The Rehabilitation Institute of Chicago/Northwestern McGaw Medical Center, Department of Physical Medicine and Rehabilitation, Chicago, Illinois, USA.
Pain Med. 2013 Aug;14(8):1187-91. doi: 10.1111/pme.12135. Epub 2013 May 3.
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.
我们报告首例非医源性运动性横纹肌溶解症导致 McArdle 病患者急性间隔综合征。我们描述了在严重急性疼痛发作期间同时使用丁丙诺啡/纳洛酮治疗的注意事项。
病例报告。
一名 50 岁男性，患有 McArdle 病，因慢性疼痛和阿片类药物依赖服用丁丙诺啡/纳洛酮，因严重双侧大腿前疼痛到急诊科就诊。在接下来的 8 小时内，他总共接受了 12 毫克静脉注射氢吗啡酮，但疼痛缓解甚微。决定开始使用氢吗啡酮患者自控镇痛（PCA），初始剂量为 0.5 毫克，按需给药，锁定时间为 15 分钟。随后，发现患者的大腿前侧非常紧张。他的肌酸激酶水平上升至 198688 单位/升，双侧间隔压力均大于 90 毫米汞柱。患者接受紧急双侧筋膜切开术。将氢吗啡酮 PCA 增加至 0.8 毫克，按需给药，锁定时间为 15 分钟，基础剂量为 0.5 毫克/小时。手术后 2 天，患者自述疼痛强度稳定在 3/10 级，随后转为使用羟考酮和氢可酮/对乙酰氨基酚。2 个月后，他到疼痛管理医生处就诊，医生重新开始使用丁丙诺啡和布非那韦透皮贴剂。
丁丙诺啡/纳洛酮越来越多地被开处方用于治疗有或没有阿片类药物滥用史的患者的疼痛管理。服用丁丙诺啡/纳洛酮的患者在出现严重急性疼痛时，用阿片类镇痛药更难控制，需要更高的剂量。如果为了更好地用其他阿片类药物治疗急性疼痛而停用丁丙诺啡/纳洛酮，则必须至少监测 72 小时，以防出现药物过量。
