Epidemiology, pathophysiology, and management of complex regional pain syndrome.

Complex regional pain syndromes (CRPS) are challenging neuropathic pain states quite difficult to comprehend and treat. Although not yet fully understood, advances are being made in the knowledge of the mechanisms involved with CRPS. Patients often present with incapacitating pain and loss of function. Patients suffering from these disorders need to have treatment plans tailored to their individual problems. A comprehensive diagnostic evaluation and early and aggressive therapeutic interventions are imperative. The therapeutic approach often calls for a combination of treatments. Medications such as antiepileptics, opioids, antidepressants, and topical agents along with a rehabilitation medicine program can help a major portion of patients suffering from these disorders. Implantable devices can aid those patients with CRPS. While progress is being made in treating patients with CRPS, it is important to remember that the goals of care are always to: 1) perform a comprehensive diagnostic evaluation, 2) be prompt and aggressive in treatment interventions, 3) assess and reassess the patient's clinical and psychological status, 4) be consistently supportive, and 5) strive for the maximal amount of pain relief and functional improvement. In this review article, the current knowledge of the epidemiology, pathophysiology, diagnostic, and treatment methodologies of CRPS are discussed to provide the pain practitioner with essential and up-to-date guidelines for the management of CRPS.

The fascia iliaca block for postoperative pain relief after knee surgery.

The fascia iliaca nerve block provides excellent postoperative pain relief after knee surgery. It is easy to perform, needle insertion is not directly next to nerves or vessels, and it is associated with minimal side effects. Instructive case reports as well as a description and discussion of the technique are presented.

What's new in practical patient monitoring and support equipment.

The author discusses state-of-the-art technology for patient monitoring in office-based anesthesia. New technology includes bispectral index monitoring to evaluate the depth of anesthesia, signal extraction for more accurate oxygen saturation monitoring, and online S-T segment analysis for monitoring multiple electrocardiographic leads.

Reducing post-traumatic morbidity with pain management.

Since significant pain can adversely affect multiple organ systems, many anesthesiologists believe that effective pain control can decrease perioperative and post-trauma morbidity. To achieve the goal of attenuating the physiological stress response associated with trauma, modalities such as patient-controlled analgesia, epidural infusions and peripheral nerve blocks are being utilized. This article will review the physiological response to pain, the new strategies and techniques for providing pain relief, and recent literature that evaluates the effect of the newer pain modalities on perioperative morbidity.

Hip fracture in the elderly: the effect of anesthetic technique.

Seven hundred forty-nine community-dwelling, previously ambulatory, elderly patients who sustained a femoral neck or intertrochanteric fracture underwent prospective follow-up to determine whether anesthetic technique (spinal or general) had an effect on inpatient morbidity and mortality, or 1-year mortality. One hundred seven patients were excluded from the study as the anesthetic technique was "predetermined" based on a underlying medical condition. Of the remaining 642 patients, 362 (56.4%) received general and 280 (43.6%) received spinal anesthesia. Twenty (3.1%) patients died during hospitalization; 73 (11.4%) patients developed one or more postoperative medical complications. The 1-year mortality rate was 12.1%. There was no difference in inpatient morbidity and mortality, or 1-year mortality rates between patients receiving general or spinal anesthesia.

Functional outcome after hip fracture. Effect of general versus regional anesthesia.

The effect of anesthetic technique on ambulation and functional recovery after hip fracture was studied in a series of 631 community dwelling, elderly patients. Functional recovery at followup was determined by an 11-item functional rating scale. In univariate analysis, recovery of ambulatory ability and percent functional recovery were significantly higher at 6 months for patients who had general anesthesia. When controlling for potential confounding variables, however, no differences were observed in recovery of ambulatory ability or percent functional recovery between the two groups at 3, 6, or 12 months after hip fracture.

Ensuring early discharge following major surgery: orthopedic surgery.

Managed care, critical pathways, and length of stay issues have a major impact on current hospital policy and patient care. In orthopedic surgery, significant strides have been made in improving efficiency, decreasing costs, and reducing length of stay. Use of vertical pathways, especially the first day of admission, the day of surgery, is important for efficient patient care. As anesthesiologists involved in the process, we must be certain that patient care is not compromised in an attempt to save money or achieve early discharge. In many studies, pain management, type of anesthesia, and amount of blood loss are not significant factors in length of hospital stay. These factors must be approached as quality-of-life issues and appropriate decisions made.

Does blood transfusion increase the risk of infection after hip fracture?

OBJECTIVE: To determine whether allogeneic red blood cell transfusion is a predictor for developing an in-hospital postoperative urinary tract, respiratory, or wound infection. STUDY DESIGN: Prospective, consecutive. METHODS: Six hundred eighty-seven community-dwelling, ambulatory, geriatric hip fracture patients were prospectively followed; all patients had operative fracture treatment and received perioperative antibiotics. RESULTS: Sixty-eight patients had a culture-positive infection before operative treatment. One hundred thirty-four of the remaining 619 patients (21.6%) developed a postoperative infection, primarily a urinary tract infection. The infection rate was 26.8% in transfused patients compared with 14.9% in nontransfused patients (p = 0.001). When stratifying by the type of infection, only the risk of urinary tract infection was statistically significant (p = 0.001). After controlling for the effect of patient age, sex, number of preinjury medical comorbidities, American Society of Anesthesiologists (ASA) rating of operative risk, fracture type, surgical delay, type of surgery, type of anesthesia, operative time, and blood loss, the relationship between allogeneic red blood cell transfusion and postoperative urinal tract infection remained statistically significant. CONCLUSIONS: Geriatric hip fracture patients who receive allogeneic red blood cell transfusions are at higher risk for developing a postoperative urinary tract infection than are those patients who are not transfused.

Accidental needlesticks: do anesthesiologists practice proper infection control precautions?

Anesthesiologists as well as patients are at risk for acquiring blood-borne infections such as hepatitis and AIDS. We surveyed 2,530 anesthesiologists, a 10% random sample of the members of the American Society of Anesthesiologists, with a response rate of 57.1%, to determine the incidence of accidental needlestick exposure among anesthesia personnel and whether anesthesiologists are adhering to infection control guidelines to protect themselves and their patients from exposure to infectious diseases. Eighty-eight percent of respondents reported at least 1 accidental needlestick in the past 10 years; 21% received a needlestick from a high-risk patient and 4.5% a needlestick from a known HIV-positive patients. Residents reported significantly more accidental needlesticks from known HIV-positive patients (8.5%). Mucous membrane, open cut, eye, or other significant exposure to HIV-contaminated blood or body fluids was sustained by 8.34% of respondents in the past 10 years. Sixty percent of respondents reported they almost never reuse common syringes now compared with a 40.8% non-reuse rate (P < 0.001) in a similar survey on infection control practices conducted in 1990. Sixty-three percent reported they almost never reuse a vasopressor syringe compared with the 1990 non-reuse rate of 52.5% (P < 0.001). In the current survey, 39% of anesthesiologists reported reusing syringes from one patient to another and 36% reported reusing the same vasopressor syringes for different patients.(ABSTRACT TRUNCATED AT 250 WORDS)