Complete recovery from intractable complex regional pain syndrome, CRPS-type I, following anesthetic ketamine and midazolam.
OBJECTIVE
To describe the treatment of an intractable complex regional pain syndrome I (CRPS-I) patient with anesthetic doses of ketamine supplemented with midazolam.


METHODS
A patient presented with a rapidly progressing contiguous spread of CRPS from a severe ligamentous wrist injury. Standard pharmacological and interventional therapy successively failed to halt the spread of CRPS from the wrist to the entire right arm. Her pain was unmanageable with all standard therapy. As a last treatment option, the patient was transferred to the intensive care unit and treated on a compassionate care basis with anesthetic doses of ketamine in gradually increasing (3-5 mg/kg/h) doses in conjunction with midazolam over a period of 5 days.


RESULTS
On the second day of the ketamine and midazolam infusion, edema, and discoloration began to resolve and increased spontaneous movement was noted. On day 6, symptoms completely resolved and infusions were tapered. The patient emerged from anesthesia completely free of pain and associated CRPS signs and symptoms. The patient has maintained this complete remission from CRPS for 8 years now.


CONCLUSIONS
In a patient with severe spreading and refractory CRPS, a complete and long-term remission from CRPS has been obtained utilizing ketamine and midazolam in anesthetic doses. This intensive care procedure has very serious risks but no severe complications occurred. The psychiatric side effects of ketamine were successfully managed with the concomitant use of midazolam and resolved within 1 month of treatment. This case report illustrates the effectiveness and safety of high-dose ketamine in a patient with generalized, refractory CRPS.
Kiefer
Ralph-Thomas
RT
Department of Anesthesiology and Intensive Care Medicine, Eberhard-Karls University, Tuebingen, Germany. thomas.kiefer@uni-tuebingen.de
Rohr
Peter
P
Ploppa
Annette
A
Altemeyer
Karl-Heinz
KH
Schwartzman
Robert Jay
RJ
D000293:Adolescent; D000700:Analgesics / Q000627:therapeutic use*; D020918:Complex Regional Pain Syndromes / Q000188:drug therapy* / Q000209:etiology; D018450:Disease Progression; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007649:Ketamine / Q000627:therapeutic use*; D008874:Midazolam / Q000627:therapeutic use*; D014954:Wrist Injuries / Q000150:complications
D000700:Analgesics; D007649:Ketamine; D008874:Midazolam