Acute Pain Control Challenges with Buprenorphine/Naloxone Therapy in a Patient with Compartment Syndrome Secondary to McArdle's Disease: A Case Report and Review. Issue 8 (3rd May 2013)

• Record Type: Journal Article
• Authors: McCormick, Zachary; Chu, Samuel K.; Chang‐Chien, George C.; Joseph, Petra
• Is Part Of: Pain medicine. Volume 14:Issue 8(2013)
• Page Start: 1187
• Page End: 1191
• Publication Date: 2013-05-03
• Subjects: Pain -- Periodicals; Pain -- Treatment -- Periodicals; Analgesics -- Periodicals; Pain -- Periodicals; Pain Management -- Periodicals; Douleur -- Périodiques; Douleur -- Traitement -- Périodiques; Analgésiques -- Périodiques; Analgésique; Soulagement de la douleur; Périodique électronique (Descripteur de forme); Ressource Internet (Descripteur de forme); 616.047205
• DOI: 10.1111/pme.12135
• Languages: English
• ISSNs: 1526-2375

Abstract

<abstract abstract-type="main"> <title>Abstract</title> <sec id="pme12135-sec-0001" sec-type="section"> <title>Objective</title> <p>We report the first case of non‐iatrogentic exertional rhabdomyolysis leading to acute compartment syndrome in a patient with McArdle's disease. We describe considerations of concurrent buprenorphine/naloxone therapy during episodes of severe acute pain.</p> </sec> <sec id="pme12135-sec-0002" sec-type="section"> <title>Design</title> <p>Case report.</p> </sec> <sec id="pme12135-sec-0003" sec-type="section"> <title>Case Presentation</title> <p>A 50‐year‐old male with a history of McArdle's disease, taking buprenorphine/naloxone for chronic pain and opioid dependence, presented to the Emergency Department with severe bilateral anterior thigh pain. Over the following 8 hours, he was given a total of 12 mg of intravenous hydromorphone with minimal pain relief. The decision was made to initiate patient‐controlled analgesia (PCA) with hydromorphone started at 0.5 mg as needed with a 15‐minute lockout. Subsequently, the patient's anterior thighs were found to be extremely tense. His creatine kinase level rose to 198, 688 units/L and compartment pressures were greater than 90 mm Hg bilaterally. The patient was taken for emergent bilateral fasciotomies. The hydromorphone PCA was increased to 0.8 mg as needed with a 15‐minute lockout and a basal rate of 0.5 mg/h. The patient's reported pain plateaued at 3/10 intensity 2 days after surgery, and he was transitioned to oxycodone and hydrocodone/acetaminophen. He followed up with his pain management physician 2 months later who restarted suboxone and a buphrenorphine transdermal patch.</p> </sec> <sec id="pme12135-sec-0004" sec-type="section"> <title>Discussion</title> <p>Buprenorphine/naloxone is being prescribed off‐label with increasing frequency for pain management in patients with or without a history of opioid abuse. Severe acute pain is more difficult to control with opioid analgesics in patients taking buprenorphine/naloxone, requiring higher than usual doses. If buprenorphine/naloxone is discontinued to better treat acute pain with other opioids, monitoring for overdose must take place for at least 72 hours.</p> </sec> </abstract>