虽然受到神经阻滞和全麻的冲击，现在硬膜外打得比以前少了很多，但毕竟是麻醉的拿手绝活，特别是在产科和骨科手术中还是很多应用。人在河边走，总会弄湿鞋。就是我这样的老司机，大意的时候也会打穿，有自身因素，也有病人因素。每个人在打穿之后的做法流程无外乎以下：改全麻或换个或同个间隙，小心翼翼地再打一次，术中给药少量多次。跟外科医生说下打穿了，术后多补水，卧床休息。至于补多少水，卧床多久也没个定数。手术结束的时候硬膜外腔打生理盐水，或者羟乙基淀粉20ml不等，基本到此为止了。至于会不会痛，就看病人的造化了，而且我们也不知道。痛的话就给点止痛药，颅痛定强痛定杜冷丁的都有，再止不住的话就要电话给你了，这时候神经内科会诊，磁共振，血补丁准备了。

2019年的 国际产科麻醉杂志 杂志（international journal of obstetric anesthesia）中 关于 产科硬膜后意外穿透后处理措施。全文摘译一下，以供参考：

（1）、卧床有用吗？

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. 卧床只能短期缓解，但不推荐长期卧床。这点在我看来值得商榷，临床确实发现产科穿透后头痛发生率较骨科高，很重要一点就是产科要求早翻身早起床。上面所提到的是头痛后卧床，而不是穿透后早期卧床。但需注意长期卧床带来的血栓栓塞并发症以及延长住院时间等，因此我们操作时应更加小心谨慎为是。

（2）、口服或静脉补液

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. 每次打穿后麻醉都会和外科说这样的话，多补点液，自己也会在术中多补液，外科也会问你补多少。我们也说不出个所以然，只会含含糊糊的说比平时多个1000ml吧。姑且不论多补液的理论基础是什么，补这么多液体会不会对患者造成伤害呢？因此，这里推荐只需要保持患者不脱水就行，而不是液体超负荷。

（3）、硬膜外注入晶胶体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.很多情况下，很多医师硬膜外穿破后会在手术结束后推注生理盐水或羟乙基淀粉，至于多少量，和文献报道一样，也是五花八门。徐铭军教授2016年发表在JCA的文章报道，使用6ml/L的速率硬膜外输注生理盐水150ml，也就是大概术后24小时，可以成功降低产科硬膜外穿透后头痛，不过这种方法尚未见其他医院使用。也有文献报道2小时内给与100-200ml生理盐水的，不过可能产生腰背痛，甚至视网膜出血的情况。因此常规操作给予10-30ml生理盐水，而胶体液的量也参考晶体。

（4）什么时候要用到血补丁

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.（当使用其他保守治疗仍不能缓解穿透后头痛问题时，应当考虑使用EPB疗法，如果不实施EPB，可能会发展为慢性头痛，慢性腰痛，硬膜下血肿，脑静脉窦血栓形成等。但目前不认为EPB可以降低慢性头痛，慢性背痛，硬膜下血肿等并发症的发生率。）

（5）血补丁的最佳时机

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.（最好在出现头痛48小时内实施，但临床中大多数都是在保守治疗之后才会采取血补丁治疗，但仍有效）

（6）血补丁疗效是否确切

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.（一般认为血补丁有效率可达到50-80%，但也有少数患者需要再来一次）

（7）血补丁打哪个位置？

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.（血补丁穿刺部位在原来穿透的节段或下一个节段）

（8）血补丁用多少？

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.（推荐20ml，但也碰到过20ml推不完或推的过程中病人很不舒服的情况，这时候应停止）

（9）血补丁无效怎么办？

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.（一针无效，在排除其他引起的头痛情况下，可以再来一针，如果还无效，那么得请神经内科会诊）

（10）血补丁的副作用有哪些？

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.（最主要的风险就是可能再穿透一次，腰背痛及神经症状也有发生，因此操作前需要与患者告知可能风险）

（11）打完血补丁，接下来还有哪些处理？

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.（打完之后注意随访，是否头痛缓解，出院时最好在病历卡里记录一下）

（12）血补丁会影响下次硬膜外效果吗？

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.（目前尚无证据表明血补丁对下一次椎管内麻醉有影响，但有一点就是，如果碰到那种容易穿透的病人最好出院的时候交待一下，很有可能再次穿透）