Drug therapy for preventing post-dural puncture headache

Spontaneous intracranial hypotension

Spontaneous intracranial hypotension (SIH) is a highly disabling but treatable secondary cause of headache. Recent progress in neuroradiological techniques has catalysed understanding of its pathophysiological basis and clinical diagnosis, and facilitated the development of more effective investigation and treatment methods. A UK-based specialist interest group recently produced the first multidisciplinary consensus guideline for the diagnosis and treatment of SIH. Here, we summarise a practical approach to its clinical and radiological diagnosis, symptomatic and non-targeted interventional treatment, radiological identification of leak site and targeted treatment of the leak once it has been localised.

Effect of aminophylline, ketamine and paracetamol on pain intensity after deep vitrectomy surgery

BACKGROUND

Pain management after surgery is a challenging medical issue, and clinical research in this area has continued. This study aimed to compare the effect of Aminophylline, ketamine, and paracetamol on the pain intensity after deep vitrectomy and compare it with the control group.

METHODS

In this clinical trial, 240 patients undergoing deep vitrectomy were included in the study. The protocol of the current study was approved in the Ethics committee of Isfahan University of Medical Sciences (IR.MUI.REC.1396.3.876) and this study was registered in Iranian Registry of Clinical Trials (IRCT20210919052523N1) (https://www.irct.ir/trial/58884). The patients were randomly divided into four equal groups. Twenty minutes before surgery, in the first group, 0.15 mg/kg ketamine, in the second group 1 g acetaminophen, in the third group 3 mg/kg of aminophylline, and in the fourth group, normal saline was infused in the same manner. All drugs were diluted with 100 ccs of normal saline and infused intravenously within 15 minutes. The four groups of hemodynamic variables, pain intensity, and rescue analgesic drugs were compared.

RESULTS

There was no significant difference between the groups based on hemodynamic variables (P>0.05). The severity of pain up to 2 hours after surgery and the rescue to analgesia in the ketamine and paracetamol groups were significantly lower than that of aminophylline and placebo.

CONCLUSION

Using ketamine or paracetamol effectively decreases pain intensity after deep vitrectomy surgery without producing significant adverse hemodynamic changes.

Aminophylline for Prevention and/or Treatment of Post-Dural Puncture Headache: A Systematic Review and Meta-Analysis Study Protocol

Objectives

Post-dural Puncture Headache (PDPH) is prevalent among individuals undergoing lumbar punctures. The non-invasive effect of some drugs, such as aminophylline on PDPH has been investigated in several clinical studies. As there is no comprehensive systematic review and meta-analysis about the preventive and therapeutic effects of aminophylline on PDPH in the literature, the clinical effectiveness of this drug on the prevention and/or treatment of PDPH will be assessed in this study.

Methods

PubMed/MEDLINE, Embase, WoS (Clarivate Analytics), the Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL Complete, Scopus, and Google Scholar as electronic databases will be precisely searched for clinical studies that assessed the effect of aminophylline on PDPH. Studies between 01-01-1980 and 30-06-2020 will be evaluated in this study, and there will not be any language restrictions. Contradictions between the reviewers within any phase of the study (screening, selecting, quality assessment, and data extraction) will be resolved by consensus; in case of unsolved disagreements, a third reviewer will eventually decide. The combination method will be applied according to the methodological resemblance in the selected articles using the Random Effect Model or the Fixed Effect Model. Also, for the included articles, forest plots will be drawn. For assessing statistical heterogeneity, the I² statistic and the Q-statistic test will be applied. In addition, funnel plots will be used for assessing non-significant study effects and potential reporting bias. Furthermore, Egger’s and Begg’s tests will be done, and publication bias will be indicated by significant findings (P < 0.05).

Conclusions

It is expected that the results of this study will be of benefit to researchers and clinicians for managing PDPH, and will be reported in conferences and publications.

The comparison of post-dural puncture headache treatment with acetaminophen-caffeine capsule and intravenous mannitol infusion: A randomized single-blind clinical trial

Background: Post-dural puncture headache (PDPH) is a common problem after spinal anesthesia. Depending on the severity of PDPH, there are both invasive and non-invasive treatments. Caffeine has been used for the treatment of PDPH since 1949, but the administration of mannitol is a novel management to tackle PDPH. This study was conducted to compare the effectiveness of acetaminophen-caffeine and mannitol in the treatment of PDPH. Methods: We enrolled 80 patients with PDPH in the present clinical trial and observed them during 72 hours after cesarean section. Participants were randomly and equally allocated to two groups for treatment with intravenous (IV) mannitol or oral acetaminophen-caffeine. The effects of treatment were evaluated using the visual analogue scale (VAS) questionnaire at hours of 1, 2, 3, 4, 6, 12, 18, 24, and 48. SPSS software was used. Results: Forty patients in each group completed the study. There was a significant reduction in the pain scores of the both groups after treatment, but the interaction between time and group demonstrated that mannitol administration was superior to acetaminophen-caffeine in pain reduction of the patients undergoing spinal anesthesia (P = 0.028). Patients' satisfaction in the mannitol group was significantly higher than the caffeine group (P = 0.001). Conclusion: This study suggests that IV mannitol infusion affects faster and earlier for the treatment of PDPH than acetaminophen-caffeine capsule. Mannitol could be probably more effective for treatment of PDPH.

Epidural analgesia followed by epidural hydroxyethyl starch prevented post-dural puncture headache: Twenty case reports and a review of the literature

BACKGROUND

Accidental dural puncture (ADP) and subsequent post-dural puncture headache (PDPH) remain common complications of epidural procedures for obstetric anesthesia and analgesia. No clear consensus exists on the best way to prevent PDPH after ADP.

CASE SUMMARY

We report our findings in twenty parturients who underwent an incorporated strategy of epidural analgesia followed by epidural hydroxyethyl starch (HES) to prevent PDPH after ADP with a 16-gauge Tuohy needle during epidural procedures. ADP with a 16-gauge Tuohy needle occurred in nine parturients undergoing a cesarean section (CS) and in eleven parturients receiving labor analgesia. An epidural catheter was re-sited at the same or adjacent intervertebral space in all patients. After CS, the epidural catheter was used for postoperative pain relief over a 48-h period. After delivery in eleven cases, epidural infusion was maintained for 24 h. Thereafter, 15 mL of 6% HES 130/0.4 was administered via the epidural catheter immediately prior to catheter removal. None of the parturients developed PDPH or neurologic deficits over a follow-up period of at least two months to up to one year postpartum.

CONCLUSION

An incorporated strategy of epidural analgesia followed by epidural hydroxyethyl starch may have great efficacy in preventing PDPH after ADP.

Dexamethasone and post-dural puncture headache in women who underwent cesarean delivery under spinal anesthesia: A systemic review and meta-analysis of randomized controlled trials

BACKGROUND

Post-dural puncture headache is a common complication after spinal anesthesia for women who undergo cesarean delivery. Intravenous (IV) dexamethasone has been used to reduce the incidence and severity of PDPH with controversial results. This Systemic review and meta-analysis aimed to assess the effects of IV dexamethasone on PDPH.

