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A multimodal approach to perioperative analgesia in a patient with CRPS undergoing cesarean delivery
Abstract Number: RF4BD-421
Abstract Type: Case Report Case Series
Complex regional pain syndrome (CRPS) is a chronic pain condition with multifactorial pathophysiology, including peripheral and central nervous system, autonomic, and inflammatory changes. Symptoms can be acute or chronic and can recur after surgery. CRPS symptoms following spinal anesthesia has been reported. This case highlights perioperative pain management strategies that were used in a parturient with a history of CRPS to in order to prevent recurrence.
A 39 year old G3P1 woman with a history of CRPS and one previous cesarean delivery (CD) presented with concerns of triggering a recurrence of CRPS after surgery or neuraxial anesthesia. She had developed CRPS 17 years prior after fracturing her right 5th metatarsal, with symptoms spreading to her left leg and upper extremities. After multiple unsuccessful procedures, she finally achieved remission after treatment with a ketamine induced coma, followed by intensive physical therapy. Her previous delivery was at our institution, for which she received a labor epidural and then epidural anesthesia for CD.
The anesthetic technique for scheduled CD was combined spinal epidural (CSE). Dexamethasone 8 mg premedication was given to prevent inflammation. After loss of resistance, 5 mL lidocaine 1.5% was injected through the Tuohy needle prior to dural puncture. She received intrathecal fentanyl 15 mcg and morphine 0.1 mg, followed by epidural fentanyl 85 mcg and epidural lidocaine 2% until a T4 level was obtained. After delivery, ketamine infusion 2.5 mg/kg/h was started. Ketorolac 30 mg IV and acetaminophen 1000 mg IV were also given. Two subcutaneous catheters were placed the by surgeons in the incision at skin closure. Postoperatively, the patient was maintained on a ketamine infusion at 30 mg/h for 24h and an epidural infusion of bupivacaine 0.0625% + fentanyl 2 mcg/mL at 12 mL/h for 24h. She received ropivacaine 0.2% at 8 mL/h through each incisional catheter for 48h postoperatively. She was also started on celecoxib 200mg BID postpartum. She did not require additional PRN opioids. The patient was discharged with the recommendation to take ibuprofen 800 mg TID, acetaminophen 1g TID and oxycodone 5 mg Q6h PRN for 3 days. She did not experience recurrence of CRPS symptoms.
A multimodal approach to analgesia for obstetric patients with a history of CRPS may be effective in preventing recurrence. In this case, a steroid, neuraxial anesthesia, intraoperative and postoperative ketamine infusion, postoperative epidural infusion, surgical site local anesthetic infusion, and oral pain medications were effective in preventing recurrence of symptoms after CD.
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