1. EBM Group 3 Sheetal Pratibha Dhaval Nachiket

2. SCENARIO A 29 year old female, who was HIV sero- positive, underwent LSCS under spinal anaesthesia. Twenty four hours later she developed bilateral severe occipital headache. Headache was radiating to the neck and was aggravated in sitting posture. It was associated with photophobia, nausea and vomiting. She was diagnosed to have Post Dural Puncture Headache (PDPH).

3. SCENARIO She was treated conservatively with complete bed rest, plenty of fluids (both oral and parenteral), abdominal binders, systemic analgesics, caffeine etc. for the next 2 days without any improvement in the symptoms.

4. SCENARIO Decision to perform epidural blood patch (EBP) was taken by the consultant. But the consultant faced the dilemma of whether infected (viremic) blood of the patient could be injected into the patient’s epidural space. So he resorted to the practice of EBM

5. COMPONENTS OF QUESTION P - Adult patients, HIV+ve, post-dural puncture headache (PDPH), female, post LSCS I – Epidural blood patch (EBP) C – HIV versus non-HIV O – CNS infection Type of question – Treatment Type of study – Meta-analysis, RCT

6. QUESTION In HIV+ve adult patients with persistent PDPH, is the EBP a safe method of treatment (outcome CNS infection) as compared to those without HIV infection?

7. KEYWORDS HIV+ve adult PDPH EBP CNS infection

8. LITERATURE SEARCH Databases searched – Medline, Google scholar, Cochrane Google search also done Search strategy - HIV positive AND epidural blood patch (no filters used)

9. RELEVANT ARTICLES FOUND Not a single RCT One case series (1 – full text available) A few case reports Expert opinions (2 - no abstracts)

10. PAPER SELECTED FOR BEST EVIDENCE Tom DJ, Gulevich SJ, Shapiro HM, Heaton RK, Grant l. Epidural Blood Patch in the HIV Patient. Anesthesiology. 76: 943-947. 1992.

11. CRITICAL APPRAISAL

12. MATERIALS AND METHODS HIV+, refractory to conservative treatment for PDPH Treated with EBP Post-EBP neuropsychological follow up Prior, 0, 6 months or more (up to 2 years) No inferential statistics, purely descriptive Convenience sampling (only men) No sample size estimation

13. RESULTS 7 of 281 HIV+, refractory to conservative treatment for PDPH Unable to identify morbidity attributable to the EBP in these patients who were followed for a period of six months to two years.

14. CONCLUSION In summary, the safety of EBP's in HIV patients remains to be fully evaluated. However, evidence from the reports to date appears to demonstrate no associated morbidity.

15. CASE REPORTS Three single case histories of EBP's (2, 3, 4) in HIV patients have likewise demonstrated no adverse sequelae. One of these patients was followed for a period of nineteen months, while a second had received two blood patches over a period of three years. 2. Frame WA, Lichtmann MW. Blood Patch in the HIV - positive Patient. Anesthesiology. 73:1297. 1990. Letter to the Editor. 3. Bevacqua BK, Slucky AV. Epidural Blood Patch in a Patient with HIV Infection. Anesthesiology. 74: 952. 1991. Letter to the Editor. 4. Gibbons JJ. Post Dural Puncture Headache in the HIV - positive patient. Anesthesiology. 74: 953. 1991. Letter to the Editor.

16. POSSIBLE ALTERNATIVE Allogenic epidural blood patch Case report – coccidiodomycosis with HIV No complications No more evidence available