Symptomatic Intrathecal Hematoma following an Epidural Blood Patch for an Obstetric Patient with Postdural Puncture Headache: A Case Report and Synthesis of the Literature.

Epidural blood patch (EBP), generally considered a low-risk procedure, can potentially lead to significant neurological complications. We report the case of a parturient who underwent an uneventful EBP for postdural puncture headache (PDPH) and subsequently presented with progressively worsening radicular symptoms. Magnetic resonance imaging (MRI) revealed an intrathecal hematoma, and conservative management with steroids led to complete recovery. Our case highlights the possibility of this rare complication following an uneventful procedure and the importance of prompt diagnosis and treatment to prevent serious adverse outcomes. Literature review, EBP alternatives, and strategies to minimize complications following blood patch will be discussed in this report.

A ten-year retrospective study of post-dural puncture headache in 32,655 obstetric patients.

PURPOSE: Accidental dural puncture and post-dural puncture headache are well-known complications of neuraxial anesthesia in parturients. The primary goal of this study was to identify the rate of post-dural puncture headache and epidural blood patch in all parturients who received a neuraxial anesthetic during a ten-year period at an academic tertiary-care medical centre. A secondary goal was to identify any delay in hospital discharge due to a post-dural puncture headache. METHODS: We conducted a retrospective analysis of all patients who received a neuraxial anesthetic on the labour and delivery unit at Stony Brook Medical Center from 1 January, 2006 to 31 December, 2015. Standardized neuraxial anesthesia equipment was used throughout this period. Chart reviews were conducted on all patients who received a neuraxial anesthetic and had an accidental dural puncture and/or developed a post-dural puncture headache. RESULTS: Of the 32,655 neuraxial anesthetics performed, 298 (0.9%) patients experienced a post- dural puncture headache. Analysis of all patients who developed a post-dural puncture headache showed that 150 (50.3%) patients received one or more epidural blood patches. Overall, 19 (0.06%) patients had a delay in hospital discharge due to a post-dural puncture headache. CONCLUSIONS: We showed a relatively low incidence (< 1%) of post-dural puncture headache following neuraxial anesthesia in parturients at an academic tertiary-care medical centre. Patients that rated their post-dural puncture headache as very severe were more likely to undergo at least one epidural blood patch procedure. Post-dural puncture headache is a well-known complication of neuraxial anesthesia, and may lead to a delay in hospital discharge.

Dexmedetomidine-Induced Massive Diuresis in a Patient Undergoing Spinal Fusion Surgery: A Case Report and Synthesis of the Literature.

Dexmedetomidine is an α2-adrenergic sedative-hypnotic medication used as an adjunct to general anesthesia. While experimental studies in animals have demonstrated a mild diuretic effect of dexmedetomidine, only recently have case reports described dexmedetomidine-induced diuresis in humans. Interestingly, the majority of such cases have involved patients undergoing spinal fusion surgery. Here, we report a case of a 30-year-old woman undergoing cervical spinal fusion surgery who experienced a massive diuresis starting 30 minutes after receiving dexmedetomidine intravenous infusion. We discuss the differential diagnosis and synthesize the current literature on this rare effect.

Clinical Updates in Women's Health Care Summary: Perioperative Pain Management: Primary and Preventive Care Review.

The opioid epidemic in the United States has become a public health crisis, which continues to worsen. The purpose of this monograph is to help obstetrician-gynecologists develop a perioperative framework with which to identify patients at risk of dependence and addiction and to describe a multimodal approach to postoperative pain management using the pathways of enhanced recovery after surgery. Preoperative counseling and optimization of comorbid medical conditions, comprehensive patient education, and optimal postoperative management also will be reviewed.

Association of postoperative nausea/vomiting and pain with breastfeeding success.

BACKGROUND: Successful breastfeeding is a goal set forth by the World Health Organization to improve neonatal care. Increasingly, patients express the desire to breastfeed, and clinicians should facilitate successful breastfeeding. The primary aim of this study is to determine if postoperative nausea and vomiting (PONV) or postoperative pain are associated with decreased breastfeeding success after cesarean delivery. METHODS: This is a historical cohort study using the Stony Brook Elective Cesarean Delivery Database. Self-reported breastfeeding success at 4 weeks postoperative was analyzed for associations with postoperative antiemetic use and postoperative pain scores. Breastfeeding success was also analyzed for associations with patient factors and anesthetic medications. RESULTS: Overall, 86% of patients (n = 81) who intended on breastfeeding reported breastfeeding success. Breastfeeding success was not associated with postoperative nausea or vomiting as measured by post anesthesia care unit antiemetic use (15% use in successful vs. 18% use in unsuccessful, p = 0.67) or 48-h antiemetic use (28% use in successful group vs 36% use in unsuccessful group, p = 0.732). Pain visual analog scale scores at 6, 12 and 24 h postoperatively were not significantly different between patients with or without breastfeeding success. Breastfeeding success was associated with having had at least 1 previous child (86% vs 36%, p < 0.001). Patients with asthma were less likely to have breastfeeding success (45% vs 4%, p = 0.002). CONCLUSIONS: Efforts to improve PONV and pain after cesarean delivery may not be effective in improving breastfeeding success. To possibly improve breastfeeding rates, resources should be directed toward patients with no previous children and patients with asthma.

