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