Pain Management Effects on Diagnosis
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.
Management of Acute Compartment Syndrome
This guideline was produced in collaboration with METRC, with funding provided by the US Department of Defense. Endorsed by: ACS, AOFAS, and SOMOS

Rationale

As there is no objective, gold standard for the diagnosis of acute compartment syndrome, the clinician should seek an aggregate of data points (including physical examination findings, escalating need for pain medication, pain out of proportion of injury, perfusion pressure, absolute pressure). At the present, in the absence of adequate studies, we believe that the risk of neuraxial anesthesia delaying and/or masking signs/symptoms associated with impending compartment syndrome (including physical examination findings, need for pain medication, magnitude of pain) outweighs the potential benefits of this treatment modality in high risk patient populations. We acknowledge that this opinion is made in the setting of only isolated extremely low-quality case reports and case series, none of which meet standards for inclusion in this analysis. The current literature suggests both that 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.

Furthermore, we believe that clinicians should be attentive to quantity of narcotic pain medications administered to patients as an indicator of impending acute compartment syndrome.

Possible Harms Of Implementation

Both delayed diagnosis of acute compartment syndrome and the increased utilization of narcotic pain medication increase risk for adverse outcomes. Excessive and prolonged narcotic use can lead to substantial patient harm however, there may be a role for neuraxial anesthesia to decrease acute narcotic use and, potentially, subsequent dependence. In patients with severe cardiopulmonary disease general anesthesia may carry substantially increased risk of anesthesia- associated complication – in this setting clinicians and patients must carefully weigh the risk/benefit ratio of neuraxial anesthesia versus general anesthesia.

Future Research

High quality studies are needed to assess the ability to diagnose acute compartment syndrome in the setting of regional anesthesia. Similar to the obtunded patient, patients who may benefit from neuraxial anesthesia would benefit from improved monitoring for compartment syndrome. Further studies are also needed evaluate the relationship between regional anesthesia and the development of chronic pain/chronic opioid use.


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