Guidelines for Regional Anesthesia and Risk of Compartment Syndrome

Identification and Monitoring of At-Risk Patients

Patients at risk of acute compartment syndrome (ACS) should be identified on admission to hospital or at the time of surgery, and managed within agreed, multidisciplinary protocols 3
Post-injury and postoperative ward observations should be performed at set frequencies by healthcare staff trained in the pathology and recognition of ACS 3
The use of objective scoring charts, such as those provided by the UK's Royal College of Nursing, is recommended to maintain heightened awareness of ACS among healthcare workers 4, 5

Clinical signs alone have relatively low sensitivity and positive predictive value for diagnosing ACS, while their specificity and negative predictive value are high 4, 6
The presence of multiple clinical signs increases the likelihood of correct ACS diagnosis, with severe pain and pain on passive stretch together having a positive predictive value of 68% 5
Pain, pain on passive stretch, and paralysis together have a predictive value of 93% (though paralysis is a late sign indicating likely irreversible muscle ischemia) 5
Direct measurement of intracompartmental pressure is indicated when the diagnosis remains in doubt, the patient is obtunded, confused, or uncooperative, or serial clinical examination is not reliable 6, 7
Fasciotomy should be performed when tissue pressure increases to within 10-30 mmHg of the diastolic pressure in a patient with other signs or symptoms of ACS 6

All patients who have suffered trauma or undergone surgery should be offered effective analgesia 3
Dense neuraxial or peripheral nerve blockade that extends significantly into the postoperative period should be avoided in patients at risk of ACS 8, 9
Single-shot or continuous peripheral nerve blocks using lower concentrations of local anesthetic without adjuncts are not associated with delays in ACS diagnosis when appropriate surveillance is maintained 8, 9

In children, ACS presents unique challenges as younger patients may have difficulty articulating symptoms, and the "three As" approach (anxiety, agitation, analgesic requirement) has been suggested for diagnosing ACS in children 8
Age is an important predictor for ACS development, with children aged 12-19 years having a high prevalence after tibial fracture 9

Relying solely on clinical signs may lead to missed or delayed diagnosis of ACS 6
Late signs of ACS (loss of pulse, paralysis, pallor, decreased temperature) indicate significant disruption to limb vascularity and viability 4
Using an 18-G needle for compartment pressure measurement may overestimate pressure by up to 18 mmHg compared with a slit catheter or side-ported needle 6