Epidural Labor Analgesia: Continuous Infusion Versus Patient-Controlled Epidural Analgesia With Background Infusion Versus Without a Background Infusion

The purpose of this study was to compare the total epidural dose of 3 commonly used labor epidural modalities. After local institutional review board approval, 195 laboring parturients received an epidural catheter for labor analgesia. All patients received an initial bolus of 0.1% ropivacaine (10 mL) and fentanyl (100 microg). Maintenance of labor analgesia consisted of ropivacaine 0.1% with fentanyl 2 microg/mL. Patients were then randomly assigned into 3 groups: Group 1 (continuous epidural infusion [CEI]), continuous infusion at 10 mL/h; group 2 (CEI + patient-controlled epidural analgesia [PCEA]), CEI at 5 mL/h with a demand dose of 5 mL allowed every 20 minutes with a 20 mL/h maximum dose; group 3 (PCEA), demand doses only of 5 mL every 15 minutes with a 20 mL/h maximum dose. Measured variables included total epidural dose, total bolus requests and boluses delivered, number of staff interventions, pain Visual Analog Scale (VAS; 0-100), modified Bromage scores, stage I and II labor duration, delivery outcome, and maternal satisfaction after delivery. No differences were noted with respect to pain VAS, modified Bromage scores, stage I and II labor duration, number of staff interventions, delivery outcome, and maternal satisfaction score. Total infusion dose was lower in demand dose only PCEA compared with CEI and CEI + PCEA groups (P = < .01). Demand dose-only PCEA results in less total epidural dose compared with CEI and CEI + PCEA without affecting labor duration, motor block, pain VAS, maternal and neonatal outcomes, and maternal satisfaction. PERSPECTIVE: This article compares 3 commonly used labor epidural delivery modalities (traditional continuous epidural infusion, patient-controlled epidural analgesia with a background infusion, and demand dose-only patient-controlled epidural analgesia). Benefits in epidural dose reduction with demand dose only PCEA does not translate into improved maternal and neonatal outcome.     

持续硬膜外镇痛用于防治硬膜穿破后头痛的疗效观察

目的:观察持续硬膜外镇痛(CEA)用于防治硬膜穿破后头痛(PDPH)的疗效。方法:30例意外出现硬膜穿破者随机分为观察组和对照组各15例。观察组采取CEA等方法,对照组则采取硬膜外腔单次注入生理盐水等方法,对2组患者头痛、头晕恶心、呕吐发生情况及不同时间段的相关评分和安全性进行观察。结果:观察组头痛发生率为13.33%、头晕恶心发生率6.67%,呕吐0例,均低于对照组,头痛持续时间较对照组明显缩短(P<0.05);且术后第2、3、4、5天观察组的头痛评分、头晕恶心评分和呕吐评分均低于对照组(P<0.05),2组安全性相比差异无统计学意义(P>0.05)。结论:CEA用于防治PDPH疗效确切。     

硬膜穿破后吸入安氟醚预防头痛的临床观察

目的：观察硬膜穿破后改用静一吸复合全麻，吸入安氟醚与异氟醚对预防术后头痛的比较。方法：ASAⅠ～Ⅱ级，择期行下腹部、会阴部手术硬膜外穿刺穿破硬膜病人26例，均改为气管插管全身麻醉。按吸入麻醉剂不同随机分成安氟醚（E）组和异氟醚（Ⅰ）组。麻醉诱导均相同：静注咪唑安定0．05mg／kg、芬太尼3Ⅱg／kg、异丙酚3mg／kg、维库溴铵0．1mg／kg，气管插管，接麻醉机。安氟醚（E）组吸入安氟醚维持全麻；异氟醚（Ⅰ）组吸入异氟醚维持全麻。术后随访3d，记录头痛情况。结果：二组病人术后头痛发生率有极显著差异（P〈0．01）。E组头痛发生率明显低于Ⅰ组。结论：硬膜穿破后改用吸入安氟醚作全麻可很好预防术后头痛。     