METHODS

This study is reported as per Preferred Reporting Items for Systematic and Meta-analysis. The primary outcome was the incidence and severity of PDPH. The secondary outcome variables were the postoperative total analgesic requirement and incidence of nausea and/or vomiting. Twelve randomized controlled trials with a total of 1548 women were included.

RESULTS

Intravenous (IV) dexamethasone had no effect on the incidence of PDPH (OR = 0.64; CI, 0.39 to 1.05; I2 = 71%, P = 0.08). Intravenous dexamethasone did not show a significant difference in the incidence of PDPH at 24 h at 48 h, and within one week postoperatively with p-values of less than 0.05. In a random-effect model, a pooled analysis showed that IV dexamethasone had no effect on the severity of PDPH in VAS (MD = 0.78; CI, -2.27 to 0.71; I2 = 98%, P = 0.30).

CONCLUSION

Intravenous dexamethasone failed to decrease the incidence and severity of PDPH in women who underwent cesarean delivery under spinal anesthesia.

[Perioperative dexamethasone]

Dexamethasone is a synthetic steroid that has been used for many years in the clinical routine due to its anti-inflammatory, anti-allergic and immunosuppressive properties. Furthermore, dexamethasone has been used for a long time for prophylaxis and treatment of chemotherapy-induced nausea and vomiting. In the meantime dexamethasone has been approved as standard for the prophylaxis and treatment of postoperative nausea and vomiting (PONV). This review article outlines the indications and side effects of the perioperative administration of dexamethasone.

Evaluation of the effectiveness and tolerance of tetracosactide in the treatment of post-dural puncture headaches (ESYBRECHE): a study protocol for a randomised controlled trial

Background

Post-dural puncture headache (PDPH) is one of the most common complications of neuraxial anaesthesia. It limits patients’ general activity and increases the length of hospital stays and the use of care. It is particularly disabling during the postpartum period, when mothers have to take care of their child. Epidural blood patch is the standard treatment for PDPH. However, it is an invasive procedure that may result in rare but serious complications. Recent evidence has suggested that adrenocorticotropic hormone (ACTH) is effective in the management of PDPH. The aim of this study is to assess the efficacy and safety of tetracosactide (Synacthen®), a synthetic analogue of ACTH, for PDPH treatment in patients who receive neuraxial anaesthesia during labour.

Methods

This randomised, double-blind, placebo-controlled, parallel-arm trial, is performed in two French university hospitals. Eligible patients are those suffering from postpartum PDPH, who are randomised to receive either 1 mg of tetracosactide intravenously over 20 min or to 0.9% saline (placebo). The primary endpoint is the rate of epidural blood patch within a 15-day follow-up period. Headache duration, pain intensity, reduction of general activity, increase in length of hospital stay, adverse events, analgesic use (type and duration) and number of blood patches per patient in each group are recorded.

Discussion

We expect a decrease in the use of epidural blood patch in those receiving tetracosactide, thus indicating a decrease in PDPH symptoms in these patients. This will define the therapeutic success of tetracosactide and the possibility to use this treatment as a non-invasive alternative to blood patch for PDPH treatment.

Trial registration

Primary Registry

ClinicalTrials.gov Protocol Registration and Results System

Date of Registration 24 June 2016

Unique Protocol ID 69HCL15_0429

Secondary IDs

EudraCT Number 2015–003357-17

ClinicalTrials.gov ID NCT02813655

ANSM 160214A-31

Protocol version

V4 28/09/2018

Caffeine and Primary (Migraine) Headaches-Friend or Foe?

Background: The actions of caffeine as an antagonist of adenosine receptors have been extensively studied, and there is no doubt that both daily and sporadic dietary consumption of caffeine has substantial biological effects on the nervous system. Caffeine influences headaches, the migraine syndrome in particular, but how is unclear. Materials and Methods: This is a narrative review based on selected articles from an extensive literature search. The aim of this study is to elucidate and discuss how caffeine may affect the migraine syndrome and discuss the potential pathophysiological pathways involved. Results: Whether caffeine has any significant analgesic and/or prophylactic effect in migraine remains elusive. Neither is it clear whether caffeine withdrawal is an important trigger for migraine. However, withdrawal after chronic exposure of caffeine may cause migraine-like headache and a syndrome similar to that experienced in the prodromal phase of migraine. Sensory hypersensitivity however, does not seem to be a part of the caffeine withdrawal syndrome. Whether it is among migraineurs is unknown. From a modern viewpoint, the traditional vascular explanation of the withdrawal headache is too simplistic and partly not conceivable. Peripheral mechanisms can hardly explain prodromal symptoms and non-headache withdrawal symptoms. Several lines of evidence point at the hypothalamus as a locus where pivotal actions take place. Conclusion: In general, chronic consumption of caffeine seems to increase the burden of migraine, but a protective effect as an acute treatment or in severely affected patients cannot be excluded. Future clinical trials should explore the relationship between caffeine withdrawal and migraine, and investigate the effects of long-term elimination.

Effect of pre-administration with aminophylline on the occurrence of post-dural puncture headache in women undergoing caesarean section by combined spinal-epidural anaesthesia

Objective

To investigate the effect of the pre-administration with aminophylline on the occurrence of post-dural puncture headache (PDPH) in women undergoing caesarean section by combined spinal-epidural anaesthesia (CSEA).

Methods

The study enrolled women undergoing elective caesarean sections with CSEA and randomly allocated them into two groups; for 30 min immediately after the infant was delivered, group A received 250 mg aminophylline intravenously and group B received an equal volume of normal saline. Demographic data, operation time, intraoperative blood loss, intraoperative transfusion volume and the occurrence of PDPH during the first 7 days after the operation were recorded. Side-effects such as hypersensitivity, convulsion and arrhythmia were also recorded in the patients and infants in group A within 24 h after aminophylline administration.

Results

A total of 120 patients aged 24–38 years (pregnancy range, 38–42 weeks) were randomly allocated into two groups (n = 60). The incidence of PDPH in group A was significantly lower than group C (two of 59 [3.4%] versus 10 of 58 [17.2%], respectively). There were no related side-effects within 24 h after aminophylline administration in group A.

Conclusions

Intraoperative intravenous infusion of 250 mg aminophylline reduced the incidence of PDPH after caesarean section under CSEA with no side-effects.

Preventing nausea and vomiting in women undergoing regional anesthesia for cesarean section: challenges and solutions

BACKGROUND

Intraoperative nausea and vomiting (IONV) or postoperative nausea and vomiting (PONV) affecting women undergoing regional anesthesia for cesarean section is an important clinical problem since these techniques are used widely. There are burdens of literature about IONV/PONV and several in parturient and cesarean. However, it needs more attention. The underlying mechanisms of IONV and PONV in the obstetrical setting mainly include hypotension due to sympathicolysis during neuraxial anesthesia, bradycardia owing to an increased vagal tone, the visceral stimulation via the surgical procedure and intravenously administered opioids.

