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. 2023 Mar 2;16:635–648. doi: 10.2147/JPR.S397428

Pain Control with Regional Anesthesia in Patients at Risk of Acute Compartment Syndrome: Review of the Literature and Editorial View

David Lam 1,*, Doris Pierson 1,*, Osman Salaria 1, Richa Wardhan 2, Jinlei Li 1,✉
PMCID: PMC9987529  PMID: 36891457

Abstract

Acute compartment syndrome (ACS) is a devastating complication that can happen in almost every part of the human body, most noticeably after long bone fractures. The cardinal symptom of ACS is pain in excess of what would otherwise be expected from the underlying injury and unresponsive to routine analgesia treatment. There is paucity of literature on major analgesic management strategies including opioid analgesia, epidural anesthesia, and peripheral nerve blocks with regard to their differential efficacy and safety of pain management in patients at risk of developing ACS. The lack of quality data has led to recommendations that are perhaps more conservative than they should be, particularly when it comes to peripheral nerve blocks. In this review article, we attempt to make recommendations in favor of regional anesthesia in this vulnerable group of patients and strategies that will optimize adequate pain control and improve surgical outcome without jeopardizing patient safety.

Keywords: regional anesthesiology, trauma, nerve blocks, acute compartment syndrome

Introduction

Despite the many well documented benefits associated with regional anesthesia in pain management as compared to opioids, controversy remains surrounding its use in certain settings where acute compartment syndrome is of concern. This includes post-trauma pain management in the emergency room as well as perioperative acute pain management. The medical management of trauma patients is a fundamental component of the practice of medicine. Trauma accounts for almost thirty percent of all life years lost in the US, which is greater than the combination of cancer, heart disease and HIV.1 The treatment of trauma patients must continue to advance. Given the variety of traumatic injuries as well as the economic burden of these patients which accounts for over $400 billion annually in the United States, new methods and treatment options should be considered and developed.2 One of these being the institution of regional anesthesiology nerve blocks and to lay to rest the speculation about their safety. Use of regional techniques in trauma patients, however, has been a controversial topic since the start because these patients are at higher risk of acute compartment syndrome (ACS) that can occur in many parts throughout upper extremity, lower extremity, and abdomen (Table 1). Those that argue against the use of regional anesthesia in these cases argue that hiding or blunting pain can mask one of the presenting symptoms of ACS.3 In this review, we argue in favor of the use of regional anesthetic techniques in trauma patients, specifically in favor of single-shot or lower doses of continuous peripheral nerve blocks over epidural or patient controlled analgesia (PCA).

Table 1.

Compartments of the Body and Their Innervation. This Chart Also Lists the Most Common Causes of Compartment Syndrome by Upper Extremity, Lower Extremity, and Abdominal Divisions, as Well as Possible Pain Control Modalities in These Areas

Compartment Nerve Common Trauma/Procedures Leading to Compartment Syndrome in this Area (Divided by Upper, Lower, and Abdomen) Regional Anesthesia Used for these Procedures (Divided by Upper, Lower, and Abdominal) Other Modalities of Pain Control
Upper arm Anterior Musculocutaneous Supracondylar humerus fracture28 Brachial plexus (interscalene, axillary, supraclavicular, infraclavicular) catheter or single shot PNB29
Wrist block30 or individual nerve block for the compartment		 Opioid based analgesia such as PCA
Posterior Radial Intraosseous fluid administration28
Deltoid Axillary
Forearm Mobile wad Radial Distal radial/ulnar fracture28
Volar Median Radial artery puncture28
Dorsal Radial (posterior interosseous)
Hand Four dorsal interossei Ulnar Carpometacarpal fracture-dislocation31
Three palmar interossei Ulnar
Thenar Median, ulnar
Hypothenar Ulnar
Adductor pollicis Ulnar
Abdomen Abdominal Intercostal nerves Coagulopathy and postoperative hemorrhage (trauma), pregnancy, abdominal aortic repair, liver transplantation32 Truncal peripheral block such as transverse abdominal plane, rectus sheath, quadratus lumborum, erector spinae, paravertebral PNBs, spinal/epidural33
Lower Leg Anterior Deep peroneal Tibial fracture10 Sciatic, femoral, adductor canal, saphenous, lateral femoral cutaneous, ankle,34 PNBs, spinal/epidural29
Lateral Superficial peroneal Fibular fracture16
Superficial posterior Tibial
Deep posterior Tibial
Thigh Anterior Femoral Acute muscle overuse, burns, arterial ischemia, compression35
Posterior Tibial
Medial Obturator
Foot Medial Tibial Crush injury, falling from height36
Lateral Tibial
Central
Interosseous
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Pain management in trauma patients is often disregarded and sidelined in favor of saving the life/limb of a patient. In the cases where pain management can be addressed, systemic opioids are by far the most utilized option given their potency and effectiveness in managing generalized pain. However, systemic opiates bring about secondary consequences that may hinder the provider’s ability to stabilize a patient. Many opiates lead to vasodilation and hypotension which is detrimental to a patient in shock. Moreover, in patients with altered mentation, the effects of respiratory depression and subsequent airway compromise may also be detrimental to these patients. The myriad of patient presentations that stem from trauma in combination with opiates are difficult to manage including polysubstance/baseline altered mentation which may be exacerbated with opiates. An accurate neurological exam is crucial especially in head trauma patients which can be skewed in the context of these medications. On a structural level, the variety of providers in an Emergency Department and staff turnover makes continuity and assurance of proper medical management difficult in these acute settings which can either lead to olio-analgesia or to overdosing patients on opiates.4

Regional Blocks

In the surgical setting, the implementation of regional anesthesia has yielded tremendous results both for intra and postoperative management of patients. The ability to provide site-specific analgesia allows for fewer systemic medications to be utilized which bring about their own side effects including sedation and hemodynamic changes. There have been multiple studies that demonstrate the benefits of the utilization of site-specific anesthesia including improvement in wound healing, decreased stressed responses on cardiovascular symptoms, and improved localized blood flow—all components that would be beneficial to trauma patients.1 From an institutional standpoint, there are also financial incentives as an enhancement in patient recovery will allow for an earlier discharge and shorter duration of hospital stay.5

