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Anesthetic Management of a Parturient with Complex Regional Pain Syndrome of the Lower Extremity
Abstract Number: S5D-9
Abstract Type: Case Report/Case Series
Chronic Regional Pain Syndrome (CRPS) is a multifactorial disorder manifesting as pain, inflammation, and sympathetic dysfunction. Pregnancy is a known predisposing factor  and incidence increases with age. As women are becoming pregnant later in life, anesthesiologists are likely to encounter more pregnant patients with CRPS.
A 25 y/o G1P0 female with a history of CRPS of the right lower extremity, sustained after hip fracture at age 13, presented for pre-delivery consultation to prevent peripartum worsening of symptoms. She was treated with opiates and an implanted spinal cord stimulator (SCS). Operative reports indicated thoracic lead placement with battery location in the left buttock.
Her outside pain physician recommended a 72 hour epidural infusion and 30 days of ketamine, both of which we felt to be excessive by our team and the patient. Multidisciplinary teams including OB anesthesia, acute/chronic pain, and obstetrics agreed upon early labor epidural placement followed by 24 hrs of continuous epidural and ketamine infusions post-delivery.
Our patient presented at 39 weeks gestation for induction of labor. An early lumbar epidural was placed at L4/5, and a continuous infusion of fentanyl-bupivacaine was started after initial bolus. We continued the epidural infusion after delivery and ketamine was started (bolus 0.5 mg/kg, infusion titrated to 25mg/hr). At 24 hours postpartum, the epidural was removed and the ketamine was slowly discontinued. She was discharged on postpartum day 3.
CRPS management is challenging; there is no established treatment standard in pregnancy. Our patient had been denied an epidural during pre-delivery consultation at other institutions due to her SCS, and was told a ketamine infusion would be impossible. Our goal was to formulate a multimodal labor analgesic plan that minimized the risk of CRPS exacerbation or spread. An alternative plan was formulated for unanticipated cesarean section.
A SCS is not recommended by the manufacturer for use during pregnancy , and it may present a challenge for epidural placement. After careful evaluation of SCS location and thorough discussion with the patient, epidural placement provided successful analgesia in this case.
Ketamine infusions are a known therapy for CRPS, as the NMDA receptor has been implicated heavily in CRPS . Our institution’s 24 hour APMS coverage allowed our patient to stay on the general post-partum floor while titrating ketamine. She remained comfortable and free of side effects.
CRPS remains one of the most challenging conditions faced by patients and physicians. Despite potential challenges, multidisciplinary development and implementation of a care plan resulted in a satisfied patient with no progression of CRPS.
1. J Obstet Anaesth Crit Care 2012;2:69-73.
2. Pain Phys 2016;19(3):E487-93.
3. Brit J Clin Pharm 2014; 77(2), 233–238.