Intravenous Regional Bretylium and Lidocaine for Treatment of Reflex Sympathetic Dystrophy

Abstract

Patients with reflex sympathetic dystrophy, who received transient pain relief from stellate ganglion blocks or lumbar sympathetic blocks and had abnormal isolated cold stress tests, were enrolled in a study to determine the efficacy of intravenous regional bretylium. Each patient received two control treatments (0.5% lidocaine) and two treatments with 0.5% lidocaine and bretylium 1.5 mg/kg in a randomized, double-blind fashion. A standard intravenous regional technique was used with a 300-mm Hg tourniquet pressure for 20 min. Patients kept a daily record of pain relief (0 = no relief, 100% = complete relief). A decrease in pain of more than 30% was considered clinically significant. Therefore, once the patient's pain relief was less than 30%, the next intravenous regional treatment was performed. Bretylium and lidocaine provided more than 30% pain relief for a mean of 20.0 (+/- 17.5) days, whereas lidocaine alone provided relief for only 2.7 (+/- 3.7) days (Mann-Whitney U-test, P less than 0.001). A mean temperature increase in the treated limb of +2.64 +/- 3.41 degrees C above the baseline temperature was noted after bretylium administration, whereas after control treatments the change was -0.086 +/- 1.30 degrees C (Mann-Whitney U-test, P less than 0.02). We conclude that the combination of bretylium and lidocaine is significantly more effective than lidocaine alone when an intravenous block is used to treat reflex sympathetic dystrophy.

Causalgia and reflex sympathetic dystrophy: Does the sympathetic nervous system contribute to the generation of pain?

“…One study demonstrated that IVRS bretylium and lidocaine produce significantly longer pain relief than lidocaine alone. 74 Two studies showed that IVRS reserpine was ineffective. 14,139 In summary, animal studies show that, after either nerve injury or inflammation, electrical stimulation of sympathetic nerves or peripheral application of catecholamines can enhance activity in primary afferent neurons and pain behavior.…”

Treatment of complex regional pain syndrome: a review of the evidence

“…A [ 30% decrease in pain was considered clinically significant; therefore, when the patient's pain relief was less than 30%, the next IVRB was performed. Hord et al 32 observed that IVRB with bretylium and lidocaine provided a longer analgesic duration than pure lidocaine (20 ± 17.5 days vs 2.7 ± 3.7 days; P \ 0.001).…”

Complex Regional Pain Syndrome: State of the Art Update

“…For example, a metaanalysis of all available controlled trials of guanethidine IVRB indicated no significant overall short-or long-term efficacy in CRPS [62]. Two randomized controlled trials suggested significant efficacy for IVRB with ketanserin [63] and bretylium [64]. In sum, research support for sympathetic blockade as a key CRPS treatment intervention is sparse and generally poorly controlled.…”