METHODS

Given the high and even increasing rate of cesarean sections and the sparse information on the etiology, incidence and severity of nausea and vomiting and the impact of prophylactic measures on the incidence of PONV/IONV, this article aims to review the available information and provide pragmatic suggestions on how to prevent nausea and vomiting in this patient cohort. Current literature and guidelines were identified by electronic database searching (MEDLINE via PubMed and Cochrane database of systematic reviews) up to present, searching through reference lists of included literature and personal contact with experts.

DISCUSSION AND CONCLUSION

Taking into account the current guidelines and literature as well as everyday clinical experience, the first step for decreasing the incidence of IONV and PONV is a comprehensive management of circulatory parameters. This management includes liberal perioperative fluid administration and the application of vasopressors as the circumstances require. By using low-dose local anesthetics, an additional application of intrathecal or spinal opioids or hyperbaric solutions for a sufficient controllability of neuraxial distribution, maternal hypotension might be reduced. Performing a combined spinal-epidural anesthesia or epidural anesthesia may be considered as an alternative to spinal anesthesia. Antiemetic drugs may be administered restrainedly due to off-label use in pregnant women for IONV or PONV prophylaxis and may be reserved for treatment.

Needle gauge and tip designs for preventing post-dural puncture headache (PDPH)

BACKGROUND

Post-dural puncture headache (PDPH) is one of the most common complications of diagnostic and therapeutic lumbar punctures. PDPH is defined as any headache occurring after a lumbar puncture that worsens within 15 minutes of sitting or standing and is relieved within 15 minutes of the patient lying down. Researchers have suggested many types of interventions to help prevent PDPH. It has been suggested that aspects such as needle tip and gauge can be modified to decrease the incidence of PDPH.

OBJECTIVES

To assess the effects of needle tip design (traumatic versus atraumatic) and diameter (gauge) on the prevention of PDPH in participants who have undergone dural puncture for diagnostic or therapeutic causes.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL and LILACS, as well as trial registries via the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) search portal in September 2016. We adopted the MEDLINE strategy for searching the other databases. The search terms we used were a combination of thesaurus-based and free-text terms for both interventions (lumbar puncture in neurological, anaesthesia or myelography settings) and headache.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) conducted in any clinical/research setting where dural puncture had been used in participants of all ages and both genders, which compared different tip designs or diameters for prevention of PDPH DATA COLLECTION AND ANALYSIS: We used the standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included 70 studies in the review; 66 studies with 17,067 participants were included in the quantitative analysis. An additional 18 studies are awaiting classification and 12 are ongoing. Fifteen of the 18 studies awaiting classification mainly correspond to congress summaries published before 2010, in which the available information does not allow the complete evaluation of all their risks of bias and characteristics. Our main outcome was prevention of PDPH, but we also assessed the onset of severe PDPH, headache in general and adverse events. The quality of evidence was moderate for most of the outcomes mainly due to risk of bias issues. For the analysis, we undertook three main comparisons: 1) traumatic needles versus atraumatic needles; 2) larger gauge traumatic needles versus smaller gauge traumatic needles; and 3) larger gauge atraumatic needles versus smaller gauge atraumatic needles. For each main comparison, if data were available, we performed a subgroup analysis evaluating lumbar puncture indication, age and posture.For the first comparison, the use of traumatic needles showed a higher risk of onset of PDPH compared to atraumatic needles (36 studies, 9378 participants, risk ratio (RR) 2.14, 95% confidence interval (CI) 1.72 to 2.67, I2 = 9%).In the second comparison of traumatic needles, studies comparing various sizes of large and small gauges showed no significant difference in effects in terms of risk of PDPH, with the exception of one study comparing 26 and 27 gauge needles (one study, 658 participants, RR 6.47, 95% CI 2.55 to 16.43).In the third comparison of atraumatic needles, studies comparing various sizes of large and small gauges showed no significant difference in effects in terms of risk of PDPH.We observed no significant difference in the risk of paraesthesia, backache, severe PDPH and any headache between traumatic and atraumatic needles. Sensitivity analyses of PDPH results between traumatic and atraumatic needles omitting high risk of bias studies showed similar results regarding the benefit of atraumatic needles in the prevention of PDPH (three studies, RR 2.78, 95% CI 1.26 to 6.15; I2 = 51%).

AUTHORS' CONCLUSIONS

There is moderate-quality evidence that atraumatic needles reduce the risk of post-dural puncture headache (PDPH) without increasing adverse events such as paraesthesia or backache. The studies did not report very clearly on aspects related to randomization, such as random sequence generation and allocation concealment, making it difficult to interpret the risk of bias in the included studies. The moderate quality of the evidence for traumatic versus atraumatic needles suggests that further research is likely to have an important impact on our confidence in the estimate of effect.

Exam 4 Questions

A 73-year-old male with a history of hypertension and hyperlipidemia is currently in the stroke unit after suffering a right middle cerebral artery infarct. His symptoms started 2 h prior to arrival at the hospital, and tPA was administered. The patient is plegic on the left side and with mild dysarthria, but is otherwise neurologically intact. His labwork is within normal limits. Which of the following describes the optimal deep venous thrombosis (DVT) prophylaxis regimen for this patient?A.

Wait 6 h post tPA, then administer unfractionated heparin (UFH) along with intermittent pneumatic compression (IPC)

B.

Wait 24 h post tPA, then administer UFH along with IPC

C.

Wait 6 h post tPA, then administer low molecular weight heparin (LMWH) along with IPC

D.

Wait 24 h post tPA, then administer LMWH along with IPC

E.

IPC only for the first 72 h, then LMWH or UFH after obtaining follow-up imaging

All of the following causes of acute encephalitis have the matching characteristic radiological features except:A.

Autoimmune limbic encephalitis: T2/FLAIR hyperintensity in the mesial temporal lobes

B.

Cytomegalovirus: T2/FLAIR hyperintensity in the subependymal white matter

C.

JC virus: T2/FLAIR hyperintensity in the parieto-occipital lobes and corpus callosum

D.

Herpes simplex virus type 1: restricted diffusion in frontal/temporal lobes and insular cortex

E.

Varicella zoster: T2/FLAIR hyperintensity in the brainstem

Which of the following categorizations is most accurate regarding acute respiratory distress syndrome (ARDS) in the setting of subarachnoid hemorrhage (SAH)?A.

Non-neurogenic, non-cardiogenic

B.

Neurogenic, non-cardiogenic

C.

Neurogenic, cardiogenic

D.

Non-neurogenic, cardiogenic

E.

