Postpartum post-dural puncture headache: is your differential diagnosis complete?

We describe a patient with an intracerebral haemorrhage following an accidental dural puncture during an attempted epidural for pain relief in labour. Anaesthetists need to include intracerebral haemorrhage in the differential diagnosis of post-dural puncture headache in the puerperium.

Inefficacy of high-dose transdermal fentanyl in a patient with neuropathic pain, a case report.

Pain partially responsive to opioids can lead to rapid escalating dosages due to tolerance development. In this report the case of a 58-year-old female with neuropathic pain using increasing transdermal (TTS) fentanyl dosages to a maximum dose of 3400 microg/h resulting in fentanyl plasma levels of 173 ng/ml is described. For pain relief an epidural infusion at the level T1-2 with bupivacaine was started. Immediate pain relief was accompanied by short lasting respiratory depression and drowsiness.

Penetrating cardiac injuries--current evaluation and management of the stable patient.

Patients with penetrating cardiac injuries present in a stable or only mildly shocked condition--especially if the laceration has sealed off and the patient has been adequately resuscitated. A large proportion of patients presenting to our unit are in a reasonably stable condition after resuscitation, and rapid diagnosis may be difficult. We present our experience over a 5-year period (191 patients), with particular reference to the stable patient. All patients with penetrating precordial wounds should be assessed for a possible cardiac injury, especially if a period of hypotension has occurred. Clinical signs, central venous pressure, chest radiograph, pericardiocentesis and subxiphoid window are not always helpful in the diagnosis. Cardiac ultrasound is very useful (in the absence of haemothorax), and was performed in 103 of 191 patients, with 8 false-negatives and 3 false-positives. When an unstable patient presents with an obvious diagnosis use of cardiac ultrasound should be restricted. A subxiphoid window has diagnostic value where the cardiac ultrasound is inconclusive.

Direct high-performance liquid chromatography determination of propofol and its metabolite quinol with their glucuronide conjugates and preliminary pharmacokinetics in plasma and urine of man.

Propofol (P) is metabolized in humans by oxidation to 1,4-di-isopropylquinol (Q). P and Q are in turn conjugated with glucuronic acid to the respective glucuronides, propofol glucuronide (Pgluc), quinol-1-glucuronide (Q1G) and quinol-4-glucuronide (Q4G). Propofol and quinol with their glucuronide conjugates can be measured directly by gradient high-performance liquid chromatographic analysis without enzymic hydrolysis. The glucuronide conjugates were isolated by preparative HPLC from human urine samples. The glucuronides of P and Q were present in plasma and urine, P and Q were present in plasma, but not in urine. Quinol in plasma was present in the oxidised form, the quinone. Calibration curves of the respective glucuronides were constructed by enzymic deconjugation of isolated samples containing different concentrations of the glucuronides. The limit of quantitation of P and quinone in plasma are respectively 0.119 and 0.138 microg/ml. The limit of quantitation of the glucuronides in plasma are respectively: Pgluc 0.370 microg/ml, Q1G 1.02 microg/ml and Q4G 0.278 microg/ml. The corresponding values in urine are: Pgluc 0.264 microg/ml, Q1G 0.731 microg/ml and Q4G 0.199 microg/ml. A pharmacokinetic profile of P with its metabolites is shown, and some preliminary pharmacokinetic parameters of P and Q glucuronides are given.