Compared with diagnostic infiltrations SPECT/CT scans showed only a moderate sensitivity and specificity and, therefore, may not be recommended as a first line diagnostic tool prior to diagnostic infiltrations.
Background
The benefit of a perianal block as an adjunct to general or regional anaesthesia is debated. This RCT aimed to compare pain at 24 h and up to 14 days after proctological surgery in patients with and without a perianal block.
Methods
Between January 2018 and April 2019, patients were allocated to receive a perianal block with ropivacaine or placebo as an adjunct to anaesthesia. Patients, surgeons and assessors were blinded. The primary outcome was pain measured on a numerical rating scale (NRS) after 24 h. Secondary outcomes were need for rescue analgesia, and pain after 1, 2, 3, 6 and 12 h. The mean, rest and maximum NRS scores were measured for 14 days.
Results
A total of 138 patients were included, of whom 46 and 44 received general anaesthesia with or without ropivacaine respectively, and 23 and 25 received spinal anaesthesia with or without ropivacaine respectively (P = 0·858). The mean NRS score differed significantly at 24 h (mean(s.d.) 1·1(0·1) versus 2·3(0·2); P < 0·001), but not at 1 h (1·4(0·2) versus 2·2(0·3); P = 0·051). The NRS score was lower with use of ropivacaine at 2 h (1·0(0·2) versus 1·6(0·2); P = 0·045), 3 h (0·9(0·2) versus 1·5(0·2); P = 0·022), 6 h (1·1(0·2) versus 1·8(0·2); P = 0·042) and 12 h (1·2(0·2) versus 1·8(0·2); P = 0·034). The use of oral morphine equivalents was 10·2(1·4) and 16·6(2·5) mg with and without ropivacaine respectively (P = 0·028). The mean and maximum NRS scores within 14 days were lower when ropivacaine was used (95 per cent c.i. for difference 0·14 to 0·49 (P = 0·002) and 0·39 to 0·63 (P < 0·001) respectively). There was no injection‐associated morbidity.
Conclusion
Perianal block as an adjunct to general or regional anaesthesia should be recommended for proctological surgery. It yields a reduction in pain, a reduced need for opioids, and a faster recovery with minimal risk of adverse events. Registration number: NCT03405922 (
http://www.clinicaltrials.gov).
I read with great interest the article, "Left Pulmonary Artery Stent Causes Ipsilateral Pulmonary Complication." 1 The author rightly pointed out the culprit: "trapped" and relatively fixed space under the curve of the aorta and the left pulmonary artery. The left recurrent laryngeal nerve travels between the pulmonary artery and aorta. There is only a 4-mm distance between the aorta and pulmonary artery in this aortic window. This anatomy makes the left recurrent laryngeal nerve vulnerable to compressive injury between the aorta and left pulmonary artery. 2 Ortnerʼs syndrome is well described in the literature as caused by compression or traction of this nerve due to cardiovascular diseases (eg, left atrial disorders). 2 Interventional procedures involving patent ductus arteriosus potentially can injure the nerve. 3 Thoracic aortic aneurysm and dissection can cause cardiovocal syndrome by compressing the left recurrent laryngeal nerve. 4 Even endoluminal treatment of a thoracic aortic aneurysm 5 has been reported to cause left vocal cord palsy. Similarly, left pulmonary artery stent in a child also has been reported to cause left recurrent laryngeal nerve palsy causing persistent hoarseness. It is essential to know that any procedure in the vicinity of this subaortic window space potentially can compress the left main bronchus and left recurrent laryngeal nerve.
Zusammenfassung. Die Behandlung eines komplexen regionalen Schmerzsyndroms stellt nach wie vor eine grosse Herausforderung dar, sowohl für den Patienten als auch für die in die Behandlung involvierten Ärzte und Therapeuten. Die Diagnose wird rein klinisch gemäss der Vorgabe der International Association for the Study of Pain (IASP) anhand der validierten und zuletzt im 2007 modifizierten „Budapester Kriterien“ gestellt. Diagnosekriterien älteren Datums sollten nicht mehr verwendet werden, da sie einerseits zu einer falsch hohen Anzahl Diagnosen führen und andererseits auch versicherungstechnisch und bei Kostengutsprachen zu Problemen führen könnten. Das Hauptmerkmal des „komplexen regionalen Schmerzsyndroms“ sind wie in der Bezeichnung enthalten starke Schmerzen, welche überproportional zum auslösenden Momentum (z. B. Bagatelltrauma, operativer Eingriff) erscheinen. Das Syndrom betrifft dabei praktisch ausschliesslich die Extremitäten. Die pathophysiologische Endstrecke scheint eine übermässig aktivierte Entzündungsreaktion zu sein, welche sich selber unterhält. Dabei spielen je nach Patientenkasuistik verschiedene Mechanismen mit. Zu diesen gehört unter anderem eine pathologische Aktivierung / Dysregulierung des Sympathikus, eine lokale Erhöhung von Entzündungsmediatoren wie Cytokinen, Interleukinen, eine aktivierte Osteoklastenaktivität mit erhöhtem Knochenabbau sowie humorale Faktoren mit Autoantikörpern u. a. gegen alpha1-Rezeptoren. Das klinische Bild eines CRPS scheint eher die gemeinsame Endstrecke von noch nicht im ganzen Umfang verstandenen Pathologien zu sein als das Resultat eines einzelnen spezifischen Pathomechanismus. Entsprechend wird bei Inexistenz einer kausalen „Standardtherapie“ die Behandlung dem Patienten angepasst. Neben Medikamenten sind auch physikalische Massnahmen und je nach Schweregrad und Leidensdruck parallel psychologische / psychoedukative Therapien indiziert. Die Prognose eines schweren CRPS ist nach wie vor ungünstig und bis zu 30 % der Patienten erleben einen permanenten Arbeitsplatzverlust im Verlauf der Erkrankung.
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