Anesth Analg 2003;96:694-695
© 2003 International Anesthesia Research Society
PEDIATRIC ANESTHESIA
Case Series: IV Regional Anesthesia with Ketorolac and Lidocaine: Is It Effective for the Management of Complex Regional Pain Syndrome 1 in Children and Adolescents?
Santhanam Suresh, MD,
Melissa Wheeler, MD, and
Arti Patel, MD
Department of Pediatric Anesthesiology, Children’s Memorial Hospital, Northwestern University’s Feinberg School of Medicine, Chicago, Illinois
Address correspondence and reprint requests to Santhanam Suresh, MD, Department of Pediatric Anesthesiology, Children’s Memorial Hospital, 2300 Children’s Plaza, Chicago, IL 60614. Address e-mail to ssuresh{at}northwestern.edu
 |
Abstract
|
|---|
IMPLICATIONS: We report our experience with ketorolac/lidocaine IV regional anesthesia (Bier block) (IVRA) in two adolescents with complex regional pain syndrome 1. IVRA resulted in complete resolution of symptoms.
|
Introduction
|
|---|
IV regional anesthesia (IVRA) (Bier block) with ketorolac and lidocaine or ketorolac alone has been reported to be effective in the management of complex regional pain syndrome 1 (CRPS 1) and sympathetically mediated pain in adults (1,2). Although less common, CRPS 1 has been described in children and adolescents (3). The pathophysiology of CRPS 1 in children is not clear. However, there may be an aberrant exaggerated inflammatory process (4), so that the regional administration of an antiinflammatory medication may be appropriate for management. We report two children with CRPS 1 who were treated successfully with IVRA by using ketorolac and lidocaine.
|
Case Report
|
|---|
Case 1
An 11-yr-old female gymnast had a fall during a practice session 1 yr before her presentation to our clinic. She was initially diagnosed as having an avulsion of her fifth metatarsal, and her foot was placed in a cast for 4 wk. She was seen by another orthopedic surgeon a month later. Tarsal coalition syndrome was suspected, and local anesthetic with steroid was injected into the joint cavity, with no relief. She had to discontinue her gymnastics and was not able to attend school for 2 mo before her presentation to the pain treatment clinic. Physical signs of CRPS 1, including allodynia, hyperalgesia, color changes, and disuse atrophy of the limb, were noted (3). She was started on a tricyclic antidepressant (nortriptyline 10 mg every night) and an anticonvulsant (gabapentin with escalating dose increments until a dose of 300 mg three times daily was achieved). Physical therapy was started three times a week. In addition, as part of her comprehensive care, she was evaluated by a child psychologist, who used behavioral modifications, including visual guided imagery and relaxation techniques. After 2 wk of medication and physical therapy, and with no improvement in symptoms (visual analog score [VAS] 8 of 10), a transcutaneous electric nerve stimulator unit was applied to the affected extremity. Despite good patient compliance with this protocol, her VAS continued to be 7–9 out of 10, so an IVRA was scheduled. With the limb elevated and with mild sedation, the patient tolerated the application of an Esmarch® bandage. After exsanguination of the extremity and inflation of the tourniquet, an IVRA was performed with ketorolac (0.5 mg/kg) and lidocaine (2 mg/kg). The tourniquet was deflated after 30 min without complication, and the patient was discharged home. She had complete resolution of her symptoms (VAS 0 of 10). She was weaned off of her other medications over 3 mo, and on further follow-up for 6 mo, there was no return of pain. The patient has been able to resume normal activity. The family has opted to keep her out of gymnastics.
Case 2
A 15-yr-old girl who sustained an injury to her right wrist while playing volleyball was evaluated by an orthopedic surgeon, who ruled out a fracture. Over 2 mo, she had increasing right wrist pain, with allodynia and hyperalgesia. She was referred to the pain treatment clinic with a diagnosis of CRPS 1. Physical signs of CRPS 1, including allodynia, hyperalgesia, and color changes, were noted. The patient was started on an oral tricyclic antidepressant (nortriptyline 20 mg every night) and gabapentin 300 mg three times daily, along with physical therapy and a transcutaneous electric nerve stimulator unit to the affected limb. Our staff psychologist performed behavioral modifications with visual guided imagery and relaxation techniques. Only mild improvements of symptoms were noted at 4 wk. An IVRA with ketorolac (0.5 mg/kg) and lidocaine (2 mg/kg) was performed, and the VAS score improved from 8 of 10 before the IVRA to 0 of 10 after the procedure. However, over 2 wk, the pain gradually increased to her original VAS of 8 of 10. At this time, a second IVRA was performed, and immediately after the IVRA, her VAS decreased to 0 of 10. The patient was able to use her extremity, and with additional physical therapy, she was able to resume normal activity. She was weaned off the nortriptyline and gabapentin over the next few months. In recent follow-up by phone, 1 yr after the IVRA, the pain had not recurred. She is able to lead a normal life with no limitations to her activities.