Nonetheless, the widespread implementation of regional blockades into common practice has not occurred due to several concerns from trauma surgeons/providers. Given certain patient presentations, neurologic exams are crucial to determine motor and sensory deficits from trauma which are often evaluated throughout patient care: from preoperatively, intraoperatively, and postoperatively. As such, the utilization of regional blocks may distort accurate patient exams as the effects of local anesthetic blockade can alter sensorium and muscle strength. This can put these patients at increased risk for falls. In addition, the effectiveness, duration, as well as variety of blocks utilized is operator dependent. Consequently, the variability in patient results unfortunately alters the general perception of the utilization of this modality in this patient care setting. Aligned with the operator dependent efficacy of regional blockades, the timing of doing these factors is often a concern for surgeons. In most surgical settings, regional blockades are well integrated into the flow of a surgery where the anesthesiologist provider has the time to appropriately perform the procedure. However, in the setting of trauma patients, there may be concern for delayed starts to the operating room.6

Compartment Syndrome

One of the greatest obstacles to the universal implementation of regional anesthetics into trauma surgery is the concern of compartment syndrome. Compartment syndrome involves the accumulation of bleeding/swelling of tissues within anatomical compartments that leads to high pressures. This can decrease blood flow and lead to substantial damage to surrounding nerves, muscles, and tissues.7 It is associated with all forms of trauma, from orthopedic, vascular reperfusion injuries/hemorrhages, and crush injuries of the soft tissues, to iatrogenic etiologies such as from arterial/venous puncture in anticoagulated patients. This pathology is a medical emergency that can be easily managed with a fasciotomy but requires emergent treatment to prevent permanent damage.8

The incidence of compartment syndrome occurring after injuries is approximately 3.1 per 100,000 with a predominance in younger males (30–35 years old) with larger muscle masses stemming from high energy activities/accidents.9,10 The most common injuries leading to compartment syndrome are tibial shaft fracture, soft tissue injury, and forearm shaft fracture.11–13 In the pediatric population, older male trauma patients, those who experience firearm injury, and lower limb fracture have increased risk of compartment syndrome.14 Another subset of the patient population that experiences compartment syndrome is the geriatric population, where initial clinical presentation can be easily masked by multiple medical comorbidities and altered mental status.15

The diagnosis of compartment syndrome is clinical and traditionally revolves around six signs and symptoms including pain, paresthesia, paresis, pallor, pulselessness, and poikilothermia.16 Paresthesia is often the earliest sign of compartment syndrome and should prompt urgent evaluation to ensure a good outcome. Given higher risk demographics, the age and gender of patients is also important in appropriately diagnosing this pathology. From there, the mechanism of injury should be evaluated to help direct patient management. The utilization of a transducer catheter can help confirm the diagnosis if the pressure of the area of concern is more than 30mmHg. An intercompartmental pressure of 10mmHg to 30mmHg of the patient’s diastolic blood pressure can also be indicative of inadequate blood perfusion and relative ischemia.17,19

The diagnosis of compartment syndrome in pediatric patients can be a challenging one, particularly in those who are non-verbal or unable to fully communicate their symptoms. In this population, the 3 A’s (anxiety, agitation, and increased analgesic requirements) are often cited as presenting symptoms instead of the traditional symptoms seen in the adult population.18 There are also reports of “silent” compartment syndrome in pediatric patients, where patients present with painless swelling and are found to have elevated compartment pressures when taken to the operating room for fasciotomy.19

With continued integration of regional anesthetic into the standard of care, there remains some concern that local nervous blockade can inhibit/delay the diagnosis of compartment syndrome. There is a paucity of randomized controlled trials on the effect of regional anesthesia on compartment syndrome, but one study by Chen et al took healthy volunteers randomized to receive adductor canal block alone or in conjunction with either low or high concentration sciatic nerve block to see if the blocks affected the patients’ ability to sense 6/10 pain induced by prolonged pressure.20 This study showed that all blocks increased the pressure-pain threshold to varying extents. Further study through randomized controlled trials is necessary.

Statements from Major Anesthesia Societies

A literature review by E. Driscoll in 2016 evaluated 34 articles with the majority (75%) demonstrating that regional anesthesia did not put the patient at an increased risk of delayed diagnosis of compartment syndrome.7,8 In evaluating these patients who had a diagnosis of compartment syndrome, there were more than enough clinical presentation factors that would be of concern to evaluate for this pathology. However, it was found that neither regional anesthetics nor the implementation of Patient Controlled Analgesia (PCA) contributed to this.7 The efficacy of regional anesthesia has made leaps and bounds with improvements in ultrasound technology and user skill set, leading to a more accurate placement of local anesthetics which also allows for lower concentrations to be utilized.

In Table 2, we detail all cases of compartment syndrome with regional anesthesia, PCA, or epidural anesthesia found in the literature and whether these modalities of pain control were seen as contributing to delayed diagnosis of compartment syndrome. In several case reports, there have been concerns that peripheral nerve blocks lead to the delay in the diagnosis of compartment syndrome although these claims are often unjust or inaccurate. There have been additional case reports that attribute epidural anesthesia and patient-controlled analgesia pumps to the delay of compartment syndrome diagnoses.21 In contrast, other studies support the claim that peripheral nerve blocks aid in diagnosis, as they do not completely block ischemic pain, therefore if a patient with a nerve block is having pain out of proportion to exam, it is more likely a pathologic process.22,23 Fundamentally, ischemic pain cannot be completely categorized as nociceptive and neuropathic as there is likely a sympathetic component which follows blood vessels and nerves. As such, there is the need to question the likelihood of completely blocking ischemic pain through regional anesthesia where systemic opiates (spinal/supraspinal) and epidurals may likely have greater/systemic effects than peripheral nerve blocks.24 Consequently, it would be more prudent to determine what patients are being offered for pain management in these cases rather than focusing on regional anesthetics as the sole offender for delayed intervention.25

Table 2.

