Abstract
A 44-year-old male who suffered a crush-degloving hand injury complicated by Complex Regional Pain Syndrome (CRPS) type I was scheduled for operative hand manipulation and inpatient physiotherapy. Preoperative placement of an ultrasound-guided infraclavicular catheter provided incomplete analgesia requiring supplemental morphine during physiotherapy sessions despite continuous infusion of 0.1% bupivacaine at 20 mL/hour. Due to the patient’s adamant refusal of replacement of the infraclavicular catheter, a second ultrasound-guided median nerve catheter was placed distally at the mid-forearm level and elicited complete sensory blockade of the hand. Dual infusions were maintained with 0.25% bupivacaine at 5 mL/hour through the median nerve catheter and 0.1% bupivacaine at 20 mL/hour through the infraclavicular catheter, and subsequent daily physiotherapy progressed productively. Continuous perineural catheter use to facilitate rehabilitation is an emerging practice that may improve overall recovery. Combination catheters, infusing local anesthetics at separate locations, can be used synergistically to preserve motor function and reach a superior analgesic endpoint.
Highlights
This medically challenging case is the first report in the literature describing the use of combined infraclavicular and distal mid-forearm median nerve catheters to provide analgesia with the goal of enabling physiotherapy in a patient who has failed hand rehabilitation as a result of uncontrollable pain due to Complex Regional Pain Syndrome (CRPS) type I.Sensory blockade of an injured hand, with preservation of motor function, is ideal during hand therapy; this goal may be elusive
The “failed” brachial plexus catheter was re-purposed to provide generalized analgesia for the injured limb via the infraclavicular route, and in the most painful area of the hand, a denser block was obtained via addition of the median nerve catheter [1]
On post-operative day (POD) 1, intravenous morphine 53 mg/24 hours and continuous infusion of 20 mL/hour of 0.1% bupivacaine administered through the infraclavicular catheter allowed the patient to participate in physiotherapy with a pain Numerical Rating Score (NRS) of 6/10
Summary
This medically challenging case is the first report in the literature describing the use of combined infraclavicular and distal mid-forearm median nerve catheters to provide analgesia with the goal of enabling physiotherapy in a patient who has failed hand rehabilitation as a result of uncontrollable pain due to CRPS type I. The effect of local anesthetic concentration and total volume on nerve blockade is complex and may vary with concentration, total dose, and location. In this case, each catheter was infused with different concentrations of local anesthetic to achieve specific treatment goals. The “failed” brachial plexus catheter was re-purposed to provide generalized analgesia for the injured limb via the infraclavicular route, and in the most painful area of the hand, a denser block was obtained via addition of the median nerve catheter [1]
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