compartment syndrome related to infusion therapy scott mckay, md texas children’s hospital baylor...
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Compartment Syndrome Related to Infusion
TherapyScott McKay, MD
Texas Children’s HospitalBaylor College of Medicine
Houston TX
Outline
• 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
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
• 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”
(2001). Journal of Pediatric Orthopedics, 21(5), 680–688.
• 3 A’s of Compartment Syndrome in children– Anxiety– Agitation– Increasing
Analgesia requirement
Compartment pressures
• So why not measure the compartment pressure?
30-35 mmHg
10-15mmHg
How high is too high?
• Absolute pressure >30mmHg
• Within 30mmHg of Diastolic pressure (ΔP)
• Within 20mmHg of Diastolic (ΔP)
• Within 30mmHg of MAP
The Journal of Trauma and Acute Care Surgery (2014) 76(2), 479–483. http://doi.org/10.1097/TA.0b013e3182aaa63e
• 48 tibial shaft fractures WITHOUT compartment syndrome
• 35% false positive rate (ΔP<30)• 22% absolute pressure >45mmHg
• 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.
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
• 20 healthy children (2m-6y) & 20 adults
• Absolute Pressures– 13-16mmHg in children– 5-9mmHg in adults
• 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 near-infrared 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
Infrared Near-infrared
Venous blood
Arterial blood
NIS device
StO2 = difference between oxygenated and deoxygenated blood
NIS uses
• 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
• 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