Ammonia tea base treatment caesarean section after atypical headache 1 case.

The clinical occurrence of headache (post duralpuncture headache, PDPH) after a broken epidural is low.
PDPH is one of the common complications after anesthesia in the obstetric vertebral tube, and its mechanism is usually thought to be low cranial pressure headache caused by leakage of cerebrospinal fluid caused by the rupcture of the epidural membrane.
According to the international classification of headache disease diagnosis standards, PDPH must be clearly related to position, that is, within 15 minutes of sitting or standing headache aggravation, 15 minutes after lying flat symptoms gradually alleviate or disappear, can be accompanied by neck stiffness, tinnitus, vision loss, fear of light and/or nausea and other symptoms, young people, women, pregnancy, chronic tension headache history has a high incidence.
its natural course of disease is self-limiting, appears in the lumbar puncture after 5 days, generally 12 to 48h, most symptoms in 1 to 2 weeks to ease.
this paper reported a case of PDPH after an epidural blocking the lower caesarean section.
1. Clinical data patient, female, 23 years old, due to "pregnancy 2 birth 1, pregnancy 38 plus 4 weeks, scar uterus, obesity (BMI36.5)" in July 2018 in Shangyu Maternal and Child Health Hospital under continuous epidural blocking caesarean section, epidural puncture after two successful operations, surgery after smooth, after the use of intravenous analgesics, drug formula for fentanyl 0.3mg , buttolphrano 8mg and toransjong 15mg with physiological saline to 100mL solution, infusion speed of 2mL/h.
After surgery on the night of occasional headache, pain nature and positioning are not clear, pain digital score (numerical rating scale, NRS) flat 1 to 2 points, get up slightly aggravated, for 2 to 3 points, similar to the symptoms of cervical vertebral disease in the past, so do not care.
day after surgery, after getting up the headache aggravated with dizziness, NRS4 points, cervical vertebral thynapse and vertebral side of the pressure pain, cervical restriction.
obstetrician considered cervical vertebral disease, bed, reduce neck activity, hot application, push and take, symptoms have been alleviated.
5 days after surgery, the symptoms were significantly relieved, NRS1 points.
morning of the 6th day after surgery, the headache symptoms worsened, NRS3 to 4 minutes, continued after about 30min natural remission, did not inform the doctor and then discharged from the hospital.
home, the symptoms worsen, the pain is located in the double-sided temporal pain, NRS4 to 5 points, flat sleep symptoms have been reduced.
after surgery on the 7th day at about 3:00, the patient woke up in sleep, for the cleavage pain, located in the double-sided palate, NRS7 to 8 minutes, to the hospital, to the hydrochloric acid fluorine capsule oral, symptoms did not improve.
8th day after surgery 11:45, due to severe pain on both sides of the tith, under the help of two people again admitted to our hospital, NRS 8 to 9 points, after lying flat some relief.
monitoring of vital signs is stable, laboratory examination is not obvious abnormal.
ct of the skull showed that the two sides of the forehead had slightly lower density shadows with arcs, and the hemispheres of the brain on both sides were symmetrical, and no abnormal density shadows were seen in the brain.
the brain room system did not expand, the brain pool, brain ditch form and age.
centerline structure of the skull, and no significant abnormalities were seen in the skull (Figure 1).
imaging diagnosis: a small amount of fluid build-up under the epidural of the two-sided forehead.
hospital after the treatment of flat rehydration fluid, no effect, at 20:00 that night to physiological saline 250mL and ammonia tea base 0.25g static droplets, infusion time of 30min.
22:00 headache began to ease.
the next day 8:00 patients complained of a significant relief of headache, NRS1 points, no aggravation after getting up, the night before a good sleep.
the physiological saline 250mL plus ammonia tea base 0.25g static droplets, infusion time 30min.
discharged on the 3rd day after the patient's symptoms improved significantly.
1 week later, 1 month after telephone follow-up, complaining of headache, dizziness no recurrence, good sleep.
