U
pper extremity ischemia & necrosis in a patient with severe secondary
Raynaud’s phenomenon, improved with an infraclavicular nerve block.
Case Presentation

A 60 y/o F

PMH: multiple sclerosis, secondary Raynaud’s phenomenon due to
limited systemic sclerosis, hypothyroidism, Dupuytren’s contracture

Presentation: right index finger ischemia with ulceration

Intolerant to diltiazem and sildenafil; poor response to alprostadil.

P ain team consulted for intractable pain in the right hand.

D ifficulty using hydromorphone (PCA) device due to digit lesions.

Oral and intravenous analgesics  in adequate pain relief.

I nfraclavicular nerve block placed with 20 mL of 0.25% ropivacaine
and 2mg of dexamethasone, followed by a catheter with a continuous
infusion of 0.2% ropivacaine.

I mmediate pain relief after block

Physical Exam:
1)
R ight arm  erythematous, dilated veins , warm skin
2)
B lister popped
3) U
lcer started to heal

Nerve block catheter  1 week

R heumatologic medications adjusted.

D ischarged pain free without the catheter.

4 month follow up:

continued healing of her finger

decreased pain

no further Raynaud’s flares


Nerve blocks  5 th line treatment for severe, refractory cases

Do cumented nerve blocks performed: stellate ganglion, lumbar
sympathetic, supraclavicular, and axillary blocks.

Our case  1 st reported case of continuous infraclavicular nerve
block for Raynaud’s Phenomenon.

S urgical sympathectomies
•
decrease severity of future Raynaud’s attacks
•
information lacking on long term effects of regional
anesthesia induced sympathectomies.

Pathophysiology of analgesia:
•
Sympathectomy  vasodilation, relieving ischemic pain &
promoting healing of ulcer
•
Local anesthetic  reduced pain transmission by inhibiting
Na channels on the neuronal cell membrane.

L ong term impact:
•
significant improvement in finger at 4 month follow up
•
no new flares

Emotional impact:
•
Could not use hydromorphone PCA  pts may feel
embarrassed
•
N otable change in affect more positive outlook on life

By sharing our case, we hope to increase awareness of the key role an infraclavicular nerve block played in our patient’s recovery from a severe Raynaud’s flare, and to encourage further research into advancing regional anesthesia techniques as earlier management options for Raynaud’s phenomenon.