A 36-year-old Caucasian woman suffered thoracic (pulmonary contusion and left clavicle fracture) and pelvic trauma as a result of a traffic accident.
Because she developed hypoxemic respiratory failure she was admitted to the resuscitation unit for treatment with invasive mechanical ventilation.
Although complicated with adult respiratory distress syndrome, the final evolution of the respiratory condition was favorable and the patient could be extubated after 72 h.
Sedoanalgesia consisted of midazolam and fentanyl in continuous intravenous infusion.
At extubation, the patient complained of severe and lancinating pain in the left shoulder with functional impotence.
Analgesic treatment was initiated with paracetamol 1g/6 h and continuous intravenous infusion of remifentanil, and magnetic resonance imaging was requested, finding left brachial plexus injury at supra and infraclavicular level.
The prescribed treatment was ineffective and the dose of remifentanil was increased to a maximum of 0.5 mcg/kg/min; in this situation this treatment was ineffective because the intensity of pain did not improve with excessive monitoring pulsed oxygen (VAS 8).
In view of the radiological images, the analgesic alternative consisted of the placement of a cervical epidural catheter at C5-C6 level for patient-controlled analgesia (PCA) with an infusion of 0.375 % ropivacaine combined with a bolus of 0.3 mL/h.
At the same time, specific treatment for neuropatic pain was started.
The patient was admitted to hospital with tramadol/ her reference hospital 12 days after admission, adequate pain control being treated with gabapentin 600 mg/8 h vo, amitriptyline 25 mg/d vo, clonacepam 2 mg/d
The catheter was then removed without incidents.