A Summary of Current Case Reports on Compartment Syndrome

Case Reports Analgesia Type Block Type Age (yr) Sex Injury/Procedure Local Anesthetic Used Diagnosis Symptoms Compartment Pressure Pain level Sequelae Relation to Diagnosis of ACS
Peripheral Nerve Block
Aguirre et al 201337 PNB Infraclavicular catheter: no anesthetic until after extubation: bolused ropivacaine 47 Female Complex distal humerus fx Ropivacaine 0.5% 14 hours after: received additional block Pain 40mmg 10/100-->90/100 Two hematomas, no compartments under tension: no disabilities Association but not fault
Cometa et al 201138 PNB Femoral and sciatic PNB w/ ropivacaine infusion 15 Male Elective distal femur/proximal tibia osteotomy w/ external-fixation 0.2%ropivacaine POD#2 Pain x>30mmhg 0-->10/10 Tissue loss from fasciotomy Did not delay ACS diagnosis
Ganeshan et al 201539 PNB Axillary PNB s/p 2 weeks after initial insult for revision 75 Male Distal radius fx Not listed 24hrs after revision Edematous, blisters 46mmHg, 50 Strength loss Patient was discharged before nerve block had worn off, initially represented with painless blistering, PNB masked pain
Hyder et al 200640 PNB Femoral/obturator/lateral cutaneous nerve of thigh 28 Male Closed fracture of tibia Bupivacaine 0.5% 48hours Altered sensory sensation and inability to extend big toe 108mmhg 0 Rhabdomyolysis in anterior compartment: patient now requires orthosis PNB masks pain
Kucera et al 201441 PNB SS femoral and sciatic PNB 29 Male Elective right lateral ankle ligament 30 mL 0.5% ropivacaine for sciatic block and 20 mL of 0.75% ropivacaine for femoral 90min s/p cast application Pain in ankle n/a Severe Resolution of symptoms thought 2/2 ischemia PNB does NOT block ischemic pain
PNB C7 paravertebral block 45 Female Ischemic pain requiring finger amputation 0.2% ropivacaine continuous infusion N/A Pain n/a Severe Nerve block was utilized after ischemic fingers diagnosed in an attempt to control ischemic pain PNB does not affect ischemic pain
LaReau et al 201242 PNB Femoral PNB catheter: 73 Male TKA 0.375% bupivacaine with epi POD#1 Pain 50mmHG None Thinks reduced sensation led to masked pain
Munk-Andersen et al 201343 PNB Continuous distal Sciatic nerve block 12 Male External fixation of tibia and fibula Lidocaine 2% w/ ropivacaine 0.2% Pain None PNB did not mask breakthrough pain
Noorpuri et al 200044 PNB SS ankle block 37 Female Revisional arthroplasty foot 0.25% bupivacaine Pain/decreased sensation/paresthesias N/A None LA obscure clinical presentation of CS
Rauf et al 201345 PNB Supraclavicular PNB 19 Male Right radius fracture (ORIF) 10 mL 2% lidocaine, 10 mL /0.5% bupivacaine 2hrs s/p block (20min s/p extubation) Severe pain/swelling/loss radial pulse n/a 10/10 None LA did not mask clinical presentation of CS
Sermeus et al 201546 PNB Infraclavicular PNB 4 Male Resection of forearm osteochondroma 0.125% bupivacaine w/ PCA POD#1 Pain/reduced motor function/disturbed capillary refill No fasciotomy: remove cast was cause of clinical features Use of low concentration was helpful in determine CS
Soberon et al 201647 PNB Perineural injection (median, ulnar, radial): proximal forearm 44 Male (ORIF) distal radial fracture 15 mL 1.3% Liposomal bupivacaine and 30 mL 1.5% mepivacaine with hydromorphone PCA POD#1 Numbness/worsening pain Emergency fasciotomy, all sensation recovered Did not result in delay
Torrie et al 201748 PNB/Spinal Spinal w/ periarticular local w/ Adductor canal catheter 56 Male Elective primary TKA 0.2% ropivacaine 6 Hours after surgery Tightness 47mmgHG 10/10 pain None: emergency fasciotomy Did not delay
Walker et al 201249 PNB Popliteal catheter w/ additional saphenous nerve block 19 Female Calcaneal lengthening osteotomy and achilles tendon lengthening 0.2% ropivacaine continuous infusion POD 2 Pain and tightness Not measured Cast was split and spacers applied due to worsening pain prompting ED visit. Breakthrough pain despite working popliteal catheter prompted diagnosis.
Uzel et al 200950 PNB SS Femoral nerve 26 Male Closed femoral fracture internal fixation Ropivacaine 0.5% 20 mL POD#1 Pain/tightness/discoloration 54mmhg severe Emergent fasciotomy May have delayed, but no functional deficits
Ivra
Ananthanarayan et al 200051 IVRA 107 min tourniquet time 57 Male Left dupuytren contracture 360 mg lidocaine w/ tourniquet Minutes of tourniquet release Muscle tension/hand anesthesia/pallor/limited motor Clinical eval None Unclear etiology
IVRA 64 Min tourniquet time 73 Female Dupuytren fasciotomy 200 mg lidocaine Pain and forearm swelling Clinical eval Severe Emergency fasciotomy with eventual complete recovery Unclear etiology
Hastings et al 198752 IVRA 85 min tourniquet time 54 Female Multiple trigger fingers 1% Lidocaine 20 mL with 20 mL hypertonic saline POD#0 after tourniquet release Skin blebs/swelling N/A Severe Persistent neuritis of median nerve w/ carpal tunnel Inadvertent injection of hypertonic saline leading to iatrogenic CS
IVRA 67 Min tourniquet time 22 Female Synovectomy of index finger 1% Lidocaine 20 mL with 20 mL hypertonic salinen/a POD#0 after tourniquet release Swelling N/a Moderate pain/swelling NONE Inadvertent injection of hypertonic saline (same day/anesthesiologist as case described above) did not result in any permanent sequelae
