesthesia. Rationale for placement of the arterial line included a known history of difficult intravenous (IV) access with minimal peripheral options, the need for on-demand blood, the patient’s body habitus, and minimization of upright position time. The arterial line was transduced to confirm intraarterial placement.

The arterial line transducer female stopcock port was connected to IV tubing with a 3-way stopcock incorporated. A 30-mL syringe was connected to the IV tubing 3-way stopcock, and the entire circuit was flushed through with normal saline while keeping the open end of the IV tubing sterile. Another IV tubing set with a 3-way stopcock incorporated into it was placed onto the sterile field and flushed with normal saline. The Figure demonstrates the circuit used for the procedure.

Figure

Figure

The patient was placed in the sitting position and administered 3-mg midazolam and 1000-μg alfentanil in divided doses for sedation and anxiolysis. Ultrasound was utilized to identify the midline spine given the patient’s body habitus, and the L2, L3, and L4 interspaces were marked with a pen. The patient was prepared and draped in a sterile fashion. A 22-gauge needle was used to introduce 5 mL of 1% lidocaine into the midline subcutaneous tissues over the L2–L3 interspace. An 18-gauge Tuohy needle was then introduced into the interspace, and a loss of resistance glass syringe filled with air was attached. Loss of resistance was achieved at a depth of 6 cm.

The sterile IV extension tubing was connected to the Tuohy needle at 1 end, and with a male–male connecter, the female end was connected to the primed IV tubing/arterial line circuit off the sterile field. The blood would now be in a continuous closed circuit. The normal saline “dead space” on the arterial side was removed using the 30-mL syringe until only blood was aspirated. This “waste” was discarded, and a 30-mL syringe was again connected to the circuit to aspirate only blood from the arterial side. This blood was then injected toward the Tuohy end of the circuit. At the Tuohy end, a stopcock was turned “off” to the patient and “on” to the environment to allow “waste” of normal saline “dead space” to flow until just before blood reached the stopcock. At this point, the stopcock was turned “on” to the patient and 25 mL of blood was injected into the epidural space. The Tuohy needle was then withdrawn and a sterile dressing was placed over the entry point. The patient was placed in a supine position with immediate benefit demonstrated by a reduction in pain score from 8/10 to 3/10. No blood exited the circuit at any point in the procedure or made contact with the environment.

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DISCUSSION

To our knowledge, this is the first case report of using an arterial-to-epidural closed-circuit technique to provide an epidural blood patch to a Jehovah’s Witness. Previous case reports have utilized IV access rather than intraarterial access to facilitate closed-circuit epidural blood patch placement.2–4

We opted for an intraarterial technique given the patient’s severe pain with the upright position and multiple failed IVs in the past as well as easily collapsible vasculature. We did not want to risk an IV that would not draw blood back after we had sat the patient in the upright position. The use of a radial intraarterial catheter placed with ultrasound and confirmed with pressure transduction is a reliable method to obtain autologous blood to be used in a closed circuit for an epidural blood patch. It may produce blood more reliably on aspiration compared with IV access, which is crucial to decrease the time that the patient is upright for the procedure and thus minimize the patient’s pain and suffering.

Patients require individualization of their care in the perioperative period that coincides with their goals and personal beliefs. Care must be taken to treat the patient in accordance with those goals and beliefs while also adhering to the principles of beneficence, nonmaleficence, autonomy, and justice. Although the procedures and techniques required to achieve the patient’s goals while respecting her beliefs and adhering to the principles outlined above may be unorthodox or unfamiliar, this case demonstrates that it is possible.

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DISCLOSURES

Name: Kevin R. Olsen, MD.

Contribution: This author helped care for the patient and write the manuscript.

Name: Ashley L. Screws, MD.

Contribution: This author helped care for the patient and write the manuscript.

Name: Stephen O. Vose, MD.

Contribution: This author helped care for the patient and write the manuscript.

This manuscript was handled by: Raymond C. Roy, MD.

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REFERENCES

1. Gaiser RR. Postdural puncture headache: an evidence-based approach. Anesthesiol Clin. 2017;35:157–167.
2. Jagannathan N, Tetzlaff JE. Epidural blood patch in a Jehovah’s Witness patient with post-dural puncture cephalgia. Can J Anesth. 2005;52:113.
3. Silva Lde A, de Carli D, Cangiani LM, Gonçalves Filho JB, da Silva IF. Epidural blood patch in Jehovah’s Witness: two cases report. Rev Bras Anestesiol. 2003;53:633–639.
4. Kanumilli V, Kaza R, Johnson C, Nowacki C. Epidural blood patch for Jehovah’s Witness patient. Anesth Analg. 1993;77:872–873.
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