PNBs and Compartment Syndrome

[wtbcrna, MSN, DNP, CRNA]

What is your facility's policy on doing PNBs on fractures and/or procedure at increased rick of developing compartment syndrome?

"IV. Implication of Regional Anesthesia in the Diagnosis of Compartment Syndrome

Regional anesthesia in patients at risk for developing an ACS is a highly controversial topic discussed.²,³,³⁵ However, there is no randomized trial comparing outcome after different anesthesia managements. Actual clinical practice is based only on case reports, retrospective case series, recommendations and reviews, and the belief that regional anesthesia completely blocks pain and alters sensory-motor response to impede diagnosis of ACS.⁴ Advances in regional anesthesia techniques, drugs, and concentrations which allow a goal-directed therapy of pain with spare of sensory-motor functions are ignored.

This patient presents an ACS of the upper extremity involving regional anesthesia. Interestingly, some of the published case reports blame a peripheral nerve block (PNB) for masking an ACS in a territory not covered by the block. This challenges the sole responsibility of the PNB in masking the ACS.⁷,¹⁰There is one recent case report blaming continuous perineural blocks for delaying diagnosis of ACS after distal femur and proximal tibia osteotomy.⁵ Additional to general anesthesia continuous sciatic and femoral nerve blocks were run with ropivacaine 0.2% after an initial bolus of 30 ml ropivacaine 0.5% through each catheter. Due to persistent breakthrough pain on postoperative day 2 the surgeon performed a clinical evaluation (dense swollen gastrocnemius muscle, excruciating upon passive plantar flexion, and dorsiflexion of the foot) and a compartment pressure measurement (30 mmHg). Despite these findings, a reevaluation was performed 2 h later showing the same findings. Finally, an emergent decompressive fasciotomy was performed. Once again, the breakthrough pain was ignored. This delay had serious consequences: tissue loss and functional deficits resulted. A second case report using continuous popliteal nerve block describes a patient who was sent home on postoperative day 1 with a popliteal catheter after foot surgery despite a dense motor and sensory block.¹¹ Pain became worse overnight and presented to the emergency department on postoperative day 2. The cast was splinted but not removed, no compartment pressures were measured. Patient refused to have the continuous PNB removed and was managed through the telephone. On postoperative day 4 the catheter was removed uneventfully. Probably, this is not a case of ACS but of pressure pain induced by tight cast which could have led to an ACS. However, patient management in this case report is not according to common standard. The case described by Noorpuri et al.⁹ describes an ACS after an ankle block for a revisional forefoot arthroplasty. The patient developed increasing pain despite receiving supplementary analgesia, paresthesia, motor weakness and showed a tense swollen forefoot with a delayed capillary refill. No compartment pressure monitoring was performed and fasciotomy was performed due to increment clinical signs. Despite the neglect of typical clinical signs the authors blamed the ankle block for masking the ACS and delaying its diagnosis.

None of the five currently published case reports blaming peripheral regional analgesia for delaying diagnosis or therapy of ACS can stand a thorough study of the case. Ignored increasing pain and typical clinical signs are present in all cases and in one regional anesthesia did not even block the area of interest."

http://journals.lww.com/anesthesiology/Fulltext/2013/05000/Case_Scenario___Compartment_Syndrome_of_the.33.aspx#!

[nomadcrna, DNP, CRNA, NP]

I stick to hematoma blocks in the ER. Great results. Both for fracture reduction and analgesia while they travel to see the ortho surgeon.

No facility policy, nor should there be. Individual practice should dictate whether you want to place a PNB.

[wtbcrna, MSN, DNP, CRNA]

I stick to hematoma blocks in the ER. Great results. Both for fracture reduction and analgesia while they travel to see the ortho surgeon.

No facility policy, nor should there be. Individual practice should dictate whether you want to place a PNB.

I should have put what is common practice instead of policy at your facility. I don't do hematoma blocks, but I perform PNBs for fractures frequently. We only have one orthopod that doesn't routinely like PNBs for fractures right now.