Differential Diagnosis of Postpartum Headache between Post-Dural Puncture Headache and Intracerebral Hemorrhage: A case report / 대한마취과학회지

We report a patient with a postpartum headache, who was later diagnosed with an intra cerebral hemorrhage. She underwent a cesarean section under the combined spinal-epidural anesthesia, and complained of a suspicious post-dural puncture headache (PDPH) in the puerperium. The headache was partially improved with analgesics and she was discharged. The day after discharge, the headache became aggravated and she visited our labor floor for further treatment. An epidural blood patch (EBP) was performed because the headache regarded as aggravation of PDPH. However, hemiparesis and dysarthria developed 40 minutes after the EBP. Computed tomography was revealed an intracerebral hemorrhage in the right side basal ganglia. She was transferred to the neurosurgical intensive care unit. She was treated conservatively and has almost completely recovered. This case highlights the need to consider an intracranial hemorrhage, a cerebrovascular accident, nonspecific headache and PDPH when making a differential diagnosis of postpartum headache, particularly when an atypical postpartum headache is noted.

Benign and Malignant Tumors Detected in the Patients with Intractable Chest Pain: 2 case reports / 대한통증학회지

Many patients with intractable chest pain visit pain clinics, two of which, with rare cases of an intraspinal tumor and malignant mesothelioma were experiences at our clinic. A 37-year old female patient presented with exacerbating chest pain, but without neurological manifestations, of 15-months duration. Her laboratory findings, such as blood tests, chest X-ray, EKG, abdominal ultrasonography and chest CT, were normal. MRI revealed an intradural extramedullary schwannoma at the T 5 and 6 levels of the thoracic spine. She completely recovered following a laminectomy, with removal of the tumor. The other case was a 65-year old male patient, who presented with chest and back pain in the thoracic area of 6 months duration. He had no cough and dyspnea, and was initially misdiagnosed with intercostal neuralgia; therefore, pain control medication was administered, but all trials were ineffective. Finally, chest CT revealed a malignant mesothelioma, with multiple spine metastases. In conclusion, patients with intractable chest pain should be re-examined both clinically and radiographically.

The Effects of 0.45% and 0.9% Saline Solutions on Serum Sodium Concentrations in Chronic Renal Failure Patients / 대한마취과학회지

BACKGORUND: To choose optimal potassium free solutions in chronic renal failure patients, we studied the effects of 0.45% or 0.9% saline solutions on the serum sodium concentrations of patients undergoing kidney transplantation surgery. METHODS: Sixty two patients, ASA physical status iii iV, undergoing kidney transplantation surgery, were allocated to receive either 0.45% saline (n = 26) or 0.9% saline solutions (n = 36). The patients received 2 L of 0.45% or 0.9% saline solutions with a CVP of 10 mmHg prior to a renal vein anastomosis. Serum sodium and potassium concentrations were measured before (Na0, K0) and after the administration of 2 L of 0.45% or 0.9% saline solutions (Na2, K2), respectively. RESULTS: Serum sodium concentrations decreased after the administration of 0.45% saline solutions, and after administrating 2 L of 0.9% saline, the serum sodium concentrations increased in patients with baseline serum sodium concentrations lower than 136 mEq/L. When we administered 0.9% saline, which had a sodium concentration lower than the serum sodium concentration, the serum sodium concentration measured after 2 L of 0.9% saline infusion proportionally decreased in patients with baseline serum sodium concentration greater than 136 mEq/L (P<0.001). CONCLUSiONS: For ideal fluid selection in chronic renal failure patients, this study suggests a 0.45% saline solution for chronic renal failure patients with a baseline serum sodium concentration below the normal range and a 0.9% saline solution for patients with a baseline sodium concentration within the normal range.