|
Discussion
|
|---|
CRPS 1 can be a debilitating problem in children and adolescents. Although the incidence reported in the literature is small, this entity may be underreported in children. Despite physical therapy, behavioral measures, and adjuvant medications, including tricyclic antidepressants and anticonvulsants, some children’s symptoms may not improve. In these children, we believe that the addition of an IVRA technique with ketorolac and lidocaine may offer relief. Applying the Esmarch bandage to the affected limb can sometimes be painful. In these patients, we elevate the extremity for approximately 10 minutes and allow it to exsanguinate by gravity before applying the tourniquet.
Although we theorize a regional mechanism of action secondary to an inflammatory process, there may be some pain relief secondary to the systemic effects of the ketorolac and lidocaine after the release of the tourniquet. However, because most of these patients have received some nonsteroidal antiinflammatory drug before presentation to the pain clinic and because the dose of lidocaine is smaller than the doses that have been suggested for the management of sympathetically mediated pain (5), we believe that it is more likely that there is a local effect of the drugs when an IVRA is performed.
We acknowledge the limited nature of our data. Because of the small prevalence of CRPS 1 in children, a multiinstitutional, prospective, randomized clinical trial would be required to establish the effectiveness of this treatment. The avoidance of other invasive sympathetic blocks, including lumbar sympathetic blocks and stellate ganglion blocks, can be very appealing to pediatric patients and their parents. Our experience with nine other patients who presented to our pain clinic with CRPS 1 symptoms has been similar to the cases we report, with the exception of one patient, who was refractory to our blocks and was lost to follow-up. We believe that after four IVRA blocks, the chances of full recovery after CRPS 1 are limited. In these patients, in our practice, we have provided more invasive blocks, i.e., stellate ganglion blocks or lumbar sympathetic blocks, for resolution of pain. The algorithm attached is descriptive of our practice in the Pediatric Pain Clinic at Children’s Memorial Hospital in Chicago (Fig. 1).
View larger version (25K):
[in this window]
[in a new window]
|
Figure 1. Children’s Memorial Hospital protocol for management of complex regional pain syndrome 1 (CRPS 1). TENS = transcutaneous electric nerve stimulator; IVRA = IV regional anesthesia.
|
|
|
References
|
|---|
- Connelly NR, Reuben S, Brull SJ. Intravenous regional anesthesia with ketorolac-lidocaine for the management of sympathetically-mediated pain. Yale J Biol Med 1995; 68: 95–9.[ISI][Medline]
- Vanos DN, Ramamurthy S, Hoffman J. Intravenous regional block using ketorolac: preliminary results in the treatment of reflex sympathetic dystrophy. Anesth Analg 1992; 74: 139–41.[Free Full Text]
- Wilder RT, Berde CB, Wolohan M, et al. Reflex sympathetic dystrophy in children: clinical characteristics and follow-up of seventy patients. J Bone Joint Surg Am 1992; 74: 910–9.[Abstract/Free Full Text]
- Veldman PH, Reynen HM, Arntz IE, Goris RJ. Signs and symptoms of reflex sympathetic dystrophy: prospective study of 829 patients. Lancet 1993; 342: 1012–6.[ISI][Medline]
- Ferrante FM, Paggioli J, Cherukuri S, Arthur GR. The analgesic response to intravenous lidocaine in the treatment of neuropathic pain. Anesth Analg 1996; 82: 91–7.[Abstract]
Accepted for publication November 4, 2002.
This article has been cited by other articles:
|
|
|
|
 
L.-C. P. Frade, G. R. Lauretti, I. C.P.R. Lima, and N. L. Pereira
The Antinociceptive Effect of Local or Systemic Parecoxib Combined with Lidocaine/Clonidine Intravenous Regional Analgesia for Complex Regional Pain Syndrome Type I in the Arm
Anesth. Analg.,
September 1, 2005;
101(3):
807 - 811.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
