Transcript Presentation Title

Compartment Syndrome Related
to Infusion Therapy
Scott McKay, MD
Texas Children’s Hospital
Baylor College of Medicine
Houston TX
Outline
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Pathophysiology
Etiology
Diagnosis
Treatment
Definition
• Tissue necrosis in a muscular
compartment resulting from increased
intra-compartment pressure
Pathophysiology
• Certain muscles are bounded by rigid
fascial linings
• Fascia cannot expand to accommodate
increased tissue pressure.
• Sustained increased pressure leads to
irreversible tissue damage.
Anatomy – lower leg
• 4 major
compartments
– Vessels
– Nerves
– Muscles
• Subcutaneous
space is separate
from muscle
compartment
Anoxic positive feedback loop
Increased
interstitial
pressure
Interstitial
edema
Cellular
ischemi
a
Venule
compression
Increased
vascular
resistance
Blood
shunted
away
from
system
Arteriovenous gradient
• Compartment
syndrome is higher
resistance system
• Blood preferentially
flows towards lower
resistance systems
Tissue Damage
• Nerves
– 1 hour to reversible
damage
– 4-6 hours irreversible
damage
• Muscle
– Reversible up to 6-8
hours
Etiology
• Tissue trauma
• Ischemia/reperfusion
– Post vascular repair/injury
• Compression
• Chemical tissue damage
Trauma
• Fractures
– Elbow, forearm, tibia
• Crush injuries
– Falls, ATV, MVA, industrial accidents,
earthquakes
Chemical Tissue Damage
• Burns
• Bites
• Medication extravasation
External compression
• Intoxication/overdose “found down”
• Tight casts/splints/dressings
• IV fluid infiltration
Ann Plast Surg 2011;67: 531–533
Infusion Extravasation/infiltration
• More common in pediatric patients
– 11% overall, 28% in ICU patients.
– Random one-day audit of Children’s
Boston showed 4% of PIV infiltration
• Smaller, fragile veins
• Smaller catheters = higher velocity
Ischemia/Reperfusion
• 4 year old girl fell from
playground equipment
• Pulseless
supracondylar
humerus fracture
• Fracture fixation,
vascular
reconstruction,
prophylactic
compartment release
Excellent outcome
Diagnosis
• Clinical diagnosis
• NOT lab/x-ray/MRI diagnosis
• Signs:
– #1 pain out of proportion
– #2 pain out of proportion
– #3 pain out of proportion
DO NOT USE 5 P’s!
• Pallor
• Pulselessness
• Paralysis
• Pain
• Paresthesias
• These are signs
of severely
decreased
perfusion, not
unique to
compartment
syndrome
Reliable Early Signs
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Pain out of proportion
Pain with passive stretch of muscles
Pain with muscle activation
Abnormal sensation in compartment
nerves
J Hand Surg Am 2011;36(3):535-543.
Not as reliable
• “Firm” or “Tense” compartments
• “Paralysis”
– Due to pain or guarding? Or true paralysis
J Bone Joint Surg Am 2010;92(2):361-367
The 3 As
• Children not little adults
• “Anxiety, Agitation, increasing Analgesia
requirement”
• 3 A’s of
Compartment
Syndrome in
children
– Anxiety
– Agitation
– Increasing
Analgesia
requirement
(2001). Journal of Pediatric Orthopedics,
21(5), 680–688.
Compartment pressures
• So why not measure the compartment
pressure?
30-35
mmHg
10-15
mmHg
How high is too high?
• Absolute pressure >30mmHg
• Within 30mmHg of Diastolic pressure
(ΔP)
• Within 20mmHg of Diastolic (ΔP)
• Within 30mmHg of MAP
• 48 tibial shaft fractures WITHOUT compartment
syndrome
• 35% false positive rate (ΔP<30)
• 22% absolute pressure >45mmHg
The Journal of Trauma and Acute Care Surgery
(2014) 76(2), 479–483.
http://doi.org/10.1097/TA.0b013e3182aaa63e
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30 kids with possible compartment syndrome
27/30 snake bites (avg age 8)
MAP – Compartment pressure ≥ 30 observed
MAP – Compartment pressure ≤ 30
fasciotomy
• “All patients did well”
(1998) Injury, 29(3), 183–185.
• 20 healthy children (2m-6y) & 20 adults
• Absolute Pressures
– 13-16mmHg in children
– 5-9mmHg in adults
Staudt, J. M., Smeulders, M. J. C., & van der Horst, C. M. A. M.
(2008). Journal of Bone and Joint Surgery - British Volume, 90(2),
215–219. http://doi.org/10.1302/0301-620X.90B2.19678
• 48% used clinical diagnosis alone
• 52% used clinical diagnosis +
compartment pressure measurements
(2011). Compartment syndrome of the forearm: a
systematic review. The Journal of Hand Surgery,
36(3), 535–543.
http://doi.org/10.1016/j.jhsa.2010.12.007
How is pressure measured?
Staudt, J. M., Smeulders, M. J. C., & van der Horst, C. M. A. M. (2008).
Normal compartment pressures of the lower leg in children. Journal of
Bone and Joint Surgery - British Volume, 90(2), 215–219.
http://doi.org/10.1302/0301-620X.90B2.19678
Most common method
• Kit with clear
directions
• Found in OR and ER
• Orthopaedic
Surgeons are the
most familiar
Or use older manometer
Or, just use arterial line set-up
Near-infrared spectroscopy
• Pulse-oximeter
principles
• Uses combination of
reflected nearinfrared and infrared
light
• Calculates tissue
perfusion ≈ 3cm
Near infrared spectroscopy: clinical and research uses. (2013). Near infrared
spectroscopy: clinical and research uses. Transfusion, 53 Suppl 1, 52S–58S.
Calculates end-organ tissue perfusion
NIS device
Infrared
Near-infrared
Venous blood
Arterial blood
StO2 = difference between oxygenated and deoxygenated blood
NIS uses
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Shock patients
Subarachnoid hemorrhage
Cerebral monitoring during CV surgery
Stroke management
Compartment Pressure monitoring
– * readings affected by hematomas and
subcutaneous fluid collections*
Treatment
• Nonsurgical
– Remove Tight dressings
– Elevation ?????
– Stop infusions
– Supplemental O2
• Surgical treatment
– fasciotomy
Surgery
• Emergent
fasciotomy
• Delayed closure
• +/- Skin graft
Factors to predict outcome
• Early diagnosis and treatment
• Severity of inciting event
• Skin graft or primary closure?
• Rhabdomyolysis causing kidney failure
(2011). The Journal of Bone and Joint Surgery. American
Volume, 93(10), 937–941.
http://doi.org/10.2106/JBJS.J.00285
Complications/sequelae
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ROM deficits in adjacent joints
Toe & ankle weakness
Claw toes
Limp
Sensation deficits
Complex regional pain syndrome
Chronic swelling
Chronic infection
Need for further reconstructive surgery
Conclusions
• Compartment syndrome requires timely
diagnosis and treatment
• Excessive pain is best clinical sign
• Diagnosis is more difficult in children
• Outcomes are generally good with
appropriate treatment
• Nurses are essential to timely diagnosis
and treatment