Does the Venovenous Bypass influence Coagulation Status in Living-Related Liver Transplantation? / 대한마취과학회지

BACKGORUND: Venovenous bypass (VVB) in liver transplantation has been used to decrease the acute hemodynamic and metabolic changes during anhepatic periods. But, the use of VVB in patients undergoing liver transplantation is still under debate concerning its relative risks and benefits. Therefore, the aim of this study was to examine the influences of VVB on the coagulation status and the amount of transfusion in living-related liver transplantation. METHODS: We conducted this retrospective study on 39 patients who underwent orthotopic living-related liver transplantation using the piggyback technique from March 2001 to April 2002. While 19 patients did not receive venovenous bypass, 20 patients received. We compared the two groups in terms of coagulation-related parameters (prothrombin time, activated partial thromboplastin time, platelet count, fibrinogen and thromboelastograph), the amount of transfusion during intraoperative and post-operative 1day. We also compared the incidences of post-reperfusion syndrome in the two groups. RESULTS: The group that underwent living-related liver transplantation with VVB required more packed red blood cell (p-RBC) transfusion than the other group without VVB from post-reperfusion untill the end of operation (P<0.05). This difference in the amount of p-RBC transfusion may be due to the blood remained in the VVB circuit at the termination of VVB. However, the two groups were similar in terms of coagulation-related parameters, the amount of other blood components, such as fresh frozen plasma, platelet concentrates, cryoprecipitate, total amount of transfusion during the 24 hours post- operatively, and the incidence of post-reperfusion syndrome. CONCLUSiONS: We conclude that the using of venovenous bypass in living-related liver transplantation did not influence coagulation status and the amount of transfusion perioperatively.

Gabapentin as a Adjuvant Analgesic in Central Pain Syndrome / 대한마취과학회지

BACKGROUND: This study was undertaken to investigate the analgesic efficacy and safety of gabapentin in central pain syndrome. METHODS: With a diagnosis of central pain syndrome, a total 24 patients were accumulated in the outpatient pain clinic. Patients had been stabilized in their analgesic regimen at least four weeks prior to the study. Anticonvulsants, if taken, were discontinued for two weeks for wash-out. Pretreatment baseline pain scores (visual analog scale and pain intensity score) were obtained. Oral administration of gabapentin 300 mg was started in all patients. Initial doses were given from 300 mg per day with gradual titration over two weeks until 1) the onset of analgesic effect, 2) the maximum of 2,400 mg per day, and 3) the onset of intolerable side effects. Dosage was adjusted weekly. At the four-week study end point, VAS, PIS, pain improvement scores judged by family members, drug efficacy, tolerability and overall evaluation were assessed. The incidence of side effects was also noted. RESULTS: Fifteen patients dropped out due to various reasons. Data was collected from 9 patients (male = 4, female = 5). Among these, 3 had strokes and 6 spinal cord lesions due to trauma, cancer metastasis or syringomyelia. The average disease duration was 4.2 years. Analgesic onset was within two weeks and the average dose taken was 477.7 mg. At the end of the study, the VAS score and PIS revealed significant pain relief. These results were objectively reflected in pain improvement scores observed by family members. The majority scored good or excellent in all scales of drug evaluation. Sedation was the most frequently reported side effect. Others included dry mouth, weakness, and diarrhea, which were spontaneously resolved with lower dose maintenance. CONCLUSIONS: Gabapentin showed analgesic effect for central pain syndrome at a lower dose range than any other neuropathic pain syndromes. It appears to have different analgesic dose requirements in this difficult pain syndrome.

The Effects of Opioid Sparing and Treatment of Opoid Bowel Syndrome of Intravenous Ketorolac in Terminal Cancer Pain Management / 대한마취과학회지

BACKGROUND: Pain management in the terminal stage of advanced cancer is often complicated by opioid-related bowel syndrome and other problems. This study was conducted to investigate the safety and efficacy of ketorolac as an adjunctive analgesic in cancer pain management. METHODS: 10 acutely ill cancer patients suffering from pain, complications of advanced disease, and opioid side effects were included. Except one acute leukemia, all of the patients had metastatic solid tumors. Pain complaints consisted of visceral, somatic and opioid bowel syndrome. They were treated with intravenous morphine patient-controlled analgesia infused with a repeated ketorolac bolus dosing. Demographic data, cancer diagnosis, change of pre- and post-treatment morphine infusion rates, and days until pain control or relief of opioid bowel syndrome were evaluated. RESULTS: Excellent pain relief with improvement of opioid bowel syndrome was achieved in a majority of cases. Ketorolac showed good morphine sparing effects. None of the patients reported gastrointestinal side effects. CONCLUSION: Ketorolac appeared to be well-tolerated in the clinical dose range and for short-term use in acutely-ill terminal cancer pain patients. It also seems to be very effective in relieving opioid-related bowel syndromes.