New Daily Persistent Headache Caused by a Multinodular Goiter and Headaches Associated With Thyroid Disease

A 33‐year‐old female is presented with the first case to our knowledge of new daily persistent headache (NDPH) with a large right benign non‐toxic multinodular goiter causing carotid and vertebral compression with complete resolution of the headache immediately after thyroidectomy. Although this may be quite rare, hypothyroidism or hyperthyroidism causing NDPH, migraine, or an exacerbation of pre‐existing migraine is not. Clinicians should consider routinely obtaining serum thyroid‐stimulating hormone (TSH) and free T4 in patients with new onset frequent headaches or an exacerbation of prior primary headaches.     

Management of an Epidural Abscess After Continuous Epidural Catheter Infusion

Abstract: Objective: ? To increase awareness of the possibility of epidural infection after continuous epidural infusion. ? Outline the salient diagnostic features of epidural infection. ? Outline a strategy to manage epidural infection and minimize morbidity. Setting: Academic multidisciplinary pain clinic Patient: A patient with a left knee meniscal tear with a history of Chronic Regional Pain Syndrome Type I (CRPS I) of the left foot. Interventions: Attempted control of CRPS I symptoms with a tunnelled epidural catheter infusion. Results and Conclusions: The patient developed an epidural abscess diagnosed on the 11^th postoperative day. The catheter was removed and the patient was treated successfully with intravenous antibiotics.     

Laughing Headache With Giant Pacchionian Granulations

Laughing is recognized as a provoking factor for headache, certainly underestimated among the general population and few cases have been published to date. We report a single case of severe headache, provoked almost exclusively by outbursts of laughing, where venous magnetic resonance imaging revealed the presence of giant Pacchioni granulations in both right and transverse sinuses. Reviewing published cases of laughing headache, we discuss possible mechanisms of pain and the role of giant Pacchionian granulations.     

Headache Associated With Aseptic Meningitis

A retrospective analysis of all patients admitted with the diagnostic codes of aseptic or viral meningitis was performed at two institutions over 3 years. Forty-one patients with cerebrospinal fluid confirmation of aseptic meningitis (increased protein; increased white count; negative gram stain; and negative fungal, tuberculosis, and bacterial cultures) were analyzed.
All the patients had headache, which was typically severe and bilateral in 39 of the 41 patients. The headache was of abrupt onset or the worst of the patient's life in 24 of the patients. The quality of the headache, when described, was usually throbbing (11 of 14). Nineteen patients had prodromal symptoms, including malaise, myalgia, gastrointestinal symptoms, and urinary tract infections. All had associated symptoms, including nausea (25), vomiting (23), photophobia (18), stiff neck (25), and back pain (11). Thirty patients were febrile. Lumbar puncture was performed for headache and fever unexplained by systemic illness in 30 patients, meningeal signs in 15, headache of abrupt onset or the worst headache ever in 24, neurologic signs or symptoms in 12, and for other reasons in 2. Computerized tomography, when performed, was negative in all cases. Focal neurologic findings were present in 5 patients, a decreased level of consciousness in 6, and papilledema in 1.
A severe headache that worsens, is abrupt in onset, or is the worst of the patient's life could be due to aseptic meningitis, bacterial meningitis, or a subarachnoid hemorrhage. Although not universally present, meningeal signs, fever, and neurologic signs or symptoms should alert one to a possible central nervous system infection.     

Headache Associated With Pituitary Adenomas

The objectives of this study were to analyze the characteristics of headache in patients with pituitary adenoma and to investigate the mechanisms involved.
Fifty-one patients (27 females and 24 males) with pituitary adenoma were examined. Nineteen (37.3%) of these patients (13 females and 6 males) had headache preoperatively. Most commonly, the headache was generalized (42.1%); overall headache was more frequent in the anterior half of the head (84.2%). Seventeen (89.5%) patients had bilateral headache. Headache was usually described as head heaviness (57.9%) and continuous (57.9%). Pulsating headache and dull pain were only reported by the female patients and were mostly intermittent. The mean age of patients with headache was younger than that of those without headache. Headache was more prevalent in patients with a prolactin-secreting adenoma (57.1%). There were no correlations between visual disturbances, hypopituitarism, tumor size, or cavernous sinus invasion and headache. Hemorrhagic pituitary adenoma in 4 (57.1%) of 7 patients did not always contribute to headache. The headache was improved after surgery in 14 (73.6%) of the 19 patients. In the male patients who survived postoperatively (5 of 6), headache was improved.     