None of the above accurately reflect ARDS in SAH

A 52-year-old female is admitted to the ICU with a Hunt-Hess 1, modified Fisher 2 subarachnoid hemorrhage. Her past medical history is significant for hypertension, diabetes mellitus, and chronic renal insufficiency. She undergoes craniotomy for surgical clipping of an anterior cerebral artery aneurysm, and does not experience any additional complications. Two weeks later, she begins complaining of left calf pain, and a lower extremity sonogram demonstrated a proximal deep venous thrombosis (DVT). The patient weighs 60 kg. Her laboratory values are as follows: sodium 142 mEq/L, potassium 3.4 mEq/L, carbon dioxide 18 mEq/L, blood urea nitrogen (BUN) 70 mg/dL, and serum creatinine 2.5 mg/dL. What would be the optimal treatment for this patient’s proximal DVT?A.

Unfractionated heparin infusion for at least 5 days concomitantly with warfarin therapy

B.

Low molecular weight heparin 60 mg twice a day for at least 5 days concomitantly with warfarin therapy

C.

Fondaparinux 7.5 mg daily for 5 days followed by warfarin therapy

D.

Apixaban 10 mg twice daily for 7 days followed by 5 mg twice daily

E.

Rivaroxaban 15 mg twice daily for 21 days followed by 20 mg once daily

All of the following are currently implicated in uremic encephalopathy except:A.

Derangements in cerebral metabolism

B.

Alterations in the blood-brain barrier

C.

Accumulation of circulating toxins

D.

Imbalance of endogenous neurotransmitters

E.

Recurrent lobar hemorrhages

A 70-year-old female is hospitalized with a recent ischemic infarct. As part of stroke core measures, you obtain a hemoglobin A1c of 10.0. What is an approximate estimation of this patient’s average blood glucose level over the last several months?A.

70 mg/dL

B.

100 mg/dL

C.

130 mg/dL

D.

190 mg/dL

E.

240 mg/dL

A 28-year-old female with no known past medical history is in the ICU in status epilepticus, with anti-N-methyl D-aspartate (NMDA) receptor antibodies isolated in the cerebrospinal fluid. Which of the following is most likely to identify the root cause of her illness?A.

Transvaginal ultrasound

B.

Contrast-enhanced CT of the chest

C.

Contrast-enhanced CT of the brain

D.

Virtual colonography

E.

Thorough examination of the skin, particularly in sun-exposed areas

A 17-year-old male with no significant past medical history collapses during a high school football game, and goes into cardiac arrest. He did not have any complaints earlier in the day. The patient is brought to a nearby hospital, where is he resuscitated, intubated, and transferred to the ICU for further management. The patient is currently undergoing therapeutic hypothermia, and a work-up is underway to determine the cause of his sudden collapse. Which of the following is the most likely diagnosis?A.

Rupture of a previously undiagnosed cerebral aneurysm

B.

Hypertrophic cardiomyopathy

C.

Commotio cordis

D.

Severe hyponatremia and cerebral edema

E.

Brugada syndrome

A 31-year-old female at 38 weeks gestation is currently hospitalized for the treatment of preeclampsia. Due to her medical condition, her obstetrician is currently considering induced labor. At which point will this patient no longer be at risk for developing frank seizure activity as a result of her condition?A.

48 h postpartum

B.

1 week after delivery

C.

2 weeks after delivery

D.

4 weeks after delivery

E.

6 weeks after delivery

A 38-year-old male with no prior medical history presents to the emergency department with fever and severe headaches for several days. A CT scan of the brain is unremarkable, and the results of a lumbar puncture are pending. What is the most appropriate empiric antimicrobial regimen at this time?A.

Cefazolin and vancomycin

B.

Ceftriaxone and vancomycin

C.

Ceftriaxone, vancomycin and ampicillin

D.

Piperacillin/tazobactam and vancomycin

E.

Meropenem and vancomycin

The majority of intramedullary spinal cord neoplasms are:A.

Astrocytomas

B.

Meningiomas

C.

Metastatic lesions

D.

Ependymomas

E.

Hemangioblastomas

Which of the following derived parameter formulas is correct?A.

Cardiac index = cardiac output x body surface area

B.

Stroke volume = cardiac output/heart rate

C.

Systemic vascular resistance = 80 × (mean arterial pressure/cardiac output)

D.

Pulmonary vascular resistance = 80 × (mean pulmonary artery pressure/cardiac output)

E.

All of the above are correct

A 23-year-old female marathon runner is currently in the ICU after suffering from heat stroke following an outdoor run on a particularly hot summer day. She was initially delirious in the emergency department, but progressed to coma and respiratory failure requiring mechanical ventilation. Her oral temperature is 42.1 °C. Which of the following would be most effective in reducing this patient’s severe hyperthermia?A.

Regularly scheduled alternating acetaminophen and ibuprofen

B.

Spraying room temperature water on the patient, followed by fanning

C.

Ice water immersion

D.

Dantrolene sodium, 2.5 mg/kg

E.

Application of ice packs to the groin and axilla

Hyperinsulinemia-euglycemia (HIE) therapy may be useful for toxicity related to which of the following?A.

Tricyclic antidepressants

B.

Calcium channel blockers

C.

Aspirin

D.

Digoxin

E.

Lithium

A 71-year-old female with a history of alcohol abuse is currently intubated in the ICU following a catastrophic spontaneous left basal ganglia hemorrhage with resultant herniation. You have just declared her brain dead. The patient’s family agrees to make her an organ donor, and the organ donation coordinator requests you initiate levothyroxine therapy. Which of the following benefits would be expected with this treatment?A.

Increase the number of solid organs available for transplant

B.

Eliminate the need for hepatic biopsy prior to liver transplant

C.

Eliminate the need for cardiac catheterization prior to heart transplant

D.

Eliminate the need for bronchoscopy prior to lung transplant

E.

Reduce the need for supplementation of sodium, potassium, calcium, and magnesium

Which of the following is not an element of the Full Outline of Unresponsiveness (FOUR) score?A.

Eye opening

B.

Respiratory function

C.

Brainstem reflexes

D.

Motor response

E.

Verbal response

A 23-year-old female is currently in the ICU with status asthmaticus. She was initially on noninvasive positive pressure ventilation, with an arterial blood gas (ABG) as follows: pH 7.13, pCO₂ 60 mmHg, PaO₂ is 61 mmHg, HCO₃ 24 mmol/L, and oxygen saturation of 90%. She is given continuous inhaled albuterol, intravenous steroids, and magnesium sulfate. She subsequently becomes more lethargic and is intubated, with settings as follows: volume assist-control, rate of 12 breaths/min, tidal volume of 500 cc, PEEP of 5 cm H₂O, and FiO₂ of 50%. Peak airway pressure is 50 cm H₂O and plateau pressure is 15 cm H₂O. A stat portable chest x-ray shows hyperinflation with no pneumothorax. A repeat ABG after 30 min of invasive ventilation shows the following: pH of 7.24, pCO₂ 49 mmHg, PaO₂ 71 mmHg, HCO₃ is 25 mmol/L. Which of the following should be performed next?A.

