“Don’t block the next patient. We are concerned about compartment syndrome”

Anyone working in the field of orthopaedic trauma will be familiar with the  above sentiment. The use of regional in the setting of trauma patients with a high risk of compartment syndrome remains controversial. Given that a delay in diagnosis of compartment syndrome is associated with potential acute kidney injury, limb and indeed life loss, the consequences of a delay are significant. Analysis of closed claims suggests that decompressive fasciotomy within 8 hours from the onset of symptoms is associated with a successful defence of a claim. Conversely, a delay of 12 hours increases the risk of amputation and death. Making the diagnosis remains challenging and requires identifying an at risk  population, a high index of suspicion, regular repeated examination and ultimately measurements of compartment pressure. Compartment syndrome remains a clinical diagnosis. Much of current practice is based around the fear of delaying the diagnosis of compartment syndrome due to the patient and medio-legal consequences of such a delay. The questions that arises therefore, is it ethical to withhold analgesia in order to facilitate an early diagnosis of compartment syndrome? Furthermore, is it ethical to withhold regional anaesthesia in a cohort of patients who would benefit from excellent analgesia?

The speaker will assess the evidence from both the orthopaedic and anaesthesiology literature and will separate the facts from the fiction.

References
1. Mar GJ, Barrington MJ, McGuirk BR. Acute compartment syndrome of the lower limb and the effect of postoperative analgesia on diagnosis. British Journal of Anaesthesia 2009;102(1):3-11.
2. Cometa MA, Esch AT, Boezaart AP. Did continuous femoral and sciatic nerve block obscure the diagnosis or delay the treatment of acute lower leg compartment syndrome? A case report. Pain Med 2011;12(5):823-8.
3. Kucera TJ, Boezaart AP. Case Report Regional Anesthesia Does Not Consistently Block Ischemic Pain: Two Further Cases and a Review of the Literature. Pain Medicine 2014;15(2):316-9.
4. Rauf J, Iohom G, O’Donnell B. Acute compartment syndrome and regional anaesthesia – a case report. Rom J Anaesth Int Care 2015;22(1):51-54.
5. Walker BJ, Noonan KJ, Bosenberg AT. Evolving compartment syndrome not masked by a continuous peripheral nerve block: Evidence-based case management. Reg Anesth Pain Med 2012;37(4):393-7.
6. Aguirre JA, Gresch D, Popovici A, Bernhard J, Borgeat A. Case Scenario: Compartment Syndrome of the Forearm in Patient with an Infraclavicular Catheter. Anesthesiology 2013; 118(5):1198-205.