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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
  1. Yun-Yun Kathy Chen1,
  2. Philipp Lirk1,
  3. K Mikayla Flowers1,
  4. Carin A Colebaugh1,
  5. Jenna M Wilson1,
  6. Jose Zeballos1,
  7. Arvind Von Keudell2,3,
  8. Karyn E Barrett1,
  9. Kamen Vlassakov1 and
  10. Kristin L Schreiber1
  1. 1Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
  2. 2Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
  3. 3Department of Orthopedic Surgery, Rigshospitalet, Kobenhavn, Denmark
  1. Correspondence to Dr Kristin L Schreiber, Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA; klschreiber{at}bwh.harvard.edu

Abstract

Introduction Early diagnosis of acute extremity compartment syndrome is crucial to timely surgical management. Pain is commonly used as an early diagnostic sign for acute extremity compartment syndrome, making regional anesthesia after lower extremity surgery controversial. This randomized study tested whether different concentrations of local anesthetics, or combinations of nerve blocks, would differentially impact the perception of acute extremity compartment syndrome-like pressure and ischemic pain.

Methods Healthy volunteers underwent quantitative sensory testing, including determination of pressure pain thresholds and prolonged pressure/ischemic pain in the leg using a variable cuff inflation system. Subjects were randomized to receive (1) adductor canal block alone (ACB), (2) ACB with low-concentration sciatic nerve block (ACB +LC SNB), or (3) ACB with high-concentration SNB (ACB +HC SNB). For the primary outcome, we assessed block-induced increases in pressure threshold to reach 6/10 pain, and compared the degree of increase between the three groups. The main secondary outcome was a comparison of average pain score during a 5 min hold at the 6/10 pressure pain threshold between the three groups.

Results All blocks raised pressure pain threshold and decreased ischemic pain, but to variable extents. Specifically, the amount the block increased pressure pain threshold was significantly different among ACB, ACB+LC SNB, and ACB+HC SNB groups (mean±SD: 24±32 mm Hg, 120±103 mm Hg, 159±93 mm Hg; p=0.002), with post hoc testing revealing ACB as less than the other two groups. Similarly, average pain scores during a prolonged/ischemic cuff hold differed among the groups (4.2±1.4, 1.4±1.7, 0.4±0.7; p<0.001), with post hoc testing revealing ACB as significantly higher.

Discussion This study suggests the possible utility of titrating regional anesthesia, to provide some analgesia while still allowing acute extremity compartment syndrome detection.

Trial registration number NCT04113954.

  • pain perception
  • lower extremity
  • anesthesia, local
  • pain, postoperative
  • acute pain

Data availability statement

Data are available on reasonable request.

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Data availability statement

Data are available on reasonable request.

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Footnotes

  • Twitter @Jose_L_Zeballos

  • Contributors Y-YKC: funding acquisition, study conception and design, investigation, data collection, data curation, analysis and interpretation of results, draft manuscript preparation (writing—original draft and writing—review and editing), data visualization. PL: study conception and design, data collection, investigation, manuscript preparation (writing—original draft and writing—review and editing). KMF: study conception and design, data collection, data curation, analysis and interpretation of results, draft manuscript contribution (writing—original draft and writing—review and editing), data visualization. CAC: study conception and design, data collection, data curation, draft manuscript preparation (writing—review and editing). JMW: draft manuscript preparation (writing—original draft and writing—review and editing). JZ: study conception and design, draft manuscript preparation (writing—review and editing). AVK: draft manuscript preparation (writing—original draft and writing—review and editing). KEB: draft manuscript preparation (writing—review and Editing). KV: study conception and design, draft manuscript preparation (writing—original draft and writing—review and editing). KLS: study conception and design, investigation, data collection, analysis and interpretation of results, draft manuscript preparation (writing—original draft and writing—review and editing), supervision, guarantor.

  • Funding This study was supported by Brigham and Women’s Hospital Department of Anesthesiology, Perioperative and Pain Medicine Seed Grant.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.