Increase rate to 16

B.

Increase tidal volume to 600 cc

C.

Initiate bicarbonate infusion

D.

Switch to pressure assist-control

E.

Maintain current settings

Which of the following mechanisms is implicated in super-refractory status epilepticus?A.

Influx of proinflammatory molecules

B.

Upregulation of NMDA receptors

C.

Upregulation of molecular transport molecules

D.

Downregulation of GABA receptors

E.

All of the above

A 85-year-old male with a history nephrolithiasis, mild dementia, and alcohol abuse presented to the emergency department after a fall from standing, and was found to a right holohemispheric subdural hematoma. His clot was evacuated successfully, in spite of his oozing diathesis in the operating room (INR on arrival was 1.4 with a platelet count of 88 × 10³/μL). His serum transaminases are twice the normal value, and he has had refractory chronic hyponatremia. He has had three convulsions during this week of hospitalization, in spite of levetiracetam therapy at 1.5 g twice a day. Over the past 24 h, he has had a marked increase in agitation. He has also just had a 5-s run of non-sustained ventricular tachycardia, and his systolic blood pressure is now 85 mmHg. You are considering discontinuing his levetiracetam and starting a new agent. Which of the following would be the best choice in this scenario?A.

Carbamazepine

B.

Phenytoin

C.

Valproate

D.

Lacosamide

E.

Topiramate

A 65-year-old male with a history of COPD on rescue albuterol and ipratropium is diagnosed with myasthenia gravis, and started on an acetylcholinesterase inhibitor. He returns several days later complaining of increased salivation and worsening bronchial secretions in the absence of fevers, purulent sputum, or increasing dyspnea. These symptoms are not relieved by use of his albuterol. On exam, he has slightly decreased air movement throughout both lung fields without any clear wheezing, no focal rales, and a normal inspiratory to expiratory ratio. Which treatment option is most likely to be beneficial?A.

Increase frequency of short-acting ß₂ agonist use

B.

Add a standing long-acting inhaled ß₂ agonist

C.

Add glycopyrrolate as needed

D.

Add inhaled corticosteroids

E.

Add oral systemic corticosteroids

Regarding states of impaired consciousness, which of the following statements regarding arousal and awareness is correct?A.

Coma: intact arousal, but impaired awareness

B.

Minimally conscious state: impaired arousal and impaired awareness

C.

Persistent vegetative state: intact arousal, but impaired awareness

D.

Locked-in state: intact arousal, but impaired awareness

E.

All of the above are correct

A 62-year-old female is currently in the ICU following craniotomy for clipping of a cerebral aneurysm. Postoperatively, she is noted to have an oxygen saturation of 92% on 50% non-rebreather face mask, and her respiratory rate is 32 breaths/min. She denies chest pain. Her blood pressure is 96/72 mmHg and heart rate is 120 beats/min. Nimodipine has been held according to blood pressure parameters. A portable chest x-ray shows hazy opacities bilaterally, and bedside echocardiogram shows decreased left ventricular systolic function with apical, septal, lateral, anterior, anteroseptal and inferolateral wall akinesis, along with apical ballooning. Which of the following should be performed next?A.

Intubate the patient and begin mechanical ventilation

B.

Call urgent cardiology consult for cardiac catheterization

C.

Start noninvasive positive airway pressure ventilation

D.

Administer broad spectrum antibiotics

E.

Administer albuterol and systemic corticosteroids

Which of the following is the most common etiology of acute spinal cord ischemia and infarction?A.

Atherosclerotic disease

B.

Rupture of an abdominal aortic aneurysm

C.

Degenerative spine disease

D.

Cardioembolic events

E.

Systemic hypotension in the setting of other disease processes

A 62-year-old female with a history of coronary artery disease has just been admitted to the ICU with a left-sided spontaneous basal ganglia hemorrhage. The patient takes 325 mg of aspirin daily at home, and you are considering platelet transfusion. Which of the following has been demonstrated regarding platelet transfusion in this setting?A.

Improved chances of survival to hospital discharge

B.

Decreased hospital length-of-stay

C.

Improved chances of survival at 3 months

D.

Improved modified Rankin scale at 3 months

E.

None of the above

Which of the following therapies has been shown to decrease the incidence of delayed cerebral ischemia (DCI) in the setting of subarachnoid hemorrhage (SAH)?A.

Atorvastatin

B.

Magnesium

C.

Methylprednisolone

D.

Nicardipine

E.

None of the above

A 70-year-old male with a history of diabetes, hypertension, and cigarette smoking (one pack per day for the last 40 years) is currently in the ICU with a COPD exacerbation. This is his third exacerbation this year, and was discharged from the hospital only 3 weeks prior. On your examination, he is alert, his breathing is labored, and he has rales at the right lung base. His vital signs are as follows: blood pressure 90/60 mmHg, heart rate 120 beats per minute, respirations 28 per minute, and temperature 38.3 °C. His oxygen saturation on 50% face mask is 93%, and his most recent PCO₂ is 55 mmHg. Labs are notable for the following: white blood cell count 14.4 × 10⁹/L with 90% neutrophils, blood urea nitrogen (BUN) 30 mg/dL, serum creatinine 1.2 mg/dL, and glucose 240 mg/dL. Ketones are negative. He is currently on noninvasive positive pressure ventilation at 10/5 cm H₂O and 50% FiO₂, and broad spectrum antibiotics have been administered. An hour later, the nurse pages you because his heart rate is now 140 beats per minute and irregular, blood pressure is 85 systolic, oxygen saturation is 85%, and he is minimally responsive. You now hear bilateral rales, most prominently in the right lung base, and scattered wheezes. Which of the following should be performed next?A.

Increase inspiratory pressure to 15 and FiO₂ to 100%

B.

Start a continuous diltiazem infusion and give intravenous furosemide

C.

Start a continuous phenylephrine infusion targeting a mean arterial pressure (MAP) > 65

D.

Give 125 mg of solumedrol and administer albuterol via nebulizer

E.

Intubate the patient and initiate mechanical ventilation

A 57-year-old male with a history of epilepsy is currently in the stroke unit following a large right middle cerebral artery infarction. A nasogastric tube has been inserted, and 24 h continuous enteral feeds have been initiated. The patient is currently on 100 mg of phenytoin every 8 h for seizure prophylaxis. Which of the following measures should be taken to prevent the patient from developing subtherapeutic phenytoin levels?A.

Change to 18 h tube feeds, and only administer phenytoin at night

B.

Change to 18 h tube feeds, and only administer phenytoin twice daily

C.

Switch from standard to hydrolyzed tube feeds

D.

Switch from standard to glycemic control tube feeds

E.

