Saved by the Massive Transfusion Protocol: A Case Report of an Obstetric Patient With Hemolysis, Elevated Liver Enzymes, and Low Platelet Count (HELLP) Syndrome and Glisson Capsule Rupture.

A 31-year-old primigravid parturient with no pertinent medical history was admitted at 40 weeks and 4 days of gestation for postdate induction of labor. She was subsequently diagnosed with preeclampsia and developed hemolysis, elevated liver enzymes, and a low platelet count. An emergency cesarean delivery ensued owing to fetal bradycardia. Massive hemorrhage occurred on incision, and a diagnosis of ruptured subcapsular hepatic hematoma was made. The hemorrhage was managed using our institution's massive transfusion protocol. Early transfusions and mobilization of necessary support stipulated in this protocol led to full recovery of the patient, with no significant morbidity.

Peripheral Nerve Stimulation for the Treatment of Chronic Intractable Headaches: Long-term Efficacy and Safety Study.

BACKGROUND: Despite the various modalities available for treating headaches, typical therapy does not provide adequate pain relief for some patients. OBJECTIVES: This study explored the efficacy and safety of long-term peripheral nerve stimulation (PNS) for intractable chronic headaches. STUDY DESIGN: Retrospective study of refractory headache patients at academic pain center. METHODS: The medical records of all patients (N = 46) permanently implanted with PNS between January 2005 and January 2012 were reviewed retrospectively. Patient records and phone interviews were used to quantify the levels of pain intensity, headache days per month, and overall patient satisfaction with treatment. The correlation between headache duration and effectiveness of PNS was also assessed. RESULTS: Pain intensity on the 11-point Numeric Rating Scale decreased from 7.60 ± 1.73 before implantation to 3.78 ± 2.41, 3.32 ± 2.67, 3.42 ± 2.74, and 2.04 ± 2.27 at one, 6, 12, and > 12 (19-98) months after implantation, respectively (P < .001). The mean number of headache days per month decreased by about 14 days from the base line. No correlation (r = -.33) was found between the number of years the patients had suffered from headaches and the efficacy of treatment. LIMITATIONS: Due to the limitation of a retrospective study, the data collected via chart reviews and phone interviews are susceptible to selection and information biases. CONCLUSIONS: PNS is an effective modality in the long-term management of intractable chronic headaches. Despite long histories of chronic headaches, the majority of patients had significant reductions in pain scores and the number of headache days per month. The outcomes were not dependent on the number of years the patients had suffered from headaches before PNS treatment.

Acute rhabdomyolysis in a patient with long-term exposure to intrathecal ziconotide: a case report.

INTRODUCTION: Ziconotide is an intrathecally administered nonopioid analgesic for the treatment of severe chronic pain. Previous reports have noted rhabdomyolysis in patients receiving ziconotide during the initial single-shot trial or due to concurrent medical problems. We present a case of an acute rhabdomyolysis following an intrathecal bolus injection of ziconotide on a patient who had long-term exposure to the drug. CASE REPORT: The patient suffered from chronic neuropathic pain with diagnosis of failed back surgery syndrome and received intrathecal ziconotide for 2 years. Moderate side effects resulting from dose escalation led to a discontinuation of the drug. The pump medication was changed to morphine, which failed to provide adequate analgesia even with dose titration. A single intrathecal bolus of ziconotide, as an adjunctive therapy, resulted in good pain control. Two months later, the patient received a second ziconotide injection. Sixteen hours after the injection, she presented to local emergency center with nausea, vomiting, diarrhea, and myalgia. She had significantly increased CK levels and was admitted for intravenous hydration and close observation. Her serum CK level peaked at 4940 IU/L. The patient was discharged on hospital day 3 with a CK level of 808 IU/L. Her symptoms resolved without renal impairment. DISCUSSION: The clinical scenario described is a case of acute rhabdomyolysis from an intrathecal bolus injection of ziconotide in a patient with prior long-term exposure to the drug. The decrease in CK levels coincided well with the average half-life of ziconotide; however, the rhabdomyolysis may have been potentiated by hypokalemia.