IVRA 25 Miin tourniquet time 37 Female Colles fracture (closed fixation) Xylocaine with hypertonic saline POD # after tourniquet release Severe swelling/pain 50 mmhg Severe Stiffness w/ strength loss Inadvertent hypertonic saline injection leading to iatrogenic CS
Mabee et al 199453 IVRA 40 Minute tourniquet time Bier block 26 Male Bennet fracture: closed reduction 0.5% lidocaine 41 mL with 20 mL hypertonic saline 30/40 min: cast removed Pain/tightness 49mmHg Severe None s/p fasciotomy Inadvertent hypertonic saline injection leading to iatrogenic CS: osmotic increase in ECF
Quigley et al 198154 IVRA IVRA (bier) 25 Male Hypertonic saline n/a Pain/fever n/a
Epidural/CSE
Beerle et al 199355 Epidural 74 Female Radical cystectomy 0.125% bupivacaine and fentany 3mcg/cc at 8cc/hrl POD#0: 30min after extubation (7.5hr surgery) Tense, swollen, left leg with distal pallor None s/p fasciotomy (kept use of epidural) Epidural did not mask CS
Bezwada et al 200556 CSE 60 Male Bilateral total knee joint replacement Bupivacaine and fentanyl
Chittoodan et al 200957 Epidural 17 Female Bowel resection Fentanyl w/ LA POD#0 Left leg pain None: no residual weakness Patient was able to verbalize her discomfort which helped lead to the diagnosis early on
Osteen et al 201058 CSE 52 Male Right TKA 0.75% Bupivacaine (subarachnoid space)/ fent 2mcg/cc ropivacaine 0.2% ropi POD#1 Numbness of left buttock with progressive LE numbness/ POD#2 based on labs n/a None
Price et al 199659 Epidural 16 Male b/l corrective osteotomies (genu varum) Fentanyl 18hrs Swelling/tense 64mmHg (Left)
Strecker et al 198660 Epidural 45 Male Infected non-union of L tibia 0.125% Bupivacaine POD 8 Pain, swelling Unable to evert foot Diagnosed on day 8, epidural discontinued day 4. Writers believe epidural anesthesia masked the pain of CS.
Sorrentino, F. et al 199861 Epidural 19 Male Bupivacaine POD#3 Painful swollen ant compartment 100mgHg Palsy of dorsiflexion of foot Not masked–patient had breakthrough pain
Tang, W. M., and Chiu, K. Y. 200062 Epidural 62 Female (Post dislocation): TKA 0.125% bupivacaine POD#2 Poor circulation/swelling 65,75,75,80 (ant/peroneal/superficial/deep) None Severe muscle necrosis Pain on passive flexion concerning for CS: epidural contraindicated for complex TKA
Pollard R.L.E., O’Broin E 200963 Epidural 44 Female Left breast flap reconstruction with deep inferior epigastric perforator (DIEP) flap Bupivacaine 0.1% and fentanyl 2 μg mL POD#4 b/l leg cramps with finding of b/l Leg ACS (chronic) n/a Physiotherapy PCA and epidural masked pain too well and delayed dx
PCA
Harrington, P. et al 200064 PCA 53 Male Isolated open oblique fracture of the mid tibia shaft (no neurovascular deficit) Morphine 36hr Tense x>50mmHg 2/3 out of 10 None s/p fasciotomy PCA delayed dx: utilization was meant to allow patient to dictate own pain control
Mannion et al 201765 PCA 21 Male Closed displaced tibia fracture Morphine 26hrs Inability to dorsiflex toes/cold ischemic limb n/a None BKA Could have dx earlier despite use of PCA (15 year later evaluation)
O’Sullivan, M. J. et al 200266 PCA 21 Male Closed displaced fracture of tibia Morphine*dosing unavailable 7–18hrs Pale/numb/cold/inability to dorsiflex n/a Inability to dorsiflex BKA Ortho team did not react to findings despite clinical evidence of ACS
Ploumis et al 201067 PCA 53 Female Anterior interbody and posterior L3-S1 instrumented fusion Hydromorphone POD #1 Pain w/ pressure ecchymosis n/a Anterolateral tibia ACS requiring fasciotomy w/ residual weakness and recurrent right foot edema PCA masked symptoms of limb ischemia
Richards, H. et al 200468 PCA 28 Male Displaced oblique fracture of tibial diaphysis Morphine (10mg-20) 18hrs Tense/foot drop 0 Clawing of toes s/p fasciotomy PCA delayed dx
PCA 27 Male Building transverse midshaft tibia fx Morphine (13mg) 26hr Unable to move toes/altered sensation x>40mmHg Toe clawing and tightness PCA delayed dx
PCA 20 Male Displaced obluqe fracture of tibia Morphine (15mg) 16hrs Altered sensorium x>50mmHg None Permanent foot drop PCA delayed dx
PCA 26 Male Oblique displaced diaphyseal tibial fracture Morphine (17mg) 18hrs Tense calf/altered sensorium n/a None 48s/p fasciotomy dead tissue: loss of power of dorsiflexion and toe clawing PCA delayed dx
Yang J. et al 201069 PCA 10 Male Left midshaft compound fracture Morphine 20 μg/kg w/ 5 min lockout POD1 Swelling, pain on passive stretching n/a 5–6 out of 10 Slight decrease in forearm power Does not delay diagnosis just needs better monitoring
7 Male Supracondylar fx Morphine PCA POD#0-1 prior to PCA Pain on active/passive movement n/a Decrease in elbow ROM Poor capillary refill requiring arteriotomy and vein patch graft
Teen M. et al 201770 PCA 29 Male Metatarsal crush injury 0.125% Bupivacaine No additional details provided NO FINDINGS OF ACS despite concerns for swelling
45 Male Metatarsal crush injury 0.125% bupivacaine No additional details provided NO FINDINGS OF ACS despite concerns for swelling
McLaughlin et al 201670 PCA 67 Female Ischemic limb 0.1% ropivacaine No additional details provided NO FINDINGS OF ACS despite concerns for swelling
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Abbreviations: PNB, peripheral nerve block; SS, single shot; POD, postoperative day; S/P: status post; ORIF, open reduction internal fixation; Fx, fracture; ACS, acute compartment syndrome; IVRA, intravenous regional anesthesia; CSE, combined spinal epidural; PCA, patient-controlled analgesia.

