title: Compartment syndrome in a patient treated with perineural liposomal bupivacaine (Exparel).
abstract: Acute compartment syndrome is a condition that may result in sensorimotor deficits and loss of function of the affected limb as a result of ischemic injury. It is considered a surgical emergency and prompt diagnosis and treatment results in more favorable outcomes. The use of regional anesthesia is controversial in patients at risk for compartment syndrome due to concern of its potential to mask symptoms of the condition. A 44-year-old African American male presented to surgery for open reduction and internal fixation of a comminuted distal radius fracture. As part of an off-label, investigator-initiated, and institutional review board-approved study, he received a perineural injection of liposomal bupivacaine (Exparel) around the median, ulnar, and radial nerves at the level of the proximal forearm. The following morning, his initial complaints of numbness and incisional pain progressively evolved into worsening numbness, diffuse discomfort, and pain with passive movement. A diagnosis of compartment syndrome was made and he underwent an emergency fasciotomy. The diagnosis of compartment syndrome requires a high index of suspicion and prompt treatment. This patient's changing pattern of symptoms-rather than his pain complaints alone-resulted in the diagnosis of compartment syndrome treated with emergent fasciotomy in spite of finger numbness that was initially attributed to the liposomal bupivacaine. While the use of liposomal bupivacaine did not preclude the diagnosis of compartment syndrome in our patient, it should be used with caution in patients at risk for compartment syndrome until additional data, particularly regarding block characteristics, are available.
authors.affiliation: Department of Anesthesiology, Ochsner Clinic Foundation, New Orleans, LA. Electronic address: jsoberon@ochsner.org.
authors.forename: José Raul
authors.initials: JR
authors.lastname: Soberón
authors.affiliation: Department of Orthopedic Surgery, Ochsner Clinic Foundation, New Orleans, LA.
authors.forename: Leslie E
authors.initials: LE
authors.lastname: Sisco-Wise
authors.affiliation: Department of Orthopedic Surgery, Ochsner Clinic Foundation, New Orleans, LA.
authors.forename: Ross M
authors.initials: RM
authors.lastname: Dunbar
mesh_terms: D000208:Acute Disease; D000328:Adult; D000779:Anesthetics, Local / Q000008:administration & dosage / Q000009:adverse effects*; D002045:Bupivacaine / Q000008:administration & dosage / Q000009:adverse effects*; D003161:Compartment Syndromes / Q000139:chemically induced* / Q000175:diagnosis; D004337:Drug Carriers; D006801:Humans; D008081:Liposomes; D008297:Male; D009407:Nerve Block / Q000009:adverse effects* / Q000379:methods; D011885:Radius Fractures / Q000601:surgery
chemical_list: D000779:Anesthetics, Local; D004337:Drug Carriers; D008081:Liposomes; D002045:Bupivacaine
keywords: Compartment syndrome; Distal radius fracture; Liposomal bupivacaine (or) Exparel; Nerve block(s); Regional anesthesia