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

Abstract

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.

Pediatric epidural analgesia (PEA)

“…A recent editorial also suggested that PEA does not delay diagnosis of compartment syndrome (27). Is it also true that morphine techniques may also mask the diagnosis of compartment syndrome if settings are not optimum (28).…”

Management of Orthopaedic Injuries in Multiply Injured Child

“…Careful titration of morphine dosage in patient/parent-controlled analgesia has also been recommended as a tool in raising the suspicion of CS in patients on narcotic analgesia. 70 Open fractures can still develop CS 71 and the presence of a wound does not automatically decompress a compartment. It should not be forgotten that CS can also develop after surgical intervention and limb should be carefully monitored in postintervention period.…”

Regional anesthesia or patient-controlled analgesia and compartment syndrome in orthopedic surgical procedures: a systematic review

“… 3 Early recognition and treatment with an emergent fasciotomy is crucial, as the risk of complications such as muscle necrosis, 4 , 5 neurological deficits, 3 , 5 , 6 delayed fracture union, 7 Volkmann ischemic contraction, 8 myoglobinuria, 8 – 10 renal failure, 8 – 12 and potentially death 10 , 11 , 13 increases as time of tissue anoxia elapses. 14 – 17 The diagnosis of CS is clinical and requires a high index of suspicion. 6 , 18 , 19 Classical symptoms of CS include pain, 13 , 20 – 25 pallor, 25 , 26 paresthesias, 20 , 24 , 25 , 27 pulselessness, 24 and paralysis.…”