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Multimodal Labor Analgesia and Surgical Anesthesia in a Patient with Complex Regional Pain Syndrome in Remission
Abstract Number: SU-80
Abstract Type: Case Report/Case Series
A 37 year old G1P0 presented at 36 weeks gestation for pre-delivery anesthesiology consultation. Her past medical history was significant for resolved Type I Complex Regional Pain Syndrome (CRPS). Her major concern was that labor may cause a recurrence of her CRPS. The patient reported a history of significant disability and failure of multiple treatment modalities. Ultimate resolution of her CRPS occurred in Germany, after she was treated with a 7-day course of high-dose ketamine, also known as a “Ketamine Coma.” The patient had been disease free for 8 years at the time of her presentation.
After a thorough literature review, plans for both vaginal and cesarean delivery (CD) were decided after multidisciplinary meetings between obstetric anesthesiology, regional anesthesiology, chronic pain, and obstetrics. A novel approach was taken, with the ultimate goal of providing multimodal analgesia for the treatment of labor pain, as well as prophylaxis against the recurrence of CRPS.
Labor was induced at 41 weeks due to late term gestation. Before labor became painful, Dexamethasone 8mg was administered intravenously to help prevent inflammation, followed by an early combined spinal epidural at initiation of labor induction. Fentanyl 15 mcg was given intrathecally, followed by continuous infusion of Ropivacaine 0.2% with Fentanyl 2.5 mcg/mL at 6 mL/hr with patient controlled epidural analgesia. Labor pain was adequately managed. Several hours later, the patient required urgent CD for arrest of descent. A low-dose ketamine infusion was started upon arrival to the operating room. The labor epidural was utilized to provide surgical anesthesia. The obstetricians infiltrated lidocaine 1% subcutaneously prior to incision. The CD proceeded uneventfully. A Jackson-Pratt drain was left in the incision site for delivery of a subcutaneous ropivacaine infusion postoperatively. The epidural catheter was utilized for postpartum analgesia. The patient remained free of CRPS on follow-up 2 months postpartum.
CRPS continues to be a medical challenge due to its chronic nature, potential for life-altering disability, and high likelihood of relapse. The disease predominantly affects females of child-bearing age and pregnancy is a known risk factor for CRPS. There is a paucity of literature to guide the treatment of parturients with CRPS, and only one case of recurrence of CRPS following CD is reported (1). It has been postulated that the underlying mechanisms of CRPS involve peripheral stimulation and central sensitization; therefore, peripheral nociceptive stimulation should be minimized (2). While there is no established standard for the treatment of CPRS in the parturient, this case is an example of a successful multimodal approach to prevent the recurrence of CRPS.
1. Kato et al. Pain Med. 2013;14:293-6.
2. Poncelet et a. Eur J Obstet Gynecol Reprod Biol. 1999;86:55-63.