In reply: Concerns regarding ‘Regional anesthesia and acute compartment syndrome: principles for practice’

We thank Drs. Vecchione and Boretsky for their comments on our recent manuscript discussing the suitability of regional anesthesia (RA) for common orthopedic injuries and procedures that may be associated with acute compartment syndrome (ACS). Although our manuscript did not specifically aim to address the use of RA in pediatric patients at risk of ACS, we agree with Drs. Vecchione and Boretsky that the diagnosis of ACS can be more challenging in young children. Missed ACS is a devastating injury that can result in limbs that are absent of function and leave both adults and children alike permanently disabled for life. A significant percentage of ACS injuries culminate in amputation. As has been widely expressed in the literature, diagnosing ACS can be difficult; it requires a high degree of clinical suspicion and recognition that certain injuries have a greater potential to cause ACS. Vigilant clinicians caring for children must anticipate and recognize the three As of pediatric compartment syndrome: agitation, anxiety and increasing analgesic requirements, which can precede the classic presentation of disproportionate pain. It stands to reason that a sensory block, however partial or mild, can potentially mask each of these three As. We acknowledge that some specialized centers, such as the ones at which Drs. Vecchione and Boretsky work, may have the clinical and logistical expertise to effectively manage a RA program for children who are at high risk of ACS. We nonetheless urge caution regarding the use of RA in highrisk clinical situations and discussion with the orthopedic surgeons who are ultimately charged with the diagnosis and treatment of ACS to save the limb and potentially life of these patients.