2. Discussing the headache symptoms of PDPH patients in this case is not typical, because the anaesthetic did not find epidural piercing, coupled with the past history of cervical vertebral disease, so the early postoperative headache and cervical vertebral disease confused, but because the headache has obvious position, coupled with the previous epidural repeated punctures, so the diagnosis of PDPH is established.
but with the headache symptoms gradually aggravated, and lost position characteristics, taking painkillers is not effective, indicating that the disease has undergone a new change.
The probability of intracranial epidural hematoma occurring after accidental epidural piercing is about 1.1%, and its diagnosis is based on three aspects: (1) atypical headache, lack of positional characteristics, duration of more than 7 days, and common pain relief The drug had no obvious effect; (2) there were signs of increased intracranial pressure or physical brain stress, such as vomiting, convulsions, changes in consciousness levels or abnormal incision, segmental movement and sensory function; and (3) imaging evidence was needed for diagnosis.
in combination with medical history, symptom signs and CT examination, can be diagnosed in 7 days after the birth of intracranial epidural hematoma.
A lot of evidence suggests that intracranial epidural hematomas are mostly caused by rupture of bridge veins, the mechanism of which is: loss of cerebrospinal fluid causes intracranial pressure to decrease, brain tissue to sink, bridge veins to be pulled, in certain cases may cause rupture bleeding at the weakest part of the bridge veins."
venous hematoma, symptoms are sometimes more hidden and do not progress as quickly as arterial bleeding.
the patient's subjective symptoms of pain, but from the CT test results, the amount of bleeding is relatively small.
Under the epidural hematoma usually only needs conservative treatment, including close observation, treatment of the disease, hematoma less than 5mm can usually gradually absorb itself;
ammonia is a phosphate gestase inhibitor, which is the basis of its pharmacological action.
A recent prospective randomized controlled study of a large multi-center sample confirmed the effectiveness of ammonia tea base therapy with PDPH, the mechanism of which may be related to aminocholine increasing the secretion of cerebrospinal fluid, blocking pain transfer of pain-sensitive structures, contraction of cerebrovascular vessels, and increased in-cell cAMP content.
but headaches for the treatment of hematomas under the epidural have not been reported.
Taking into account the small amount of hematoma hemorrhage under the epidural in this case, the headache and PDPH are secondary to the epidural piercing, the pathogenesis has some commonality, so we try to apply ammonia tea base to treat (medical department filing).
The results, the patient's original long-term recurrent headache by ammonia tea base treatment 2 days after the obvious relief, and did not recur, suggesting that its treatment combined with the epidural hematoma headache is effective, the contraction of cerebrovascular help to reduce continued bleeding.
the patient's previous application of fluorine is a calcium channel blocker, dilating cerebrovascular vessels may actually aggravate the condition.
, of course, more cases will need to accumulate in the future to confirm the effectiveness of ammonia therapy for epidurals to break secondary epidural hematomas.
however, it is very difficult to conduct a prospective randomized controlled study because of the low incidence of epidural piercing and the lower incidence of secondary hematoma under the epidural (about 1.1%).
ammonia tea base in the body quickly released tea base, the latter protein binding rate of 60%, 70% to 90% by liver oxidation metabolism, serum half-life of 6 to 12h, metabolites excreted by the kidneys.
The bioconsevergation rate of the drug is influenced by many factors, has obvious individual differences, its efficacy and toxicity reaction is closely related to its blood drug concentration and the speed of drug dissertation, and the adverse reactions of ammonia alkaloid include nausea, vomiting, arrhythrosis and convulsions.
patients received a lower dose of ammonia than conventional clinical treatment, and the infusion speed is slow, this drug treatment has been shown to be safe.
Although epidural blood patch is currently the recommended method of international treatment of PDPH, and there are also reports for the treatment of hematoma under the epidural, but because of its invasive operation, and there is a certain failure rate and potential invertebral infection and other risks, most patients in China difficult to accept.
, once it is clear that PDPH can be considered intravenously for early treatment with ammonia, it may be beneficial to avoid the occurrence of hematomas under the epidural.
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