Hold tube feeds for 2 h before and after phenytoin administration

A 37-year-old female presents to the emergency department with approximately 2 weeks of progressively worsening clumsiness and drastic mood swings. Her past medical history is significant only for Crohn’s disease, for which she takes both natalizumab and infliximab. A contrast-enhanced CT scan of her head is performed, revealing hypodense, non-enhancing lesions in the cortical white matter of the frontal and parietal lobes. Despite treatment, the patient expires 1 month later. Which of the following is true regarding the most likely diagnosis?A.

The diagnosis may be confirmed via CSF analysis

B.

The pathologic process spares oligodendrocytes

C.

It is a prion-based disease

D.

The condition is universally fatal despite treatment

E.

All of the above

A 58-year-old female presents to the emergency department with dry cough, fever and rapidly progressive dyspnea over 1 week. She has a history of rheumatoid arthritis (RA) and is maintained on weekly methotrexate and daily prednisone (which was increased to 30 mg starting 1 month ago for an acute flare). She takes no other medications. Her vital signs are as follows: blood pressure 100/70 mmHg, heart rate 110 beats/min, respiratory rate 20 breaths/min, and temperature 38.0 °C. In the ED she develops progressive hypoxemia with oxygen saturation 92% on 100% nonrebreather, and is increasingly diaphoretic. She is emergently intubated, and a chest x-ray post intubation shows extensive bilateral lung opacities. Which of the following should be administered at this time?A.

Ceftriaxone and azithromycin

B.

Vancomycin and piperacillin-tazobactam

C.

Vancomycin, cefepime, and fluconzole

D.

Ceftriaxone, levofloxacin, and trimethoprim-sulfamethoxazole

E.

Tigecycline only

A 45-year-old woman undergoes uncomplicated transsphenoidal resection of a pituitary macroadenoma. She appears well hydrated and is not complaining of excessive thirst. Post-operatively, she is noted to have increased urine output. Serum sodium is 137 mEq/L, and serum osmolarity is 275 mOsm/kg. What is the most likely cause of her polyuria?A.

Syndrome of inappropriate antidiuretic hormone

B.

Diabetes insipidus

C.

Cerebral salt wasting

D.

Fluid mobilization

E.

All of the above are equally likely

A 36-year-old female with a recent lumbar puncture to rule out subarachnoid hemorrhage is now complaining of a severe headache unlike anything she has experienced previously. She reports her headache is worse when standing, and better upon lying flat. She is otherwise neurologically intact. All of the following medications may be beneficial in this scenario except:A.

Acetaminophen

B.

Ibuprofen

C.

Caffeine

D.

Aminophylline

E.

Methylprednisolone

Which of the following is the most common overall cause of acute myocardial infarction?A.

Coronary dissection

B.

Plaque rupture

C.

Imbalance between oxygen demand and supply across a fixed obstruction

D.

Coronary vasospasm

E.

Ischemia related to hypotension and decreased perfusion

A 78-year-old male is in the ICU recovering from sepsis and pneumonia. He was just recently extubated after 2 days of mechanical ventilation and sedation with a fentanyl infusion. Over the ensuing days, he develops worsening abdominal distention, poor bowel sounds, and no stool output. CT scan reveals significant colonic distention, but no mass or obstruction. Records demonstrate a normal routine colonoscopy performed 6 weeks ago. You have appropriately hydrated the patient, corrected any electrolyte abnormalities, placed a rectal tube, withheld all opiates, and given intravenous erythromycin, but to no avail. Abdominal x-rays continue to demonstrate marked cecal dilatation greater than 12 cm in diameter. What is the next best appropriate therapy for this patient?A.

Neostigmine

B.

Naloxone

C.

Metoclopromide

D.

Surgical consultation for hemicolectomy

E.

Endoscopic percutaneous cecostomy tube placement

Which of the following is the most common cerebral vascular malformation in the general population?A.

AV malformation

B.

Dural AV fistula

C.

Developmental venous anomaly

D.

Cavernous malformation

E.

Vein of Galen malformation

A 49-year-old female with a history of acute lymphoblastic leukemia and recent subcutaneous cerebrospinal fluid (CSF) reservoir placement presents to the emergency department with fever, chills, and increased confusion for the past 3 days. Her CSF reservoir was last accessed 1 week ago. A thorough work-up reveals no other obvious infectious source, and there is concern for CSF reservoir-associated meningitis. Which of the following is the most likely causative organism?A.

Coagulase-negative staphylococci

B.

Propionobacterium acnes

C.

Methicillin-resistant Staphylococcus aureus

D.

Klebsiella pneumoniae

E.

Neisseria meningitidis

A 47-year-old woman presents to the emergency department with headache, nausea, and vomiting. Non-contrast head CT is performed, revealing subarachnoid blood in the right Sylvian fissure, and conventional angiography reveals the presents of a large right-sided MCA aneurysm. The patient undergoes successful surgical clipping of her aneurysm, and is being observed in the ICU. On admission, the patient’s serum sodium was 142 mEq/L and the hematocrit was 37%; by the seventh post-operative day, the serum sodium is 127 mEq/L and the hematocrit is 44%. Bedside ultrasonography demonstrates an IVC diameter of approximately 0.9 cm. Which of the following interventions would be least reasonable at this time?A.

Fludrocortisone, 0.2 mg twice a day

B.

2% hypertonic saline, infused peripherally

C.

3% hypertonic saline, infused centrally

D.

Sodium chloride oral tablets

E.

1500 mL daily fluid restriction

Which of the following is true regarding central (non-infectious) fever?A.

Less common in subarachnoid hemorrhage

B.

More common versus infectious fever

C.

Earlier onset versus infectious fever

D.

Easier to confirm versus infectious fever

E.

All of the above

Flaccid paralysis is most commonly associated with which of the following forms of encephalitis?A.

West Nile

B.

Varicella zoster

C.

Rabies

D.

Herpes simplex

E.

Epstein-Barr

Which of the following would not be considered appropriate therapy for heparin-induced thrombocytopenia (HIT)?A.

Discontinuation of heparin products alone

B.

Danaparoid

C.

Fondaparinux

D.

Argatroban

E.

All of the above are acceptable treatment options

A 45-year-old male with severe blunt traumatic brain injury (TBI) from a motor vehicle collision suffered a ventricular fibrillation cardiac arrest at the time of injury with return of spontaneous circulation (ROSC) in the field after endotracheal intubation and one dose of epinephrine. On arrival to the emergency department, no regional wall motion abnormalities were noted on surface echocardiography and no ST segment changes were seen on the presenting EKG. Head CT revealed cerebral contusions but no extra-axial mass lesions. The patient is now in the ICU and found to be comatose without sedation. Mild therapeutic hypothermia to 33° is being considered in the management of this post-arrest patient. Which of the following statements is true?A.

Mild therapeutic hypothermia is contraindicated due to the risk of induced epilepsy

B.

Mild therapeutic hypothermia is contraindicated with any intracranial pathology on CT imaging

C.

Mild therapeutic hypothermia does not induce a clinically significant coagulopathy

D.

Patients who have sustained ROSC after an arrest associated with TBI do not benefit from therapeutic hypothermia

E.

