What are the guidelines for using regional anesthesia in orthopedic trauma surgery?

Guidelines for Regional Anesthesia in Orthopedic Trauma

Single-shot or continuous peripheral nerve blocks using lower concentrations of local anesthetic drugs without adjuncts are recommended for orthopedic trauma surgery, as they provide effective analgesia without delaying diagnosis of acute compartment syndrome (ACS) when appropriate post-injury and postoperative surveillance is used. 1

Key Recommendations for Regional Anesthesia in Orthopedic Trauma

Patient Selection and Risk Assessment

• Regional anesthesia should be considered a fundamental right for pain relief in trauma patients, as supported by the Declaration of Montreal 1
• Patient evaluation should include:
  • Neurological assessment
  • Pulmonary assessment
  • Cardiovascular assessment
  • Hematological assessment 2

Technique Selection for Lower Limb Trauma

1. For patients at risk of ACS (particularly tibial fractures):

   • Use low concentration local anesthetic solutions without adjuncts for peripheral nerve blocks 1
   • This approach preserves some sensation and movement while allowing for breakthrough pain 1
   • Avoid dense, long-duration blocks that significantly exceed the duration of surgery 1

2. Lower extremity block options:

   • Femoral nerve block
   • Saphenous nerve block
   • Sciatic nerve block
   • iPACK block
   • Ankle block
   • Lumbar plexus block 2

Multimodal Analgesia Approach

• Regional anesthesia should be part of a multimodal strategy including:
  • Paracetamol/acetaminophen
  • NSAIDs (if not contraindicated)
  • Opioids (as adjuncts)
  • Other adjuvant medications 1, 3

Monitoring and Safety Considerations

• Ultrasound guidance should be used for all regional anesthesia procedures to improve efficacy and minimize complications 2
• LAST (Local Anesthetic Systemic Toxicity) treatment guidelines and rescue medications (intralipid) must be readily available during administration 2
• Implement appropriate post-injury and postoperative surveillance for patients at risk of ACS 1

Special Considerations for Acute Compartment Syndrome Risk

Risk Stratification

• High-risk injuries include:
  • Tibial fractures
  • High-energy penetrating injuries involving bone and soft tissue
  • Battlefield injuries and similar civilian trauma (gunshot wounds, terror-related bombings) 1

Balancing Analgesia and Diagnosis

• Pain is not always a reliable feature of ACS 1
• Military experience shows successful use of continuous peripheral nerve analgesia with low-dose local anesthetic solutions in high-energy injuries at risk of ACS 1
• Education of medical teams on injury patterns and team-based care can reduce adverse events like missed ACS 1

Consent and Shared Decision-Making

• The choice of analgesia belongs to the patient with capacity 1
• Patients should be given treatment options based on an open discussion of risks and benefits 1
• For patients lacking capacity, appropriate consent should be sought from legal guardians when possible 1

Implementation Pitfalls and Caveats

1. Avoid these common mistakes:

   • Using high concentrations of local anesthetics that cause dense sensory and motor blockade in patients at risk for ACS
   • Adding adjuncts to local anesthetics that prolong block duration excessively
   • Failing to implement appropriate post-block monitoring protocols

2. Team communication:

   • Consensus between surgeon and anesthetist is ideal, but the anesthetist as pain expert should have final authority on analgesic techniques 1
   • Document discussions about analgesic choices and patient consent 1

3. Training considerations:

   • Team-based training similar to military models (like MOSTT) can improve outcomes 1
   • Familiarity with regional techniques among all staff caring for trauma patients is essential 1

Regional anesthesia is an integral component of successful orthopedic trauma care that provides quality analgesia while minimizing systemic complications when properly implemented 2, 4. The evidence strongly supports that with appropriate technique selection and monitoring, regional anesthesia can be safely used even in patients at risk for compartment syndrome.