Authors: Fritsch G M et al.
Source: Anesthesiology, January 2026;
Summary:
Acute compartment syndrome (ACS) is a limb-threatening condition traditionally associated with elevated compartment pressures, ischemia, and progressive muscle necrosis. The role of regional anesthesia (RA) in this setting remains controversial, largely due to concerns that sensory blockade could mask symptoms or worsen ischemic injury. In this controlled porcine model, investigators evaluated whether continuous ropivacaine-based regional anesthesia alters compartment pressure, systemic physiology, biochemical markers of injury, and histopathologic muscle damage following experimentally induced ACS.
Twenty male pigs underwent induction of ACS in the tibialis anterior compartment via angioplasty balloon inflation and were randomized to receive either continuous ropivacaine 0.2% or placebo through a regional catheter. Compartment pressures and mean arterial pressure were continuously monitored, while serial plasma and interstitial fluid samples were collected to measure creatine kinase, lactate, lactate dehydrogenase, and glucose. Muscle tissue was examined histologically at the end of the observation period.
Despite significantly higher compartment pressures in the ropivacaine group at the end of the experiment, systemic hemodynamics and plasma markers of muscle injury were not different between groups. Importantly, interstitial fluid analysis revealed substantially lower concentrations of lactate dehydrogenase and glucose in ropivacaine-treated tissue, suggesting reduced local metabolic distress. Histopathologic evaluation corroborated these biochemical findings, demonstrating less muscle fiber degeneration and necrosis in the ropivacaine group when assessed in a blinded fashion.
These results indicate that ropivacaine-based regional anesthesia may exert local muscle-protective effects during ACS, even in the presence of elevated compartment pressures. The authors propose that modulation of regional metabolism and microcirculatory processes may contribute to this protective profile. While the findings do not eliminate concerns regarding diagnosis or monitoring of ACS in clinical practice, they challenge the assumption that regional anesthesia is inherently harmful in this context and support further clinical investigation.
Key Points:
• In a porcine model of acute compartment syndrome, ropivacaine-based regional anesthesia increased compartment pressure but did not worsen systemic perfusion.
• Regional metabolic markers and histopathology showed reduced muscle injury despite higher pressures.
• Plasma biomarkers did not reliably reflect local tissue injury compared with interstitial sampling.
• These findings suggest a potential muscle-protective effect of regional anesthesia in ACS that warrants cautious clinical exploration.
Thank you to Anesthesiology for allowing us to summarize and discuss this important experimental work.