Endovascular cooling is superior to surface cooling in young patients with ROSC

A 35-year-old male is in the intensive care unit following resection of a large right-sided meningioma. He is currently intubated and sedated on a continuous fentanyl infusion. The nurse calls you to the bedside due to concerns over “unusual ventilator waveforms”. Upon arrival, you note the following (see Image 1). What is the best way to describe this phenomenon?A.

Reverse triggering

B.

Double triggering

C.

Breath stacking

D.

Missed triggering

E.

None of the above; normal ventilator waveforms are present

Intravenous Cosyntropin Versus Epidural Blood Patch for Treatment of Postdural Puncture Headache

OBJECTIVE

This study evaluated the efficacy of IV cosyntropin as an alternative to epidural blood patch (EBP) for refractory or severe post-dural puncture headache (PDPH).

METHODS

Twenty-eight patients were randomized to receive EBP or intravenous cosyntropin after diagnosis with post-dural puncture headache. Efficacy was evaluated immediately after treatment and at 1 day, 3 days, and 7 days following treatment using self-reported verbal reported scores for pain and function related to their headache on a 10-point scale using two-way repeated measures analysis of variance (ANOVA) with multiple comparisons.

RESULTS

Baseline information for the control and study cohorts showed no difference based on intent to treat analysis. EBP showed significant improvement over cosyntropin at day 1 (P < 0.001) for VRS pain and function scores; however, cosyntropin demonstrated similar efficacy to EBP immediately after treatment and days 3 and 7 post treatment (respectively, P = 0.459, P = 0.391 and 0.925 for pain and P = 0.189 and 0.478 for function). Treatment effects remained at day 1 after multivariate analysis (P < 0.001 and P = 0.002 for pain and function, respectively).

CONCLUSIONS

It is reasonable to consider IV cosyntropin as the treatment of choice for patients in whom EBP is contraindicated or in austere environments where there is limited or no access to anesthesia trained providers. Future research should compare efficacy and cost of prophylaxis to treatment of PDPH with intravenous cosyntropin and evaluate the most effective dosing regimen, including duration, number, and strength of doses.

Posture and fluids for preventing post-dural puncture headache

BACKGROUND

Post-dural puncture headache (PDPH) is a common complication of lumbar punctures. Several theories have identified the leakage of cerebrospinal fluid (CSF) through the hole in the dura as a cause of this side effect. It is therefore necessary to take preventive measures to avoid this complication. Prolonged bed rest has been used to treat PDPH once it has started, but it is unknown whether prolonged bed rest can also be used to prevent it. Similarly, the value of administering fluids additional to those of normal dietary intake to restore the loss of CSF produced by the puncture is unknown. This review is an update of a previously published review in the Cochrane Database of Systematic Reviews (Issue 7, 2013) on "Posture and fluids for preventing post-dural puncture headache".

OBJECTIVES

To assess whether prolonged bed rest combined with different body and head positions, as well as administration of supplementary fluids after lumbar puncture, prevent the onset of PDPH in people undergoing lumbar puncture for diagnostic or therapeutic purposes.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and LILACS, as well as trial registries up to February 2015.

SELECTION CRITERIA

We identified randomized controlled trials that compared the effects of bed rest versus immediate mobilization, head-down tilt versus horizontal position, prone versus supine positions during bed rest, and administration of supplementary fluids versus no/less supplementation, as prevention measures for PDPH in people who have undergone lumbar puncture.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the studies for eligibility through the web-based software EROS (Early Review Organizing Software). Two different review authors independently assessed risk of bias using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions. We resolved any disagreements by consensus. We extracted data on cases of PDPH, severe PDPH, and any headache after lumbar puncture and performed intention-to-treat analyses and sensitivity analyses by risk of bias. We assessed the evidence using GRADE (Grading of Recommendations Assessment, Development and Evaluation) and created a 'Summary of findings' table.

MAIN RESULTS

We included 24 trials with 2996 participants in this updated review. The number of participants in each trial varied from 39 to 382. Most of the included studies compared bed rest versus immediate mobilization, and only two assessed the effects of supplementary fluids versus no supplementation. We judged the overall risk of bias of the included studies as low to unclear. The overall quality of evidence was low to moderate, downgraded because of the risk of bias assessment in most cases. The primary outcome in our review was the presence of PDPH.There was low quality evidence for an absence of benefits associated with bed rest compared with immediate mobilization on the incidence of severe PDPH (risk ratio (RR) 0.98; 95% confidence interval (CI) 0.68 to 1.41; participants = 1568; studies = 9) and moderate quality evidence on the incidence of any headache after lumbar puncture (RR 1.16; 95% CI 1.02 to 1.32; participants = 2477; studies = 18). Furthermore, bed rest probably increased PDPH (RR 1.24; 95% CI 1.04 to 1.48; participants = 1519; studies = 12) compared with immediate mobilization. An analysis restricted to the most methodologically rigorous trials (i.e. those with low risk of bias in allocation method, missing data and blinding of outcome assessment) gave similar results. There was low quality evidence for an absence of benefits associated with fluid supplementation on the incidence of severe PDPH (RR 0.67; 95% CI 0.26 to 1.73; participants = 100; studies = 1) and PDPH (RR 1; 95% CI 0.59 to 1.69; participants = 100; studies = 1), and moderate quality evidence on the incidence of any headache after lumbar puncture (RR 0.94; 95% CI 0.66 to 1.34; participants = 200; studies = 2). We did not expect other adverse events and did not assess them in this review.

AUTHORS' CONCLUSIONS

Since the previous version of this review, we found one new study for inclusion, but the conclusion remains unchanged. We considered the quality of the evidence for most of the outcomes assessed in this review to be low to moderate. As identified studies had shortcomings on aspects related to randomization and blinding of outcome assessment, we therefore downgraded the quality of the evidence. In general, there was no evidence suggesting that routine bed rest after dural puncture is beneficial for the prevention of PDPH onset. The role of fluid supplementation in the prevention of PDPH remains unclear.

Drug therapy for treating post-dural puncture headache

BACKGROUND

This is an updated version of the original Cochrane review published in Issue 8, 2011, on 'Drug therapy for treating post-dural puncture headache'.Post-dural puncture headache (PDPH) is the most common complication of lumbar puncture, an invasive procedure frequently performed in the emergency room. Numerous pharmaceutical drugs have been proposed to treat PDPH but there are still some uncertainties about their clinical effectiveness.

OBJECTIVES

To assess the effectiveness and safety of drugs for treating PDPH in adults and children.

SEARCH METHODS

The searches included the Cochrane Central Register of Controlled Trials (CENTRAL 2014, Issue 6), MEDLINE and MEDLINE in Process (from 1950 to 29 July 2014), EMBASE (from 1980 to 29 July 2014) and CINAHL (from 1982 to July 2014). There were no language restrictions.