Table 3 further details the existing society statements on use of regional anesthesia when compartment syndrome is likely or present. Although there is no universal consensus, the Association of Anesthetists of Great Britain and Ireland have stated that compartment syndrome is not a contraindication for usage of regional anesthesia modalities.3 Pain is not the only criteria for its diagnosis. Another factor being that patient’s complaints of pain are subjective and are not a reliable benchmark for an instant, definitive diagnosis.32 With this mindset that there is no evidence that regional anesthesia increases risks/delays acute compartment syndrome, the European Society of Regional Anesthesia and Pain Therapy (ESRA) in conjunction with the American Society of Regional Anesthesia and Pain Medicine (ASRA) joint committee have helped establish guidelines for best practices in pediatric patients26 (Box 1).

Table 3.

Summary Table of World Society Guidelines on Use of Regional Anesthesia and Its Effect on Compartment Syndrome

Specialty Society Statement
Anesthesia
Association of Anaesthetists of Great Britain and Ireland3 ”Use of neuraxial or peripheral regional techniques that result in dense blocks of long duration that significantly exceed the duration of surgery should be avoided.single-shot or continuous peripheral nerve blocks using lower concentrations of local anaesthetic drugs without adjuncts are not associated with delays in diagnosis provided post-injury and postoperative surveillance is appropriate and effective”
American Society of Anesthesia No consensus statement
American Society of Regional Anesthesia No consensus statement in adults
European Society of Regional Anaesthesia & Pain Therapy No consensus statement in adults
European Society of Regional Anaesthesia and Pain Therapy and the American Society of Regional Anesthesia and Pain Medicine (joint statement)26 ”There is no current evidence that the use of regional anesthetics increases the risk for ACS or delays its diagnosis in children”
French Physical and Rehabilitation Medicine (SOFMER) and Anesthesia and Intensive care (SFAR) societies71 “Consider the risk of the consequences of the occurrence of a hematoma: minimal in the case of a superficial hematoma, more significant in the case of a deep hematoma threatening a compartment syndrome”
Asian & Oceanic Society of Regional Anaesthesia and Pain Medicine No consensus statement
African Society of Regional Anesthesia No consensus statement
Surgery
International Orthopaedic Trauma Association No consensus statement
American Academy Of Orthopedic Surgeons72 “Risk of neuraxial anesthesia delaying and/or masking signs/symptoms associated with impending compartment syndrome. outweighs the potential benefits of this treatment modality in high risk patient populations.regional anesthesia may delay diagnosis of acute compartment syndrome and that regional anesthesia does not mask timely diagnosis. If neuraxial anesthesia is administered, we recommend that more emphasis is placed on intra-compartmental pressure monitoring as well as break through pain despite regional anesthesia”.
European Orthopaedic Research Society No consensus statement
Asia Pacific Orthopaedic Association No consensus statement
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Box 1.

ESRA and ASRA Joint Committee Statement

Six Best Practice Rules for Use of Regional Anesthesia in Pediatric Patients
1. A single injection peripheral nerve block or neuraxial concentration of 0.1% to 0.25% bupivacaine, levobupivacaine, or ropivacaine.
2. Continuous peripheral nerve block or neuraxial concentrations of 0.125% bupivacaine, or 0.1–0.2% ropivacaine at a rate of 0.1–0.3 mg/kg/hr.
3. Exercise caution with local anesthetic adjuvants as they can increase the duration and intensity of a block.
4. In high-risk acute compartment syndrome areas such as the tibia: restrict the volume and concentration of local anesthetic.
5.Patients should follow up regularly with the acute pain service.
6. If acute compartment syndrome is suspected, urgent compartment pressure measurement should be performed.
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In addition to the primary concern for compartment syndrome, local anesthetic blockade is not a simple procedure without any risks in which patients receiving these procedures should be evaluated on a holistic basis prior to proceeding. Local anesthetic systemic toxicity is a low risk but nonetheless should be monitored especially in cases that require multiple catheters and infusions which can be further complicated by periodic boluses. Patients prior to regional anesthesia may also present with pre-existing nerve injuries which may be challenging to determine an accurate assessment of the blockade. Coagulopathies and bleeding risks are also considered in addition to infections which are concerns for any interventional procedure.

Conclusion

The practice of acute pain management is not simply the utilization of regional blockade, but rather a comprehensive multimodal approach to anesthesia and analgesia. The addition of standard medications including acetaminophen and nonsteroidal inflammatory drugs are fundamental tenets of pain management which can be further supplemented by additional regiments including dexmedetomidine and ketamine which has gained recent popularity for its analgesic effects. Benzodiazepines also have utility as medications such as valium have been extremely helpful in reducing muscle spasms in patients post-operatively. This multimodal approach of usage of a variety of medications and nerve blockades helps in many aspects. This approach minimizes the utilization of opiates and their unwanted side effects and helps improve patient clinical outcomes and satisfaction.

Trauma pain management has substantial importance and should continue to evolve to help improve patient outcomes. With substantial improvements in regional anesthesia and greater integration into clinical practice, anesthesiologists are in a unique position to become more involved in trauma pain management in multimodal format. Given some concerns with the use of regional blockade for acute compartment syndrome diagnosis, it should be noted that peripheral nerve blocks would be the preferred method for pain management rather than usage of patient-controlled analgesia or placement of an epidural.27 The practice of medicine is a team effort and the incorporation of new innovative procedures aligned with improved patient communication and medical colleagues is key to ensuring clinical improvements, particularly in patients at risk for the development of acute compartment syndrome.

Disclosure

The authors report no conflicts of interest in this work.

