Der Anaesthesist
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The acute phase of complex regional pain syndrome (CRPS) is pathophysiologically characterized by an activation of the immune system and its associated inflammatory response. During the course of CRPS, central nervous symptoms like mechanical hyperalgesia, loss of sensation, and body perception disorders develop. ⋯ A stage adapted, targeted treatment could improve the prognosis. Effective multidisciplinary treatment includes the following: pharmacotherapy with steroids, bisphosphonates, or dimethylsulfoxide cream (acute phase), and antineuropathic analgesics (all phases); physiotherapy and behavioral therapy for pain-related anxiety and avoidance of movement; and interventional treatment like spinal cord or dorsal root ganglion stimulation if noninvasive options failed.
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The authors describe in a clinical case series (n = 7) of older (age 78-95 years) high-risk patients the successful surgical treatment of proximal femoral fractures in a peripheral regional anesthesia technique. After positioning on the non-fractured side, a double injection technique (dual guidance concept: sonography plus nerve stimulation) was chosen. The injections were performed parasacrally (blockade of the sacral plexus under the piriformis muscle) and lumbar-paravertebrally (psoas compartment block and transmuscular quadratus lumborum block). ⋯ The total dose of 225 mg ropivacaine was never exceeded. In 5 out of 7 cases a supplemental medication with 2 times 5 μg sufentanil (n = 2) and/or 1-1.5 mg/kg body weight and h propofol (n = 4) was administered with spontaneous breathing. In addition to potential benefits, the authors also discuss limitations of the procedure, for example by the use of oral anticoagulants.
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Abstract