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Complex Regional Pain Syndrome Management for C-section
Abstract Number: 203
Abstract Type: Case Report/Case Series
Complex Regional Pain Syndrome (CRPS) is a chronic progressive neuropathic pain syndrome. Currently no definite cause has been link to the occurrence of the disease; however, today the disease progress has been categorized into to two different distinctions. Type I is defined for cases with no known nerve injury or tissue trauma. Type II is defined for cases with a known peripheral nerve damage or tissue trauma. We present a patient who previously had a CRPS type I exacerbation during an epidural anesthetic, and present alternative management with ketamine, lidocaine infusion, and opioids.
A 33 year old 38 weeks parturient was scheduled for an elective cesarean delivery. PMH included a 13 year history of CRPS type I in the upper extremities and complains of severe burning pain and sensitivity to light touch. Previous, pain management included sympathetic nerve blocks, hydromorphone, and gabapentin. Presently, she is taking hydromorphone 4 to 8 mg PO QID for pain control along with stellate ganglion blocks and triggers point injections. She has good function of her upper extremities and still has sensitivity to touch in both arms. The patient had a previous cesarean delivery with an epidural anesthetic. Intraoperativley, she did not have complete anesthetic comfort and required supplement IV medication. Post operatively, she developed CRPS exacerbations with severe burning, swelling, and hyperthesia to the upper extremities. Currently, she is apprehensive to having an epidural anesthetic and is requesting a general anesthetic.
The anesthetic plan was to continue hydromorphone up to the day of the surgery. In the OR, no intravenous lines were to be placed the upper extremities. A femoral central line was placed in the lower extremity. Induction of anesthesia included ketamine 1.5 mg/kg and succinycholine 1 mg/kg. Intubation was uneventful. The cesarean delivery proceeded without complications. Once the baby was delivered, pitocin was started and no uterine atony was noted. At this point, an IV lidocaine infusion 100 mg in 100 cc normal saline was infused over one hour. Additionally, 100 mcg of fentanyl was administered during the case. The patient was extubated in the OR and taken to the recovery room for monitoring. Upon arrival to the PACU, the patient stated she was comfortable and did not complain of any pain. Post operatively, she was started on hydromorphone IV and switched to PO upon tolerating orals. The patient had a follow up phone call 10 days later at home and stated that she did not have any CRPS exacerbations after surgery. We present a successful anesthetic with ketamine, lidocaine infusion, and opioids for a patient with a history of previous CRPS exacerbation during an epidural anesthetic.