雖然受到神經阻滯和全麻的沖擊，現在硬膜外打得比以前少了很多，但畢竟是麻醉的拿手絕活，特別是在產科和骨科手術中還是很多應用。人在河邊走，總會弄濕鞋。就是我這樣的老司機，大意的時候也會打穿，有自身因素，也有病人因素。每個人在打穿之后的做法流程無外乎以下：改全麻或換個或同個間隙，小心翼翼地再打一次，術中給藥少量多次。跟外科醫生說下打穿了，術后多補水，臥床休息。至于補多少水，臥床多久也沒個定數。手術結束的時候硬膜外腔打生理鹽水，或者羥乙基淀粉20ml不等，基本到此為止了。至于會不會痛，就看病人的造化了，而且我們也不知道。痛的話就給點止痛藥，顱痛定強痛定杜冷丁的都有，再止不住的話就要電話給你了，這時候神經內科會診，磁共振，血補丁準備了。

2019年的 國際產科麻醉雜志 雜志（international journal of obstetric anesthesia）中 關于 產科硬膜后意外穿透后處理措施。全文摘譯一下，以供參考：

（1）、臥床有用嗎？

Although most patients gain some relief from PDPH when supine, the effects may be transient. Prolonged bed rest is not recommended as it may increase the risk of thromboembolic complications. 臥床只能短期緩解，但不推薦長期臥床。這點在我看來值得商榷，臨床確實發現產科穿透后頭痛發生率較骨科高，很重要一點就是產科要求早翻身早起床。上面所提到的是頭痛后臥床，而不是穿透后早期臥床。但需注意長期臥床帶來的血栓栓塞并發癥以及延長住院時間等，因此我們操作時應更加小心謹慎為是。

（2）、口服或靜脈補液

Normal hydration should be maintained but there is no evidence of benefit from excessive fluid administration in the treatment of PDPH. intravenous fluids need only be used to prevent dehydration when adequate fluid cannot be taken orally. 每次打穿后麻醉都會和外科說這樣的話，多補點液，自己也會在術中多補液，外科也會問你補多少。我們也說不出個所以然，只會含含糊糊的說比平時多個1000ml吧。姑且不論多補液的理論基礎是什么，補這么多液體會不會對患者造成傷害呢？因此，這里推薦只需要保持患者不脫水就行，而不是液體超負荷。

（3）、硬膜外注入晶膠體There is currently insufficient evidence to recommend the use of epidural crystalloid and colloid infusions in the treatment of obstetric PDPH. Epidural saline bolus administration may improve symptoms but the effect is usually transient.很多情況下，很多醫師硬膜外穿破后會在手術結束后推注生理鹽水或羥乙基淀粉，至于多少量，和文獻報道一樣，也是五花八門。徐銘軍教授2016年發表在JCA的文章報道，使用6ml/L的速率硬膜外輸注生理鹽水150ml，也就是大概術后24小時，可以成功降低產科硬膜外穿透后頭痛，不過這種方法尚未見其他醫院使用。也有文獻報道2小時內給與100-200ml生理鹽水的，不過可能產生腰背痛，甚至視網膜出血的情況。因此常規操作給予10-30ml生理鹽水，而膠體液的量也參考晶體。

（4）什么時候要用到血補丁

There is currently insufficient evidence to suggest that an EBP reduces the risk of chronic headache, chronic back pain, cranial subdural haematoma, CVST or improves outcome in those with cranial nerve palsy in women with obstetric PDPH.（當使用其他保守治療仍不能緩解穿透后頭痛問題時，應當考慮使用EPB療法，如果不實施EPB，可能會發展為慢性頭痛，慢性腰痛，硬膜下血腫，腦靜脈竇血栓形成等。但目前不認為EPB可以降低慢性頭痛，慢性背痛，硬膜下血腫等并發癥的發生率。）

（5）血補丁的最佳時機

Patients should be informed that performing an EBP within 48 hours of dural puncture is associated with a reduction in its efficacy and a greater requirement for a repeat EBP. However, in severe obstetric PDPH, an EBP within 48 hours of dural puncture may be considered for symptom control, although it may need to be repeated.（最好在出現頭痛48小時內實施，但臨床中大多數都是在保守治療之后才會采取血補丁治療，但仍有效）

（6）血補丁療效是否確切

Multiple factors are likely to affect the success of an EBP. Although success rates of over 90% have been reported in older observational studies, more recent evidence suggests that complete and permanent relief of symptoms following a single EBP is only likely to occur in up to one third of cases where headache follows dural puncture with an epidural needle. Complete or partial relief may be seen in 50–80%. In cases of partial or no relief, a second EBP may be performed after consideration of other causes of headache.（一般認為血補丁有效率可達到50-80%，但也有少數患者需要再來一次）

（7）血補丁打哪個位置？

The major effect of an EBP appears to be within a few segments of the site of injection. Blood injected during an EBP spreads predominantly cranially. It is therefore recommended that an EBP is performed at the same level or one space lower than that at which the original dural puncture occurred.（血補丁穿刺部位在原來穿透的節段或下一個節段）

（8）血補丁用多少？

A volume of blood of 20 mL is recommended when performing an EBP. Injection should stop before 20 mL is injected if not tolerated by the patient.（推薦20ml，但也碰到過20ml推不完或推的過程中病人很不舒服的情況，這時候應停止）

（9）血補丁無效怎么辦？

A second EBP may be performed once other causes of headache have been excluded. If an EBP has produced some improvement in symptoms but the headache persists, a second EBP can be considered as it may be of benefit. In cases where an EBP has no effect on headache, or if the diagnosis of obstetric PDPH is less certain, or the nature of headache has changed, discussion with other specialties including obstetrics, neurology and neuroradiology should take place before a second EBP is performed.（一針無效，在排除其他引起的頭痛情況下，可以再來一針，如果還無效，那么得請神經內科會診）

（10）血補丁的副作用有哪些？

There is a risk of further inadvertent dural puncture during an EBP and this should form part of the consent process.

Back pain during an EBP may occur in 50% of women, and 24 hours after an EBP more than 80% of women may experience back pain.

Neurological symptoms such as Arachnoiditis, Spinal haematoma may occasionally develop after an EBP.（最主要的風險就是可能再穿透一次，腰背痛及神經癥狀也有發生，因此操作前需要與患者告知可能風險）

（11）打完血補丁，接下來還有哪些處理？

Patients who receive an EBP should be reviewed by an anaesthetist within four hours of the procedure. Women who are discharged home on the day of an EBP should be contacted the following day. Information on obstetric PDPH and EBP should also be given to the woman’s general practitioner and community midwife.（打完之后注意隨訪，是否頭痛緩解，出院時最好在病歷卡里記錄一下）

（12）血補丁會影響下次硬膜外效果嗎？

Evidence of the effect of an EBP on the success of subsequent neuraxial blockade is equivocal. All studies that have assessed the effect have methodological flaws. Current evidence is insufficient to comment on whether an EBP affects the outcome of subsequent neuraxial blockade.（目前尚無證據表明血補丁對下一次椎管內麻醉有影響，但有一點就是，如果碰到那種容易穿透的病人最好出院的時候交待一下，很有可能再次穿透）