Effects of dose ranging of adenosine infusion on electrocardiographic findings during and after general anesthesia.

PURPOSE: To assess changes in the electrocardiogram (ECG) associated with intraoperative infusion of adenosine in patients undergoing open abdominal gynecological surgery. METHODS: One hundred and sixty-six patients undergoing gynecological surgery were randomly assigned to receive one of four doses of adenosine infusion (25, 50, 100, or 200 µg/kg/min) or matching placebo. Study drug administration was started at skin incision and discontinued at end of surgery. A standardized general anesthetic regimen was used and adjusted based on hemodynamic and bispectral index values. Heart rate and rhythm variables, and PR, QRS, QT, and QTc intervals were recorded from 12-lead ECGs before anesthesia and immediately after patient arrival in the postanesthesia care unit. In addition, a rhythm strip was obtained during administration of the loading dose of the study drug. ECG variables were compared within and between groups. Incidence of ECG and hemodynamic abnormalities was recorded. RESULTS: One hundred and fifty-one subjects had a full set of electrocardiographic data: placebo (n = 38), group adenosine 25 µg/kg/min (n = 31), group adenosine 50 µg/kg/min (n = 29), group adenosine 100 µg/kg/min (n = 28), and group adenosine 200 µg/kg/min (n = 25). Statistically significant postoperative QTc prolongation was observed in all study groups when compared with baseline except for the adenosine 200 µg/kg/min group. However, these changes from baseline were not different among the groups. There were also no significant differences in PR, QRS, and QT intervals between the treatment groups. CONCLUSION: There was no difference in QTc prolongation following intraoperative administration of adenosine infusion compared with placebo during isoflurane general anesthesia. However, QTc prolongation is common following general anesthesia.

Evaluation of prostaglandin D2 as a CSF leak marker: implications in safe epidural anesthesia.

BACKGROUND: It is accepted that there is a severe risk of dural puncture in epidural anesthesia. Of major concern to anesthesiologists is unintentional spinal block. Reliable identification of cerebrospinal fluid (CSF) from the aspirate is crucial for safe epidural anesthesia. The aim of this study was to determine whether prostaglandin D2 could be clinically used as a marker for the detection of CSF traces. METHODS: After obtaining Institutional Review Board approval and patient consent, CSF was obtained from patients undergoing spinal anesthesia, and blood, urine, and saliva were obtained from normal subjects and analyzed for prostaglandin D2 (PGD). CSF (n=5) samples were diluted with local anesthetic (bupivacaine), normal saline and blood in the ratios of 1:5 and 1:10. PGD levels in the CSF samples were analyzed with a PGD-Methoxime (MOX) EIA Kit (Cayman Chemicals, MI). This assay is based on the conversion of PGD to a stable derivative, which is analyzed with antiserum specific for PGD-MOX. RESULTS: Different concentrations of pure PGD-MOX conjugate were analyzed by EIA and a standard curve was derived. PGD levels in CSF and CSF with diluents were determined and the values were extrapolated onto the standard curve. Our results show a well-defined correlation for the presence of PGD both in straight CSF samples and in diluted CSF (dilution factor of 1:5 and 1:10). CONCLUSION: Prostaglandin D2 was reliably identified in CSF by enzyme-linked immunosorbent assay when diluted with local anesthetic, saline, and serum, and can be used as a marker to identify the presence of CSF in epidural aspirates.

Change in pulse pressure during the preclinical phase of preeclampsia.

OBJECTIVE: To measure and compare pulse pressure in early pregnancy between parturients who subsequently did or did not develop preeclampsia. STUDY DESIGN: Retrospective chart review of 44 parturients with preeclampsia and 187 controls without. The groups were compared for blood pressure indices before 15 weeks' gestation and other maternal variables. RESULTS: The preeclampsia group had a higher proportion of African Americans (23% vs. 9.6%, p = 0.005) and higher body mass index (26.2 +/- 7.1 SD vs. 24.0 +/- 4.9 kg/m2, p = 0.03). Before 15 weeks' gestation, women who later developed preeclampsia had higher systolic (114.3 +/- 11.6 vs. 107 +/- 12 mm Hg, p = 0.001), mean arterial (83.7 +/- 8.8 vs. 79.6 +/- 7.6 mm Hg, p = 0.002) and pulse (45.8 +/- 7.7 vs. 42.4 +/- 8.3 mm Hg, p = 0.001) pressure. On multivariable logistic regression analysis, only African American race (OR 3.1; 95% CI 1.13, 8.40; p = 0.028), and pulse pressure (OR 1.05; 95% CI 1.01, 1.1; p = 0.014) were independently associated with the development of preeclampsia. CONCLUSION: Primiparous women who later develop preeclampsia have an elevation in pulse, systolic and mean arterial pressure before 15 weeks.