**6. Special problems**

#### **6.1. Compartment syndrome**

Compartment syndrome is the most dreaded complication following a limb trauma. Acute compartment syndrome commonly occurs following forearm and leg fractures in young adults less than 35 years of age. Who has more tissue mass. Acute trauma leads edema of injured tissues, due to closed osteofacial compartment in forearm and leg, increased pressure following tissue swelling causes collapse of arterioles and capillaries, which leads to cessation of circulation and tissue hypoxia. Following tissue hypoxia inflammatory mediators will be released leading to increased vascular permeability and worsening tissue edema. Regional anesthesia and peripheral nerve blocks provide excellent perioperative analgesia, but few clinicians fear an anesthetized limb may delay the diagnosis of acute compartment syndrome by masking symptoms due to regional block. However, sensitivity of these subjective symptoms is less than 20% [11, 12].

There are only five case reports of compartment syndrome following peripheral nerve blocks. At present, it is difficult to make direct correlation peripheral nerve blocks to compartment syndrome. The use of lower concentration of local anesthetics, intermittent analgesic, measuring compartment pressure in high-risk patients, limb elevation and careful monitoring are key for early diagnosis and prompt treatment.

#### **6.2. Preexisting nerve injury**

Regional anesthesia for hip fractures is associated with less delirium and better analgesia. For lower leg injuries, sciatic nerve block by parasacral, mid sciatic or popliteal approach facilitate superior analgesia. Ankle blocks are almost replaced by popliteal nerve block with saphenous

Careful risk–benefit analysis must be used while considering RA techniques. Circumstances where RA is not appropriate include: the debate on whether peripheral blocks are safer when performed on awake or anesthetized patients is unresolved. Available evidence is low-level and conflicting and expert opinion is divergent. Regional anesthesia in sedated patients hide presentation of complications associated with RA like intraneural injections and local anes-

Compartment syndrome is the most dreaded complication following a limb trauma. Acute compartment syndrome commonly occurs following forearm and leg fractures in young

**Options for pain management in lower limb include the following:**

• Peripheral nerves (e.g. femoral sciatic, saphenous, and obturator)

**Regional anesthesia is contraindicated in the following situations:**

• Trauma victims with hemorrhagic shock and threatened airway

• Raised intracranial pressure (for neuraxial blocks)

• Lack of appropriate training, equipment, and care bundles

• Patient refusal for regional anesthesia

**5. Limitations of regional anesthesia in trauma**

nerve block to allow surgery to the foot.

96 Anesthesia Topics for Plastic and Reconstructive Surgery

• Compartment blocks (e.g. fascia iliac)

• Lumbar epidural

thetic toxicity.

• Traumatic brain injury

**6. Special problems**

**6.1. Compartment syndrome**

• Coagulopathy

• Allergy to LA

• Subarachnoid block

• Lumbar/sacral plexus block

The "double crush syndrome" proposes that patients with pre-existing nerve lesions are more susceptible to further injury when exposed to a secondary insult. Preexisting nerve injury in trauma victims may be exacerbated by nerve blocks, either by direct damaging nerve or due to local anesthetic induced neuronal toxicity, although the evidence of neuronal injury due to PNB is unequivocal.

Careful neurological assessment risk stratification and usage of ultrasonography for peripheral nerve blocks will substantially reduce direct nerve injury. Usage of USG during peripheral nerve blocks allows low volume and concentration of LA by precisely localizing neuronal structures, and this reduces the incidence of neuronal injury [13].

#### **6.3. Anticoagulation**

Trauma victims with multiple injuries predisposes to coagulopathy, this may be exacerbated by massive blood transfusion, hypothermia, medications and disseminated intravascular coagulation. Risk depends on the patient, mechanism of injury and medicines. In acute phase hypothermia and hemorrhage may lead to a coagulopathy. Best way is to individually weigh risk against the benefit of RA in trauma patients with coagulation abnormalities [14]. If the RA is chosen for the patients with coagulation abnormalities, extreme vigilance and monitoring for eventual side effects is mandatory.

Recommendations for performing RA should be done according to latest American Society of Regional Anesthesia and Pain Medicine guidelines [15]. Spinal and epidural anesthesia in patients the coagulopathy poses greater risk than peripheral nerve blocks since hemorrhage into the central neuraxis causes more disastrous complication. Thromboprophylaxis in trauma victims could contraindicate usage of neuraxial block. Choosing appropriate anticoagulation schedules and usage of ultrasonography for regional anesthesia provides the safer option in anticoagulated patients.

Recent advances in point-of-care coagulation testing like thromboelastography provide rapid, objective assessment of hemostatic function. This may be used before interventions, to detect type of coagulopathy and to administer specific coagulation factors.

**Thanks**

**Author details**

**References**

Shivakumar M. Channabasappa

Shimoga, Karnataka, India

bjaceaccp/mkt048

DOI: 10.1097/TA.0000000000000188

I would like to thank my wife Dr. Shruthi for her support in preparing this chapter.

Regional Anesthesia for Urgent Reconstructive Surgery http://dx.doi.org/10.5772/intechopen.80647 99

Department of Anesthesiology and Critical Care, Subbaiah Institute of Medical Sciences,

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Address all correspondence to: drshivakumar.m.c@gmail.com

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#### **6.4. Chronic pain**

Chronic pain is more common following trauma than often realized, inadequate management of acute pain increases the risk of development of chronic pain syndrome. It may be due to nociceptive pain or often include a neuropathic component, which can be difficult to treat. There are several pain syndromes such as complex regional pain syndrome (CRPS), postamputation pain, and posttraumatic stress disorder which are specifically associated with trauma.

Early, effective and sustained analgesia and usage of peripheral nerve blocks after injury decreases the incidence and severity of chronic pain syndromes. Administration of low and therapeutic doses of antidepressants, oral ketamine and gabapentin should be considered for persistent pain [16, 17].
