buprenorphine and Compartment-Syndromes

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.. Case report.. 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.. 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.

Topics: Acetaminophen; Acute Pain; Analgesia, Patient-Controlled; Analgesics, Non-Narcotic; Analgesics, Opioid; Buprenorphine; Compartment Syndromes; Creatine Kinase; Drug Combinations; Glycogen Storage Disease Type V; Humans; Hydromorphone; Injections, Intramuscular; Male; Middle Aged; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Pain Measurement; Rhabdomyolysis

To retrospectively analyse injection drug users (IDUs) with complications after intra- or extra-vasal administration of dissolved tablets.. A retrospective study.. The hospital discharge registers were used to identify the patients admitted in different clinics in Helsinki University Central Hospital during 2000-2005. The patient demographics and social background were clarified. The type of the crushed drugs, the injection route and the timing of administration were registered. Medical interventions, examinations and surgical procedures were recorded.. Between January 2000 and December 2005, 24 patients had been treated on 30 occasions for manifestations caused by injecting crushed tablets. The main types of manifestations were acute limb ischaemia (16 patients) and infection (eight patients), and eight cases led to distal or proximal amputations. Men (19 of 24) were affected more frequently than were women (5 of 24). Their ages ranged between 20 and 39 years (mean: 26 years). All the patients had a previous history of intravenous drug abuse, and they lived in Greater Helsinki region. The incidence of seropositivity for hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV) was 33% (n=8), 88% (n=21) and 4% (n=1), respectively. The time between injection and presentation to the Emergency Department varied between 3h and 10 days (mean: 62 h). Buprenorphine was the most commonly used drug in 10 of the 24 patients, and benzodiazepine derivatives were also used in 11 of the 24 patients.. Intra- or extra-vasal administration of dissolved tablets leads to serious consequences, including limb amputations. Vascular and soft-tissue imaging may be helpful in the diagnosis. Prompt drainage of any abscess and fasciotomies for compartment syndrome treatment are essential. Controversy exists over the best medical therapy.

Topics: Adult; Amputation, Surgical; Anticoagulants; Benzodiazepines; Buprenorphine; Combined Modality Therapy; Communicable Diseases; Compartment Syndromes; Debridement; Drug Users; Embolectomy; Extremities; Fasciotomy; Female; Finland; Hospitals, University; Humans; Injections; Ischemia; Male; Retrospective Studies; Skin Transplantation; Solubility; Substance Abuse, Intravenous; Tablets; Time Factors; Treatment Outcome; Vasodilator Agents; Young Adult

Various kinds of neuromuscular manifestations are known with the recreational drugs. We report an interesting case of extensive myositis and fasciitis of thigh following an injection of a solution of Buprenorphine. The inflammatory process affected the sciatic and obturator nerve as well.

Topics: Adult; Buprenorphine; Compartment Syndromes; Fasciitis; Gait Disorders, Neurologic; Humans; Injections, Intramuscular; Magnetic Resonance Imaging; Male; Muscle, Skeletal; Myositis; Narcotics; Obturator Nerve; Opioid-Related Disorders; Sciatic Nerve; Sciatic Neuropathy; Thigh