Seizures after epidural blood patch in a postpartum patient later diagnosed with hypertension and proteinuria: a diagnostic conundrum.

Seizures are a rare, but documented, consequence of accidental dural puncture and epidural blood patch. They are also the cardinal feature of eclampsia. We present a postpartum patient who suffered a tonic-clonic seizure within 1 hour of an epidural blood patch procedure for a suspected post-dural puncture headache. Investigations also revealed hypertension, proteinuria and subdural collections. This case demonstrates the diagnostic dilemma associated with postpartum headache and late postpartum eclampsia. We illustrate the importance of a thorough clinical assessment of postpartum patients presenting with headache, highlighting the possibility of more than one underlying pathological cause. We also consider the role of epidural blood patch in both precipitating, and preventing, complications of accidental dural puncture.

The use of separate-level neuraxial anaesthesia for caesarean delivery in a patient with a history of spinal tuberculosis.

We present the case of a 33-year-old parturient who required caesarean delivery at 31 weeks' gestation. She had a history of degenerative disease of the lumbar spine secondary to tuberculosis, acquired as a child in India. Her complex medical history also included ischaemic heart disease and obstructive sleep apnoea, and due to this general anaesthesia was considered to be of high risk. However, regional anaesthesia also posed significant challenges because magnetic resonance imaging of the spine showed a partial collapse with subsequent fusion of second and third lumbar vertebral bodies with thoracolumbar kyphosis. Neuraxial anaesthesia was performed with ultrasound guidance for determining levels and depth of epidural space. An epidural was inserted at the T12-L1 interspace and a spinal anaesthetic block was placed at L4-L5. Delivery and recovery were uneventful. This case highlights the safe and effective use of neuraxial anaesthesia in an asymptomatic patient with treated spinal tuberculosis as well as the usefulness of high-quality imaging of the spine in the decision to perform neuraxial anaesthesia.

Saving Blood and Reducing Costs: Updating Blood Transfusion Practice in Lower Limb Arthroplasty

Aim Our aim was to quantify blood transfusion rates in lower limb arthroplasty following the introduction of a multimodal enhanced recovery programme (ERP). We then sought to update the maximum surgical blood ordering schedule (MSBOS) and calculate cost savings achieved. Methods A retrospective cohort study was conducted of all patients who required blood transfusion following primary and revision total hip and knee arthroplasty in 2012 and 2015. A multimodal ERP was introduced in 2015. Cost savings were calculated following the introduction of a new MSBOS. Results During the two-year study period 1467 lower limb arthroplasty procedures were performed. The cross-match to transfusion ratio was 3.6:1 in 2012 and 9.9:1 in 2015. The updated MSBOS resulted in a 46% reduction of cross-matched blood and savings of €54,375 per annum. Conclusion Improved perioperative management in lower limb arthroplasty has reduced blood transfusion rates. Updating blood transfusion practice can result in considerable savings in blood, resources and costs.

DNA probes for the detection of toxin genes in Escherichia coli isolated from diarrhoeal disease in cattle and pigs.

DNA gene probes specific for genes coding for heat labile toxin (LT), heat stable toxins (STpa, STpb) and Vero-cell toxins (VT1, VT2) were used to examine 1031 diarrhoeal disease isolates of E. coli (345 from cattle and 686 from pigs). Of the bovine strains, 60 hybridized with the STpa probe and most possessed the K99 (F5) or F41 adhesin. Five bovine strains possessed STpb genes and five either VT1 or VT2 genes. Of the porcine strains, 245 hybridized with one or more gene probes. Of 160 K88 (F4) positive strains, 133 possessed both LT and STpb genes, whilst 17 possessed LT or STpb or STpa alone or in combination. Ten K88 strains did not possess toxin genes. Isolates bearing the K99 (F5) adhesion possessed either STpa, STpb and VT2 genes alone or in combination; in one isolate only the LT gene was detected. Isolates belonging to serogroup 0138:K81 were more heterogeneous as to their toxin genes; of the 60 strains, fourteen carried only VT2 genes, thirty-two carried VT2, STpa and STpb genes, one carried LT, VT2, STpa and STpb genes, two carried STpb gene, four carried STpa and STpb genes, one carried LT and VT2 genes, two carried LT and STpa genes, whilst four carried none. Twenty-four percent of all toxigenic strains apparently did not possess adhesins.