P040: ANESTHETIC PERIPARTUM MANAGEMENT OF PATIENT WITH SEVERE CRPS AND MULTIPLE COMORBIDITIES
Alan Hsieh, MD; Maksym Doroshenko, MD; Thais Santos, MD; Eric Alan Harris, MD; Selina Patel, MD; Jackson Memorial Hospital/ University of Miami Hospital
Introduction/Background: We would like to present a case of peripartum management of a parturient with complex medical history of intractable CRPS and substance abuse, resulting in severe generalized hyperalgesia and allodynia in affected body part. Management was complicated by morbid obesity, uncontrolled gestational diabetes, difficult IV access and history of multiple previous pregnancies, caesarian sections and abortions, predisposing patient to hemorrhage and transfusion related complications.
Methods: This case report was written after thorough chart and anesthetic records review, and discussion of case with medical staff who participated in the care of patient.
Results: A 37 year old G7P1233 at 37 weeks of gestation presented to our obstetric service for scheduled repeat caesarian section. She had complex past medical history of obesity (BMI 49), cervical intervertebral disk herniation (s/p anterior cervical discectomy and fusion) complicated by severe right upper extremity complex regional pain syndrome (CPRS), opioid and marijuana use, generalized hyperalgesia, poorly controlled gestational diabetes, unspecified psychiatric history, multiple prior C-sections and abortions, and history of difficult IV access, complicated by left arm deep venous thrombosis.
Patient had inadequate and unreliable IV access at presentation to our anesthetic service. Following ultrasound visualization of upper body peripheral and central vessels, the left internal jugular vein was identified as the only adequate vessel for catheterization. Acute pain service was consulted for pre- and post-operative management of hypersensitivity and CRPS. Blood products were ordered and placed on hold. Left radial arterial line was placed preoperatively, followed by left IJ central venous catheter placement, both with remifentanil sedation and generous application of EMLA cream. Patient had a modified combined spinal epidural analgesia with fentanyl 15mcg, morphine 0.1mg, and bupivacaine 7.5mg intrathecally. Ketamine infusion was started immediately after delivery and continued post op for 24 hours. In addition, epidural analgesia was continued for the next two days, acetaminophen, toradol and gabapentin titrated. On POD #5, patient had a CPRS flare up, which was alleviated with a rescue addition of an opioid (oxycodone).
Discussion/Conclusion: CRPS is a chronic pain condition with clear female predominance. Association of CRPS and pregnancy has been increasingly reported in recent literature. Despite a commonly reported pregnancy related pain relief, our patient had significant generalized hyperalgesia, a long-standing history of substance abuse and psychiatric disorder, which prompted us to devise a modified pain management algorithm, aiming to prevent the exacerbation of CRPS and avoid a relapse of opioid addiction. All of this was complicated by difficulty obtaining reliable venous access, in anticipation of hemodynamic instability and high likelihood of obstetric hemorrhage.