 |
 |
 |
|
| home | CME | help | feedback | subscriptions | archive |
|
© 1997 The Journal of Bone and Joint Surgery, Inc.
CorrespondenceTO THE EDITOR: Price et al., in "Compartment Syndromes Associated with Postoperative Epidural Analgesia. A Case Report" (78-A: 597–599, April 1996), reported on a sixteen-year-old boy with hypophosphatemic rickets in whom a compartment syndrome developed after bilateral corrective osteotomy. Price et al. believed that the epidural analgesia masked the symptoms of the compartment syndrome. We believe that this conclusion is in error for the following reasons. First, the postoperative pain was treated with an epidural infusion of fentanyl. The authors, however, did not report either the dosage utilized for the infusion or the size of the patient. Second, drugs that may alter sympathetic tone or blood flow to the extremity, or both, when given in the epidural space were mentioned in the Discussion; however, none of the drugs mentioned are pharmacologically similar to fentanyl. Finally, it was suggested that fentanyl may act more like meperidine than morphine to produce alterations in blood flow in a limb at rest. This is a completely unfounded hypothesis. Contrary to the authors' allegations, the epidural analgesia did not completely mask the classic symptoms of compartment syndrome. The patient had paresthesias. A patient who has paresthesias after an osteotomy should be evaluated first for compartment syndrome, given the devastating implications of the condition. All patients should have appropriate monitoring, such as neurovascular checks of the extremity, to prevent postoperative nerve damage. No mention was made of neurological monitoring, which might have indicated the onset of compartment syndrome if the monitoring had been performed correctly. The authors stated that "paresthesias were attributed to the epidural analgesia," but fentanyl does not cause paresthesias in the epidural space. It is not a local anesthetic. The authors did not say why the patient was uncomfortable or describe the nature of the discomfort. They said only that the patient did not request pain medication, which is different than not having pain. The analgesia rendered by fentanyl administered in the epidural space is equivalent to that provided by the same dose administered intravenously; the blood levels of fentanyl are not substantially different between these two modes of administration1,4. Therefore, at reasonable doses, fentanyl in the epidural space is not capable of producing decrements in sensation that are greater than those produced by narcotics administered intravenously. All caregivers should familiarize themselves with the pharmacology of perioperative drugs, and nursing personnel should be provided with parameters regarding which signs and symptoms should be reported to the anesthesiologist. If the epidural catheter or the drug infusate physically placed pressure on a nerve structure in the patient described by Price et al., the paresthesias could have been due to the epidural treatment. However, in this case, the infusion should have been stopped and the anesthesiologist should have been notified immediately. In the final paragraph, Price et al. stated, "when epidural analgesia is used [after corrective osteotomies of the long bones], the surgeon should be aware that the classic symptoms of compartment syndrome may be masked." If this is true, it would be unreasonable for any surgeon to take that risk. This statement is tantamount to suggesting that epidural analgesia should never be used after this type of operation. Such a conclusion is not justified by either the brief review of the literature provided in the Discussion or the case that they present. We are concerned that case reports used to support conclusions without factual foundation may result in unfavorable alterations in the care of patients.
Michael L. Schmitz, M.D.; Raeford E. Brown, Jr., M.D.; JoAnne M. Stoner, M.D.; J. Michael Vollers, M.D.: Division of Pediatric Anesthesiology and Pain Management, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, 800 Marshall Street, S-319, Little Rock, Arkansas 72202-3591
Dr. Price, Dr. Ribeiro, and Dr. Kinnebrew reply: It is unusual for an orthopaedic case report to stimulate a scientific rebuttal from an entire division of pediatric anesthesiologists. It would not be prudent for us to argue with them about the neuropharmacology of epidural analgesia. Therefore, we accept their criticism that fentanyl cannot be compared to opioids and does not cause paresthesias. One purpose of our case report was to suggest the possibility that epidural analgesia contributed to the development of compartment syndrome. Perhaps this case report will stimulate more rigorous and dependable scientific investigation. An increased frequency of compartment syndrome and peroneal nerve palsy has been reported following epidural analgesia2,3. Theoretical scientific debate must address this reality. Finally, it is known that pain is, without a doubt, the primary harbinger of compartment syndrome. Epidural analgesia masks this most important symptom and obscures the early diagnosis of compartment syndrome. To argue otherwise is ludicrous.
Charles T. Price, M.D.: 89 West Copeland Avenue, Orlando, Florida 32806
John Ribeiro, M.D.: Department of Orthopaedics, 3024, 12021 South Wilmington Avenue, Los Angeles, California 90059
Todd Kinnebrew, M.D.: 4660 Riverside Park Boulevard, Macon, Georgia 31210
References
  CiteULike  Connotea  Del.icio.us  Facebook  Technorati  Twitter What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| home | CME | help | feedback | subscriptions | archive | site index |
|
Stanford University Libraries' HighWire Press (TM) assists in the publication of JBJS Online. |