SKIN BLOOD FLOW CHANGES DURING KETAMINE / MIDAZOLAM ANESTHESIA FOR INTRACTABLE CRPS-I
ANNETTE PLOPPA1, RALPH T. KIEFER1, BORIS NOHE1, PETER ROHR2, JOHN GROTHUSEN3, LUDWIG DISTLER4, HANS J. DIETERICH1, KLAUS UNERTL1, AND
ROBERT J. SCHWARTZMAN31Dept. of Anesthesiology, Eberhard-Karls University, Tübingen, Germany; 2Dept. of Anesthesiology, Klinikum Saarbrücken, Saarbrücken, Germany; 3Dept. of Neurology

Drexel-University, Philadelphia, USA; 4Dept. of Pain Therapy, Caritasklinik St. Theresia, Saarbrücken, Germany

INTRODUCTION
Skin blood flow (SBF) changes are a characteristicfeature of CRPS-I. SBF-changes used to assess
the effectiveness of therapies, i.e. sympathetic
blocks, are well discribed. Ketamine/midazolam
anesthesia seems to be a new therapeutic option
for intractable CRPS-I. So far, effects of ketamine/midazolam anesthesia on SBF have not been
investigated in patients with severe CRPS-I.

Figure I: Significant increase in SBF at rest
80

PUPU
right forearm

D III right
D III left

60

2040
20

1000beforetherapy

80

left forearm30day 1day 2day 3

day 4

day 5

day6after
therapy

CMBC

beforetherapyday 1day 2

day 3

day 4

day 560

3040202010left forearm

00
beforetherapyday 1day 2day 3

day 4

day 5

day6

beforetherapy

after
therapy

day 1

day 2

day 3

day 4

day 5

day6

after
therapy

Figure II: Significant increase in SBF under heating conditions at day 2/3% change

1000

D III right
D III left

800% change

8 Patients with intractable CRPS-I
Laser doppler flowmetry (PF 4001), heatingprobe (PF 371)
D III, forearm, upper arm, area of maximal pain
& allodynia
Conditions: rest & vasomotor challenge
Analysis: Perfusion Units (PU)Calculated Mean of circulating
Blood Cells (CMBC)

1000

200
500
0

10000

day2

day3

day4

day5

day6

day1

after
therapy% change

day2

day3

day4

day5

day6

after
Therapy% change
12000
D III right8000

forearm right

10000

forearm left

D III left

8000
6000

6000
4000

4000
2000

2000
0

0

day1

day2

day3

day4

day5

day6

after
therapyspreadboth arms

nomaximal pain
hands (r>l)

Duration
1 year246

fright arm

yes, gen.

arms (r>l)

6 years

344fright footyes, gen.

upper arms (r>l)

6 years

430

fright arm

noright hand

2 years

541

fright knee

noright knee

2 years

619

fright footyes, genright body side

6 years722

fright hand

yes, genright body side

6 years

Table I: Patient‘s characteristics, primary site of CRPS manifestation, statusof spread (gen.: generalized), area of maximal pain/allodynia and duration.

Under ketamine anesthesia, a significant increase in
SBF occured (clinically: hyperemia, edema) in thefirst 72 hours. Areas of maximal allodynia showed
the strongest increase in SBF (up to ten-fold,p<0.05). Then, normalization of SBF and regained
vasomotor reagibility (clinically: decrease of swelling,
hyperemia, temperature changes) followed. Duringlocal heating highest Increase of SBF was observedon the 2nd and 3rd day during therapy.

CONCLUSIONS

1500

day1

primary site

mleft forearm

600

0Sex

24

right forearm

2500
2000

METHODS

Age

1

3500
3000

400

#RESULTS
right forearm

D III left

To collect first data on SBF in CRPS-Iat rest and during vasomotoric challenge (localheating) with relief of spontaneous cutaneous
vasoconstrictor activity
before, during & after ketamine anesthesia
to assess vasomotor regulatory capacity
as potentially useful tool to objectively
monitor treatment successassess vasomotor impairment in CRPS

aftertherapy

CMBC40
D III right

AIMS OF INVESTIGATION

day61211-P127

day1

day2

day3

day4

day5

day6

aftertherapy

LDF might become a useful tool to:monitor SBF-changes in CRPS-therapy
potentially predict therapeutic successto quantify vasomotor reactive capacity (rest /vasomotor challenge)
to indirectly asses sympathetic activity
contibute to objectify diagnosis in CRPS
However, more evidence to support these first datais needed (homogenized groups) before LDF can berecommended as a valid tool in CRPS-I diagnosis &therapy.