Headache in Patients With Neurofibromatosis Type 1

A study of headache in a homogeneously ascertained population of 181 subjects suffering from neurofibromatosis type I is described. All subjects underwent a diagnostic protocol including imaging studies (for subjects over 5 years old up until 1992). Headache data were collected by means of a questionnaire. Headache was present in 55 of 181 subjects (25 males). Overall headache frequency was 30%, which is not significantly different from the frequency of headache reported in the general population. Headache was primary in 52 cases (5 migraine and 47 tension-type) and secondary to obstructive hydrocephalus with brain tumor-induced intracranial hypertension in 3 with a tension-type pattern.
It was concluded that headache is not a specific feature of neurofibromatosis ype 1, it is not significantly related to central nervous system abnormalities, and in itself, it is not an indication for neuroradiological examination.     

Management of Pediatric Migraine Headache in the Emergency Room and Infusion Center

Migraine is a common disorder that starts at an early age and takes a variable pattern from intermittent to chronic headache with several exacerbations throughout a lifetime. Children and adolescents are significantly affected. If an acute headache is not aborted by outpatient migraine therapy, it often causes severe disability, preventing the child from attending school and social events. Treating the acute severe headache aggressively helps prevent prolonged disability as well as possible chronification. Multiple medications are available, mostly for the outpatient management of an attack and include the use of over‐the‐counter anti‐inflammatory medications as well as prescribed medications in the triptan group. These therapies do sometime fail and the exacerbation can last from days to weeks. If the headache lasts 72 hours or longer it will fall in the category of status migrainosus. Status migrainosus is described as a severe disabling headache lasting 72 hours or more by the ICHD3 criteria. Disability is a major issue in children and adolescents and aggressive acute measures are to be taken to control it as soon as possible. Early aggressive intravenous therapy can be very effective in breaking the attack and allowing the child to be quickly back to normal functioning. This article reviews what is available for the treatment of pediatric primary headaches in the emergency room.     

Headache Prophylaxis With BoNTA: Patient Characteristics

( Headache 2010;50:63-70)
Objective.— To assess the characteristics of patients receiving botulinum toxin type A (BoNTA; BOTOX^®) in the treatment of headache (HA) disorders.
Methods.— The following observational epidemiologic data and baseline patient characteristics were prospectively collected from eligible patients treated with BoNTA at 10 US HA specialty centers: demographics; HA diagnoses and characteristics (frequency, severity, and disability); prior and current HA treatments and response; clinical response to BoNTA; Migraine Disability Assessment (MIDAS) questionnaire; and adverse events. Patients maintained a daily HA diary and were evaluated at each follow-up visit.
Results.— Of 703 patients enrolled (mean age 43.1 years, 78.5% females, 95.4% white), nearly 66% had a diagnosis of chronic migraine (CM), with or without medication overuse. Approximately 75% had severe disability (MIDAS grade IV), and the mean pain rating was 6.5 (where 0 = no pain, 10 = pain as bad as it can be). More than 90% of patients had ≥1 prophylactic HA treatment failure; median number of failures was 4. Significant association was observed between HA frequency and MIDAS grade ( P  < .001). Approximately 80% of patients with CM had severe (grade IV) disability. The median number of monthly medication days was higher in the group with MIDAS grade IV ( P  < .001). HA frequency and severity, failed prophylactic therapies, and greater number of coexisting medical conditions were all negatively associated with measures of health-related quality of life.
Conclusions.— Majority of patients treated with BoNTA in a specialty HA center presented with a CM diagnosis. HA disability was correlated with measures of frequency and treatment utilization.