Part II: Algorithm for Perioperative Management

of CRPS Patients

Timothy Lubenow, M.D.

Rush University Medical Center
Chicago, Illinois

Anthony Kirkpatrick, MD., PhD.
University of South Florida
Tampa, Florida

Scott Reuben, MD

Tufts University School of Medicine

Springfield, Massachusetts

 

 

 

**Recommended medications may be started earlier if the surgery is to involve more trauma (major surgery) as opposed to starting them the morning of surgery for "minor surgery".  Penetration of 1 dose of celecoxib (400 mg) gets into the CSF within 2 hours. Penetration of pregabalin into the CSF is under investigation.   A 30 mg dose of ketamine is recommended for minor surgeries; but, a ketamine infusion should be used for major surgeries. If it's knee arthroscopy, intraarticular bupivacaine, clonidine, and morphine are recommended.  A study utilizing this cocktail and showing a reduction in both acute and chronic pain (including CRPS) for ACL surgery has recently been published. The administration of celecoxib as a component of a preventive multimodal analgesic technique for anterior cruciate ligament reconstruction reduces long-term patellofemoral complications and increases the likelihood of returning to a preinjury level of activity.(Reuben SS, Ekman EF. The effect of initiating a preventive multimodal analgesic regimen on long-term patient outcomes for outpatient anterior cruciate ligament reconstruction surgery. Anesth Analg 2007;105:228-32).

Drs. Reuben & Ekman Article:

CLICK HERE

 

 

The above algorithms are for surgery for CRPS patients. These treatment protocols are intended to minimize the risk of exacerbating CRPS. The protocols suffice for minor surgical procedures. For major surgeries, more aggressive / invasive interventions may be required. However, the risks and expense of more invasive procedures need to be weighed in relation to the potential benefits on a case-specific basis.   

Example:

Major surgery on an upper or lower extremity (e.g., revision rotator cuff surgery, shoulder or hip replacement):

1. Place cervical epidural catheter immediately preoperatvely under fluoroscopy to produce unilateral epidural block

2.  General anesthetic or regional anesthetic at the anesthesiologist's and surgeon's discretion. Low dose ketamine infusion is recommended (1/2 mg / kg / h)

3. Restart acetaminophen, gabapentin and celecoxib as soon as possible

4.Continuous epidural infusion of a clonidine-bupivacaine-fentanyl infusion for 5 days to 6 weeks to facilitate early physical therapy.  For catheter infusions longer than 5 days, a tunneled catheter is recommended

5.  Weekly evaluations by the pain medicine specialist to monitor the effects of the infusion both in terms of pain relief and side effects

6.  If a longer infusion period is used the patient will need to be weaned off the clonidine and fentanyl to avoid withdrawal syndrome with PO clonidine and hydrocodone or transdermal preparations of clonidine and fentanyl

Acetominophen, celecoxib and gabapentin should be started with a sip of water just prior to surgery. However, if NSAIDs are discontinued three days prior to surgery to decrease intraoperative bleeding, these three pain medications should be started three days prior to surgery to avoid breakthrough pain.

Acetominophen, celecoxib and gabapentin should also be started according to the above protocol for oral surgery/dental procedures. In addition, generous infiltration of local anesthetic at the operative site for oral surgery is recommended.

Early ambulation and mobilization of the affected extremity is essential to the optimal rehabilitation of the patient. The cornerstone in the treatment of RSD / CRPS is normal use of the affected part as much as possible.

 

 Part I: Introduction

 

Part III: Highlights for Patients

 

 

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