References

  • 1.National Center for Health Statistics: FastStats of All Injuries. Available from: http://www.cdc.gov/nchs/fastats/injury.htm. Accessed September 3, 2022.
  • 2.Corso P. Incidence and lifetime costs of injuries in the United States. Injury Prevent. 2006;12(4):212–218. doi: 10.1136/ip.2005.010983 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3.Nathanson MH, Harrop-Griffiths W, Aldington DJ, et al. Regional analgesia for lower leg trauma and the risk of acute compartment syndrome: guideline from the Association of Anaesthetists. Anaesthesia. 2021;76(11):1518–1525. doi: 10.1111/anae.15504 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4.Hernandez N, de Haan JB. Regional anesthesia for trauma in the emergency department. Curr Anesthesiol Rep. 2022;12(2):240–249. doi: 10.1007/s40140-022-00531-3 [DOI] [Google Scholar]
  • 5.Bulka CM, Shotwell MS, Gupta RK, Sandberg WS, Ehrenfeld JM. Regional anesthesia, time to hospital discharge, and in-hospital mortality: a propensity score matched analysis. Reg Anesth Pain Med. 2014;39(5):381–386. doi: 10.1097/AAP.0000000000000121 [DOI] [PubMed] [Google Scholar]
  • 6.Wordsworth H, Wickham A, Bellew B, Gilfillan N. Attitudes towards safety of regional anaesthesia in trauma patients: a survey of surgeons and anaesthetists in a major trauma centre and a specialist hand unit. In: Anaesthesia. Vol. 70. NJ USA: WILEY-BLACKWELL 111 RIVER ST, HOBOKEN 07030-5774; 2015:100. [Google Scholar]
  • 7.Driscoll EB, Maleki AH, Jahromi L, et al. Regional anesthesia or patient-controlled analgesia and compartment syndrome in orthopedic surgical procedures: a systematic review. Local Reg Anesth. 2016;9:65–81. doi: 10.2147/LRA.S109659 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 8.Torlincasi AM, Lopez RA, Waseem M. Acute compartment syndrome. In: StatPearls. StatPearls Publishing; 2022. [PubMed] [Google Scholar]
  • 9.McQueen MM, Gaston P, Court-Brown CM. Acute compartment syndrome. Who is at risk? J Bone Joint Surg Br. 2000;82(2):200–203. [PubMed] [Google Scholar]
  • 10.Shadgan B, Menon M, Sanders D, et al. Current thinking about acute compartment syndrome of the lower extremity. Can J Surg. 2010;53(5):329–334. [PMC free article] [PubMed] [Google Scholar]
  • 11.Pechar J, Lyons MM. Acute compartment syndrome of the lower leg: a review. J Pract. 2016;12(4):265–270. doi: 10.1016/j.nurpra.2015.10.013 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12.Gamulin A, Wuarin L, Zingg M, Belinga P, Cunningham G, Gonzalez AI. Association between open tibia fractures and acute compartment syndrome: a retrospective cohort study. Orthop Traumatol Surg Res. 2022;108(5):103188. doi: 10.1016/j.otsr.2021.103188 [DOI] [PubMed] [Google Scholar]
  • 13.Mar GJ, Barrington MJ, McGuirk BR. Acute compartment syndrome of the lower limb and the effect of postoperative analgesia on diagnosis. Br J Anaesth. 2009;102(1):3–11. doi: 10.1093/bja/aen330 [DOI] [PubMed] [Google Scholar]
  • 14.Sees JA, Cutler GJ, Ortega HW. Risk factors for compartment syndrome in pediatric trauma patients. Pediatr Emerg Care. 2020;36(3):e115–e119. doi: 10.1097/PEC.0000000000001636 [DOI] [PubMed] [Google Scholar]
  • 15.Kurmis. Diagnosing acute lower-limb compartment syndrome in the older population: a clinical conundrum. Clin Geriatr. Available from: https://www.researchgate.net/profile/Andrew-Kurmis/publication/287320403_Diagnosing_acute_lower-limb_compartment_syndrome_in_the_older_population_A_clinical_conundrum/links/56a9666808ae2df82165324f/Diagnosing-acute-lower-limb-compartment-syndrome-in-the-older-population-A-clinical-conundrum.pdf. Accessed February 2, 2023.
  • 16.Cone J, Inaba K. Lower extremity compartment syndrome. Trauma Surg Acute Care Open. 2017;2(1):e000094. doi: 10.1136/tsaco-2017-000094 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 17.Torlincasi AM, Lopez RA, Waseem M Acute compartment syndrome. Available from: https://europepmc.org/books/nbk448124. Accessed August 26, 2022. [PubMed]
  • 18.Johnson DJG, Chalkiadis GA. Does epidural analgesia delay the diagnosis of lower limb compartment syndrome in children? Paediatr Anaesth. 2009;19(2):83–91. doi: 10.1111/j.1460-9592.2008.02894.x [DOI] [PubMed] [Google Scholar]
  • 19.Frei B, Sommer-Joergensen V, Holland-Cunz S, Mayr J. Acute compartment syndrome in children; beware of “silent” compartment syndrome: a CARE-compliant case report. Medicine. 2020;99(23):e20504. doi: 10.1097/MD.0000000000020504 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 20.Chen YYK, Lirk P, Mikayla Flowers K, et al. Impact of varying degrees of peripheral nerve blockade on experimental pressure and ischemic pain: adductor canal and sciatic nerve blocks in a human model of compartment syndrome pain. Reg Anesth Pain Med. 2022;47(10):630–636. doi: 10.1136/rapm-2022-103671 [DOI] [PubMed] [Google Scholar]
  • 21.Tran AA, Lee D, Fassihi SC, Smith E, Lee R, Siram G. A systematic review of the effect of regional anesthesia on diagnosis and management of acute compartment syndrome in long bone fractures. Eur J Trauma Emerg Surg. 2020;46(6):1281–1290. doi: 10.1007/s00068-020-01320-5 [DOI] [PubMed] [Google Scholar]
  • 22.Gadsden J, Warlick A. Regional anesthesia for the trauma patient: improving patient outcomes. Local Reg Anesth. 2015;8:45–55. doi: 10.2147/LRA.S55322 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 23.Nair GS, Soliman LM, Maheshwari K, Esa WAS. Importance of vigilant monitoring after continuous nerve block: lessons from a case report. Ochsner J. 2013;13(2):267–269. [PMC free article] [PubMed] [Google Scholar]
