Does patient-controlled analgesia lead to delayed diagnosis of lower limb compartment syndrome?

Compartment Syndrome and Patient-Controlled Analgesia in Children – Analgesic Complication or Early Warning System?

We present two cases of children who developed compartment syndrome after upper limb fractures. Morphine patient-controlled analgesia was used in a bolus-only mode for analgesia (bolus 20 μg/kg, five minute lockout and hourly limit of 150 μg/kg). An increase in patient-controlled analgesia use was observed up to 12 hours before the decision was made to proceed to fasciotomy but neither child exceeded the hourly limit or had an excessive increase in pain scores. Clinical risk factors for compartment syndrome should be identified and appropriate monitoring instituted. A subtle increase in patient-controlled analgesia use may be an early indicator of impending compartment syndrome before classical signs such as reporting of pain, pallor, paraesthesiae, paralysis and pulselessness develop. These cases and review of the literature suggest techniques which may assist earlier diagnosis of compartment syndrome include setting a more conservative hourly limit of morphine patient-controlled analgesia such as 80 to 100 μg/kg/hour and graphing of patient-controlled analgesia demands and boluses, pain scores at rest and pain scores with passive flexion and extension of digits. These practices could identify trends that pain or analgesia requirement is increasing leading to earlier diagnosis of compartment syndrome.

Does epidural analgesia delay the diagnosis of lower limb compartment syndrome in children?

One of the cardinal symptoms of compartment syndrome is pain. A literature review was undertaken in order to assess the association of epidural analgesia and compartment syndrome in children, whether epidural analgesia delays the diagnosis, and to identify patients who might be at risk. Evidence was sought to offer recommendations in the use of epidural analgesia in patients at risk of developing compartment syndrome of the lower limb. Increasing analgesic use, increasing/breakthrough pain and pain remote to the surgical site were identified as important early warning signs of impending compartment syndrome in the lower limb of a child with a working epidural. The presence of any should trigger immediate examination of the painful site, and active management of the situation (we have proposed one clinical pathway). Avoidance of dense sensory or motor block and unnecessary sensory blockade of areas remote to the surgical site allows full assessment of the child and may prevent any delay in diagnosis of compartment syndrome. Focusing on excluding the diagnosis of compartment syndrome rather than failure of analgesic modality is vital. In the pediatric cases reviewed there was no clear evidence that the presence of an epidural had delayed the diagnosis.

Acute traumatic compartment syndrome: a systematic review of results of fasciotomy

Issues around diagnosis and treatment of acute compartment syndrome were investigated through a systematic review that examined results of 55 reports of fasciotomy published over four decades and reporting on 1920 fasciotomies. Most were reported since 2000. Injuries below the elbow and knee accounted for at least 75% of cases. The consensus was that diagnosis of compartment syndrome remains primarily based on a high index of suspicion and interpretation of clinical signs and symptoms over high technology methods of diagnosis. Compartment syndrome related amputation occurred in 5.5% of cases and death in 3.3% overall. Compared with fasciotomy before 6 h, delayed fasciotomy beyond 12 h was associated with a lower rate of acceptable outcome (15% for more than 12 h vs. 88% for <6 h), a higher rate of amputation (14% vs. 3.2%) and death (4.3% vs. 2.0%).

Does patient controlled analgesia delay the diagnosis of compartment syndrome following intramedullary nailing of the tibia?

We report on four cases in which the diagnosis of compartment syndrome was delayed by the administration of patient controlled analgesia (PCA) following intramedullary nailing of tibial shaft fractures. We believe that this poses a diagnostic problem and can lead to lasting sequelae as decompression is delayed. We recommend extra vigilance with the use of PCA in patients with intramedullary nailing following tibial shaft fractures.