SELECTION CRITERIA

We considered randomised controlled trials (RCTs) assessing the effectiveness of any pharmacological drug used for treating PDPH. Outcome measures considered for this review were: PDPH persistence of any severity at follow-up (primary outcome), daily activity limited by headache, conservative supplementary therapeutic option offered, epidural blood patch performed, change in pain severity scores, improvements in pain severity scores, number of days participants stay in hospital, any possible adverse events and missing data.

DATA COLLECTION AND ANALYSIS

Review authors independently selected studies, assessed risk of bias and extracted data. We estimated risk ratios (RR) for dichotomous data and mean differences (MD) for continuous outcomes. We calculated a 95% confidence interval (CI) for each RR and MD. We did not undertake meta-analysis because the included studies assessed different sorts of drugs or different outcomes. We performed an intention-to-treat (ITT) analysis.

MAIN RESULTS

We included 13 small RCTs (479 participants) in this review (at least 274 participants were women, with 118 parturients after a lumbar puncture for regional anaesthesia). In the original version of this Cochrane review, only seven small RCTs (200 participants) were included. Pharmacological drugs assessed were oral and intravenous caffeine, subcutaneous sumatriptan, oral gabapentin, oral pregabalin, oral theophylline, intravenous hydrocortisone, intravenous cosyntropin and intramuscular adrenocorticotropic hormone (ACTH).Two RCTs reported data for PDPH persistence of any severity at follow-up (primary outcome). Caffeine reduced the number of participants with PDPH at one to two hours when compared to placebo. Treatment with caffeine also decreased the need for a conservative supplementary therapeutic option.Treatment with gabapentin resulted in better visual analogue scale (VAS) scores after one, two, three and four days when compared with placebo and also when compared with ergotamine plus caffeine at two, three and four days. Treatment with hydrocortisone plus conventional treatment showed better VAS scores at six, 24 and 48 hours when compared with conventional treatment alone and also when compared with placebo. Treatment with theophylline showed better VAS scores compared with acetaminophen at two, six and 12 hours and also compared with conservative treatment at eight, 16 and 24 hours. Theophylline also showed a lower mean "sum of pain" when compared with placebo. Sumatriptan and ACTH did not show any relevant effect for this outcome.Theophylline resulted in a higher proportion of participants reporting an improvement in pain scores when compared with conservative treatment.There were no clinically significant drug adverse events.The rest of the outcomes were not reported by the included RCTs or did not show any relevant effect.

AUTHORS' CONCLUSIONS

None of the new included studies have provided additional information to change the conclusions of the last published version of the original Cochrane review. Caffeine has shown effectiveness for treating PDPH, decreasing the proportion of participants with PDPH persistence and those requiring supplementary interventions, when compared with placebo. Gabapentin, hydrocortisone and theophylline have been shown to decrease pain severity scores. Theophylline has also been shown to increase the proportion of participants that report an improvement in pain scores when compared with conventional treatment.There is a lack of conclusive evidence for the other drugs assessed (sumatriptan, adrenocorticotropic hormone, pregabalin and cosyntropin).These conclusions should be interpreted with caution, due to the lack of information to allow correct appraisal of risk of bias, the small sample sizes of the studies and also their limited generalisability, as nearly half of the participants were postpartum women in their 30s.

Caffeine as an analgesic adjuvant for acute pain in adults

BACKGROUND

This is an updated version of the original Cochrane review published in Issue 3, 2012. Caffeine has been added to common analgesics such as paracetamol, ibuprofen, and aspirin, in the belief that it enhances analgesic efficacy. Evidence to support this belief is limited and often based on invalid comparisons.

OBJECTIVES

To assess the relative efficacy of a single dose of an analgesic plus caffeine against the same dose of the analgesic alone, without restriction on the analgesic used or the pain condition studied. We also assessed serious adverse events.

SEARCH METHODS

We searched CENTRAL, MEDLINE, and EMBASE from inception to 28 August 2014, the Oxford Pain Relief Database, and also carried out Internet searches and contacted pharmaceutical companies known to have carried out trials that have not been published.

SELECTION CRITERIA

We included randomised, double-blind studies that compared a single dose of analgesic plus caffeine with the same dose of the analgesic alone in the treatment of acute pain.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the eligibility and quality of studies, and extracted data. Any disagreements or uncertainties were settled by discussion with a third review author. We sought any validated measure of analgesic efficacy, but particularly the number of participants experiencing at least 50% of the maximum possible pain relief over four to six hours, participants reporting a global evaluation of treatment of very good or excellent, or headache relief after two hours. We pooled comparable data to look for a statistically significant difference, and calculated numbers needed to treat to benefit (NNT) with caffeine. We also looked for any numerical superiority associated with the addition of caffeine, and information about any serious adverse events.

MAIN RESULTS

We identified no new studies with available results for this update. The earlier review included 20 studies (7238 participants) in valid comparisons, but because we used different outcomes for some headache studies, the number of participants in the analyses of the effects of caffeine is now 4262 when previously it was 5243. The studies were generally of good methodological quality, using standard designs and mostly standard scales of pain measurement, although many of those treating postoperative pain were small.Most studies used paracetamol or ibuprofen, with 100 mg to 130 mg caffeine, and the most common pain conditions studied were postoperative dental pain, postpartum pain, and headache. There was a small but statistically significant benefit with caffeine used at doses of 100 mg or more, which was not dependent on the pain condition or type of analgesic. About 5% to 10% more participants achieve a good level of pain relief (at least 50% of the maximum over four to six hours) with the addition of caffeine, giving a NNT of about 14 (high quality evidence).Most comparisons individually demonstrated numerical superiority with caffeine, but not statistical superiority. One serious adverse event was reported with caffeine, but was considered unrelated to any study medication.We know of the existence of around 25 additional studies with almost 12,500 participants for which data for analysis were not obtainable. The additional analgesic effect of caffeine remained statistically significant but clinically less important even if all the known missing data had no effect; the bulk of the unobtainable data are reported to have similar results as this review.

AUTHORS' CONCLUSIONS

The addition of caffeine (≥ 100 mg) to a standard dose of commonly used analgesics provides a small but important increase in the proportion of participants who experience a good level of pain relief.

Treatment of post-dural puncture headache using epidural injection of fibrin sealant as an alternative to autologous epidural blood patch (case report)

Background Post dural puncture headache (PDPH) is an iatrogenic cause of patient morbidity in pain management after spinal or epidural anaesthesia, as well as after diagnostic lumbar puncture. Most patients respond to conservative treatment or to epidural blood patch, yet limited options for effective treatment are available for patients who fail these treatments or present with theoretical contraindication. Case report We present a case of a patient with previously diagnosed human immunodeficiency virus and hepatitis C, who presented with signs of PDPH, which placed him at a theoretical risk of meningeal seeding of the virus during the blood patching procedure. Conclusion We successfully treated the post dural puncture headache and avoided the risk of viral seeding of the meninges by using a fibrin sealant.