  • 24.Nin OC, Patrick MR, Boezaart AP. The controversy of regional anesthesia, continuous peripheral nerve blocks, analgesia, and acute compartment syndrome. Tech Orthopaed. 2017;32(4):243–247. doi: 10.1097/BTO.0000000000000260 [DOI] [Google Scholar]
  • 25.Hoogma. Peripheral blocks are contraindicated when there is a high risk of compartment syndrome: con. Reg Anesth Pain Med. Available from: https://lirias.kuleuven.be/1813599?limo=0. Accessed February 15, 2023.
  • 26.Ivani G, Suresh S, Ecoffey C, et al. The European Society of Regional Anaesthesia and Pain Therapy and the American Society of Regional anesthesia and pain medicine joint committee practice advisory on controversial topics in pediatric regional anesthesia. Reg Anesth Pain Med. 2015;40(5):526–532. doi: 10.1097/aap.0000000000000280 [DOI] [PubMed] [Google Scholar]
  • 27.Klucka J, Stourac P, Stouracova A, Masek M, Repko M. Compartment syndrome and regional anaesthesia: critical review. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2017;161(3):242–251. doi: 10.5507/bp.2017.025 [DOI] [PubMed] [Google Scholar]
  • 28.Leversedge FJ, Moore TJ, Peterson BC, Seiler JG. Compartment syndrome of the upper extremity. J Hand Surg Am. 2011;36(3):544–559; quiz 560. doi: 10.1016/j.jhsa.2010.12.008 [DOI] [PubMed] [Google Scholar]
  • 29.Yurgil JL, Hulsopple CD, Leggit JC. Nerve blocks: part I. upper extremity. Am Fam Physician. 2020;101(11):654–664. [PubMed] [Google Scholar]
  • 30.Operater. Wrist block - landmarks and nerve stimulator technique. NYSORA; 2018. Available from: https://www.nysora.com/techniques/upper-extremity/wrist/wrist-block/. Accessed October 14, 2022. [Google Scholar]
  • 31.Oak NR, Abrams RA. Compartment syndrome of the hand. Orthop Clin North Am. 2016;47(3):609–616. doi: 10.1016/j.ocl.2016.03.006 [DOI] [PubMed] [Google Scholar]
  • 32.Saggi BH, Sugerman HJ, Ivatury RR, Bloomfield GL. Abdominal compartment syndrome. J Trauma. 1998;45(3):597–609. doi: 10.1097/00005373-199809000-00033 [DOI] [PubMed] [Google Scholar]
  • 33.Thoracic and abdominal wall blocks. NYSORA. Available from: https://www.nysora.com/techniques/truncal-and-cutaneous-blocks/. Accessed October 14, 2022. [Google Scholar]
  • 34.NYSORA. Ankle block - landmarks and nerve stimulator technique. NYSORA; 2018. Available from: https://www.nysora.com/topics/regional-anesthesia-for-specific-surgical-procedures/lower-extremity-regional-anesthesia-for-specific-surgical-procedures/foot-and-anckle/ankle-block/. Accessed November 1, 2022. [Google Scholar]
  • 35.Burns BJ, Sproule J, Smyth H. Acute compartment syndrome of the anterior thigh following quadriceps strain in a footballer. Br J Sports Med. 2004;38(2):218–220. doi: 10.1136/bjsm.2003.004762 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 36.Ojike NI, Roberts CS, Giannoudis PV. Foot compartment syndrome: a systematic review of the literature. Acta Orthop Belg. 2009;75(5):573–580. [PubMed] [Google Scholar]
  • 37.Aguirre JA, Gresch D, Popovici A, Bernhard J, Borgeat A. Case scenario: compartment syndrome of the forearm in patient with an infraclavicular catheter: breakthrough pain as indicator. Anesthesiology. 2013;118(5):1198–1205. doi: 10.1097/ALN.0b013e31828afa96 [DOI] [PubMed] [Google Scholar]
  • 38.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):823–828. doi: 10.1111/j.1526-4637.2011.01109.x [DOI] [PubMed] [Google Scholar]
  • 39.Ganeshan RM, Mamoowala N, Ward M, Sochart D. Acute compartment syndrome risk in fracture fixation with regional blocks. BMJ Case Rep. 2015;2015. doi: 10.1136/bcr-2015-210499 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 40.Hyder N, Kessler S, Jennings AG, De Boer PG. Compartment syndrome in tibial shaft fracture missed because of a local nerve block. J Bone Joint Surg Br. 1996;78(3):499–500. doi: 10.1302/0301-620X.78B3.0780499 [DOI] [PubMed] [Google Scholar]
  • 41.Kucera TJ, Boezaart AP. Regional anesthesia does not consistently block ischemic pain: two further cases and a review of the literature. Pain Med. 2014;15(2):316–319. doi: 10.1111/pme.12235 [DOI] [PubMed] [Google Scholar]
  • 42.LaReau JM, Robbins CE, Talmo CT, Mehio AK, Puri L, Bono JV. Complications of femoral nerve blockade in total knee arthroplasty and strategies to reduce patient risk. J Arthroplasty. 2012;27(4):564–568. doi: 10.1016/j.arth.2011.06.028 [DOI] [PubMed] [Google Scholar]
  • 43.Munk-Andersen H, Laustrup TK. Compartment syndrome diagnosed in due time by breakthrough pain despite continuous peripheral nerve block. Acta Anaesthesiol Scand. 2013;57(10):1328–1330. doi: 10.1111/aas.12187 [DOI] [PubMed] [Google Scholar]
  • 44.Noorpuri BSW, Shahane SA, Getty CJG. Acute compartment syndrome following revisionai arthroplasty of the forefoot: the dangers of ankle-block. Foot Ankle Int. 2000;21(8):680–682. doi: 10.1177/107110070002100809 [DOI] [PubMed] [Google Scholar]
  • 45.Rauf J, Iohom G, O’Donnell B. Acute compartment syndrome and regional anaesthesia - a case report. Rom J Anaesth Intensive Care. 2015;22(1):51–54. [PMC free article] [PubMed] [Google Scholar]
  • 46.Sermeus L, Boeckx S, Camerlynck H, Somville J, Vercauteren M. Postsurgical compartment syndrome of the forearm diagnosed in a child receiving a continuous infra-clavicular peripheral nerve block. Acta Anaesthesiol Belg. 2015;66(1):29–32. [PubMed] [Google Scholar]
  • 47.Soberón JR, Sisco-Wise LE, Dunbar RM. Compartment syndrome in a patient treated with perineural liposomal bupivacaine (Exparel). J Clin Anesth. 2016;31:1–4. doi: 10.1016/j.jclinane.2015.11.001 [DOI] [PubMed] [Google Scholar]
