The value of nerve blocks in the diagnoses and treatment of complex regional pain syndrome type 1: a series of 14 cases.

OBJECTIVES: Complex regional pain syndrome type 1 (CRPS-1) can progress to joint stiffness, which may be related to pain and/or capsule-ligament contracture. In this context, it is difficult to distinguish the respective causative roles of pain and contractures. Nerve blocks (NBs) can be used to determine the aetiology of joint stiffness. Subsequent treatment will depend on whether contractures are present or not. The objective of the present study was to evaluate the diagnostic and therapeutic value of the nerve blocks in the management of joint stiffness caused by CRPS-1. DESIGN OF THE STUDY: A retrospective case series. METHODS: Implementation of NBs in subjects with joint stiffness caused by CRPS-1. Primary efficacy criterion: an increase in the range of joint movement. Secondary criteria: pain level, treatment decision, duration of therapeutic NBs, return to work. RESULTS: Fourteen patients with joint stiffness underwent 17 NBs. Ten NBs (59%) were associated with the normalization of the range of joint movement (i.e. the absence of contractures and the presence of an isolated pain component), prompting the implementation of physical therapy during NBs ("therapeutic NBs") in 90% of these cases. Three NBs (18%) were associated with a partial increase in the range of joint movement (i.e. a background of joint stiffness due to a combination of pain and contracture), prompting the implementation of a therapeutic NB in all of these cases. Four NBs (23%) were not associated with any increase in the range of joint movement (i.e. pure contractures), prompting consultation with a surgeon in all of these cases. Forty-three percent of the patients have since returned to work. CONCLUSIONS: Nerve block is a valuable diagnostic and therapeutic option in the management of joint stiffness caused by CRPS-1.

[Postoperative cognitive dysfunction (POCD): strategy of prevention, assessment and management]. / Dysfonctions cognitives postopératoires: stratégie de prévention, de dépistage et de prise en charge.

The femoral neck fracture is a major cause of morbidity and mortality in the elderly. The etiology of cognitive impairment observed in this population of aged patient seems to be multifactorial. In the strategy of prevention, elderly patient must have the clearer information dealing with the postoperative cognitive dysfunction. This would reduce the incidence of POCD and some cognitive complaints, which often reflect the anxiety of the elderly patient facing the possibility of cognitive impairment. During the anaesthesia consultation, it seems important to assess the cognitive function of this elderly patient (like using neuropsycholgical scale as the MMSE) and to identify associated risk factors of cognitive dysfunction. The management of cognitive disorders should be multidisciplinary, the anesthesiologist being the main referent, in collaboration with the geriatrician and the surgeon. In the clinical setting of femoral neck fracture in the elderly, this multimodal management (pain, nutrition, functional rehabilitation to make these patients autonomous as quickly as possible), seems to improve the functional prognosis and to have the observed POCD decreased.

Influence of preoperative cognitive status on propofol requirement to maintain hypnosis in the elderly.

BACKGROUND: The loss of cholinergic neurones in the basal forebrain has been shown to correlate to the extent of cognitive dysfunction during ageing in humans and to the hypnotic potency of propofol in animal models. We examined how the preoperative cognitive status, as assessed by mini-mental state examination (MMSE), may interact with propofol consumption during anaesthesia in the elderly. METHODS: In a prospective study, we recruited 41 patients (65-99 yr) undergoing surgery for hip fracture. Femoral nerve block was performed for analgesia. Target-controlled infusion of propofol (Schnider's model) was adjusted to the bispectral index within the range 40-60. Multiple linear regression analysis determined whether age, BMI, gender, duration of anaesthesia, and preoperative MMSE score affected the propofol consumption (general linear model, Systat 8.0). RESULTS: BMI and MMSE score significantly affected the mean value of propofol consumption. A low MMSE score (below 19) was associated with an observed decrease in propofol requirement in patients >65 yr of age. No significant effect of age, gender, and duration of anaesthesia on the propofol consumption was observed. CONCLUSIONS: Propofol requirement to maintain hypnosis during general anaesthesia appears to decrease with deterioration in the cognitive status in the elderly. We suggest that a cognitive dysfunction linked to a cerebral cholinergic dysfunction may influence the brain sensitivity for propofol in aged patients.

[Postoperative ischemic acute stroke and thrombolytic therapy]. / Thrombolyse postopératoire immédiate dans un contexte d'accident vasculaire sylvien gauche.

Intravenous thrombolytic therapy for ischemic stroke was performed on a 75-year-old patient at recovery from cervicocephalic superficial surgery. The patient recovered totally from ischemic stroke and no neurologic sequelae was observed. Thrombolytic therapy must be performed in an intensive care unit in order to manage some bleeding events which can occur.

[Pathophysiology of post-operative cognitive dysfunction: current hypotheses]. / Physiopathologie de la dysfonction cognitive postopératoire du sujet âgé: hypothèses actuelles.

Post-operative cognitive dysfunction (POCD) has been reported after a variety of surgical procedures. POCD is associated with a decline in performance of activities of daily living of elderly patients and can cause substantial damage to family and/or to social support systems. The incidence of POCD in the first week after surgery is 23% in patients between 60 and 69 years of age and 29% in patients older than 70. Cognitive dysfunction was still present in 14% of patients over 70 at three month after surgery. The risk of POCD increases with age, and the type of surgery is also important since there is very low incidence of POCD after minor surgery. For many years, it has been known that general anaesthesia is associated with persistent changes in gene expression in the brain for at least 72 hours. These observed modifications suggest an interesting hypothesis to explain the side effects of anaesthetic agents on cognitive dysfunction, particularly in the elderly. The inflammatory response to surgery is consistent with the hypothesis that inflammation contributes to cognitive decline in the elderly. Most of the drugs administered during anaesthesia interact with the cerebral cholinergic system, which seems to be impaired with ageing. One can hypothesize that this cholinergic dysfunction is a potent factor in the pathogenesis of POCD. These findings have implications for the information provided before obtaining consent from elderly patients prior to surgery; a careful evaluation of mental status is mandatory for all elderly patients undergoing general anaesthesia. Perioperative physicians should be familiar with the prevention, diagnosis, and management of postoperative cognitive dysfunction.

Central cholinergic depletion induced by 192 IgG-saporin alleviates the sedative effects of propofol in rats.

We examined the effect of central cholinergic depletion on the sedative potency of propofol in rats. Depletion was produced by intracerebroventricular administration of an immunotoxin specific to cholinergic neurones (192 IgG-Saporin; 2 microg). As a result of this lesion, acetylcholine concentration was reduced by about 40% in the frontoparietal cortex and in the hippocampus but was essentially normal in the striatum and cerebellum. Sedation in rats was assessed as the decrease in locomotor activity. Sedative potency of propofol (30 mg kg(-1) i.p.) was reduced by about 50% in rats who received the injection of 192 IgG-Saporin as compared to controls. These results show that a central cholinergic depletion alleviates the sedative effect of propofol, and indicates that basal forebrain cholinergic neurones might mediate part of the sedative/hypnotic effects of propofol.