  • 48.Torrie A, Sharma J, Mason M, Eng HC. Regional anesthesia did not delay diagnosis of compartment syndrome: a case report of anterior compartment syndrome in the thigh not masked by an adductor canal catheter. Am J Case Rep. 2017;18:444–447. doi: 10.12659/ajcr.902708 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 49.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):393–397. doi: 10.1097/AAP.0b013e31824df1ac [DOI] [PubMed] [Google Scholar]
  • 50.Uzel AP, Steinmann G. Thigh compartment syndrome after intramedullary femoral nailing: possible femoral nerve block influence on diagnosis timing. Orthop Traumatol Surg Res. 2009;95(4):309–313. doi: 10.1016/j.otsr.2009.03.014 [DOI] [PubMed] [Google Scholar]
  • 51.Ananthanarayan C, Castro C, McKee N, Sakotic G. Compartment syndrome following intravenous regional anesthesia. Can J Anaesth. 2000;47(11):1094–1098. doi: 10.1007/BF03027961 [DOI] [PubMed] [Google Scholar]
  • 52.Hastings H, Misamore G. Compartment syndrome resulting from intravenous regional anesthesia. J Hand Surg Am. 1987;12(4):559–562. doi: 10.1016/S0363-5023(87)80208-3 [DOI] [PubMed] [Google Scholar]
  • 53.Mabee JR, Bostwick TL, Burke MK. Iatrogenic compartment syndrome from hypertonic saline injection in Bier block. J Emerg Med. 1994;12(4):473–476. doi: 10.1016/0736-4679(94)90342-5 [DOI] [PubMed] [Google Scholar]
  • 54.Quigley JT, Popich GA, Lanz UB. Compartment syndrome of the forearm and hand: a case report. Clin Orthop Relat Res. 1981;161:247–251. doi: 10.1097/00003086-198111000-00031 [DOI] [PubMed] [Google Scholar]
  • 55.Beerle BJ, Rose RJ. Lower extremity compartment syndrome from prolonged lithotomy position not masked by epidural bupivacaine and fentanyl. Reg Anesth. 1993;18(3):189–190. [PubMed] [Google Scholar]
  • 56.Bezwada HP, Nazarian DG, Booth RE Jr. Compartment syndrome following total knee arthroplasty: a case report. Am J Orthop. 2005;34(8):386–388. [PubMed] [Google Scholar]
  • 57.Chittoodan S, Crowe S. Epidural analgesia and compartment syndrome. Paediatr Anaesth. 2009;19(5):542. doi: 10.1111/j.1460-9592.2009.02975.x [DOI] [PubMed] [Google Scholar]
  • 58.Osteen KD, Haque SH. Bilateral gluteal compartment syndrome following right total knee revision: a case report. Ochsner J. 2012;12(2):141–144. [PMC free article] [PubMed] [Google Scholar]
  • 59.Price C, Ribeiro J, Kinnebrew T. Compartment syndromes associated with postoperative epidural analgesia. A case report. J Bone Joint Surg Am. 1996;78(4):597–599. doi: 10.2106/00004623-199604000-00016 [DOI] [PubMed] [Google Scholar]
  • 60.Strecker WB, Wood MB, Bieber EJ. Compartment syndrome masked by epidural anesthesia for postoperative pain. Report of a case. J Bone Joint Surg Am. 1986;68(9):1447–1448. doi: 10.2106/00004623-198668090-00022 [DOI] [PubMed] [Google Scholar]
  • 61.Sorrentino F, Eggli S, Stricker U, Ballmer FT, Hertel R. Missed compartment syndrome after replacement of the anterior cruciate ligament following continuous epidural analgesia. Unfallchirurg. 1998;101(6):491–494. doi: 10.1007/s001130050300 [DOI] [PubMed] [Google Scholar]
  • 62.Tang WM, Chiu KY. Silent compartment syndrome complicating total knee arthroplasty: continuous epidural anesthesia masked the pain. J Arthroplasty. 2000;15(2):241–243. doi: 10.1016/S0883-5403(00)90440-6 [DOI] [PubMed] [Google Scholar]
  • 63.Pollard RLE, O’Broin E. Compartment syndrome following prolonged surgery for breast reconstruction with epidural analgesia. J Plast Reconstr Aesthet Surg. 2009;62(12):e648–e649. doi: 10.1016/j.bjps.2008.11.078 [DOI] [PubMed] [Google Scholar]
  • 64.Harrington P, Bunola J, Jennings AJ, Bush DJ, Smith RM. Acute compartment syndrome masked by intravenous morphine from a patient-controlled analgesia pump. Injury. 2000;31(5):387–389. doi: 10.1016/S0020-1383(99)00308-3 [DOI] [PubMed] [Google Scholar]
  • 65.Mannion S, Lee P, Taylor C. Cold Case Files: 15 years on, did patient controlled analgesia mask acute compartment syndrome? Ir Med J. 2017;110(7):625. [PubMed] [Google Scholar]
  • 66.O’Sullivan MJ, Rice J, McGuinness AJ. Compartment syndrome without pain! Ir Med J. 2002;95(1):22. [PubMed] [Google Scholar]
  • 67.Ploumis A, Casnellie M, Graber JN, Dykes DC. Acute tibial compartment syndrome following spine surgery. Orthopedics. 2010;33(6):447. doi: 10.3928/01477447-20100429-27 [DOI] [PubMed] [Google Scholar]
  • 68.Richards H, Langston A, Kulkarni R, Downes EM. Does patient controlled analgesia delay the diagnosis of compartment syndrome following intramedullary nailing of the tibia? Injury. 2004;35(3):296–298. doi: 10.1016/S0020-1383(03)00311-5 [DOI] [PubMed] [Google Scholar]
  • 69.Yang J, Cooper MG. Compartment syndrome and patient-controlled analgesia in children--analgesic complication or early warning system? Anaesth Intensive Care. 2010;38(2):359–363. doi: 10.1177/0310057X1003800219 [DOI] [PubMed] [Google Scholar]
  • 70.Cases MC. ASRA 41st annual regional anesthesiology and acute pain medicine meeting March 31--April 2 2016. Reg Anesth Pain Med. 2016;41(5):1396–1414. [DOI] [PubMed] [Google Scholar]
  • 71.Yelnik AP, Hentzen C, Cuvillon P, et al. French clinical guidelines for peripheral motor nerve blocks in a PRM setting. Ann Phys Rehabil Med. 2019;62(4):252–264. doi: 10.1016/j.rehab.2019.06.001 [DOI] [PubMed] [Google Scholar]
  • 72.American Academy of Orthopedic Surgeons (AAOS): In the absence of reliable evidence, it is the opinion of the work group that neuraxial anesthesia may complicate the clinical diagnosis of acute compartment syndrome. If neuraxial anesthesia is administered, frequent physical examination and/or pressure monitoring should be performed in Guideline: Management of Acute Compartment Syndrome. Available from: https://www.orthoguidelines.org/go/cpg/detail.cfm?id=1456. Accessed October 10, 2022.

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