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Compartment Syndrome Related to Infusion Therapy

Compartment Syndrome Related to Infusion Therapy. Scott McKay, MD Texas Children’s Hospital Baylor College of Medicine Houston TX. Outline. Pathophysiology Etiology Diagnosis Treatment. Definition.

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Compartment Syndrome Related to Infusion Therapy

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  1. Compartment Syndrome Related to Infusion Therapy Scott McKay, MD Texas Children’s Hospital Baylor College of Medicine Houston TX

  2. Outline • Pathophysiology • Etiology • Diagnosis • Treatment

  3. Definition • Tissue necrosis in a muscular compartment resulting from increased intra-compartment pressure

  4. 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.

  5. Anatomy – lower leg • 4 major compartments • Vessels • Nerves • Muscles • Subcutaneous space is separate from muscle compartment

  6. Anoxic positive feedback loop

  7. Arteriovenous gradient • Compartment syndrome is higher resistance system • Blood preferentially flows towards lower resistance systems

  8. Tissue Damage • Nerves • 1 hour to reversible damage • 4-6 hours irreversible damage • Muscle • Reversible up to 6-8 hours

  9. Etiology • Tissue trauma • Ischemia/reperfusion • Post vascular repair/injury • Compression • Chemical tissue damage

  10. Trauma • Fractures • Elbow, forearm, tibia • Crush injuries • Falls, ATV, MVA, industrial accidents, earthquakes

  11. Chemical Tissue Damage • Burns • Bites • Medication extravasation

  12. External compression • Intoxication/overdose “found down” • Tight casts/splints/dressings • IV fluid infiltration

  13. Ann Plast Surg 2011;67: 531–533

  14. 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

  15. Ischemia/Reperfusion • 4 year old girl fell from playground equipment • Pulseless supracondylar humerus fracture • Fracture fixation, vascular reconstruction, prophylactic compartment release

  16. Excellent outcome

  17. 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

  18. DO NOT USE 5 P’s! • Pallor • Pulselessness • Paralysis • Pain • Paresthesias • These are signs of severely decreased perfusion, not unique to compartment syndrome

  19. 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.

  20. 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

  21. The 3 As • Children not little adults • “Anxiety, Agitation, increasing Analgesia requirement”

  22. 3 A’s of Compartment Syndrome in children • Anxiety • Agitation • Increasing Analgesia requirement (2001). Journal of Pediatric Orthopedics, 21(5), 680–688.

  23. Compartment pressures • So why not measure the compartment pressure? 30-35 mmHg 10-15 mmHg

  24. How high is too high? • Absolute pressure >30mmHg • Within 30mmHg of Diastolic pressure (ΔP) • Within 20mmHg of Diastolic (ΔP) • Within 30mmHg of MAP

  25. 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

  26. 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.

  27. 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

  28. 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

  29. 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

  30. Most common method • Kit with clear directions • Found in OR and ER • Orthopaedic Surgeons are the most familiar

  31. Or use older manometer

  32. Or, just use arterial line set-up

  33. 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.

  34. Calculates end-organ tissue perfusion NIS device Infrared Near-infrared Venous blood Arterial blood StO2 = difference between oxygenated and deoxygenated blood

  35. NIS uses • Shock patients • Subarachnoid hemorrhage • Cerebral monitoring during CV surgery • Stroke management • Compartment Pressure monitoring • * readings affected by hematomas and subcutaneous fluid collections*

  36. Treatment • Nonsurgical • Remove Tight dressings • Elevation ????? • Stop infusions • Supplemental O2 • Surgical treatment • fasciotomy

  37. Surgery • Emergent fasciotomy • Delayed closure • +/- Skin graft

  38. Factors to predict outcome • Early diagnosis and treatment • Severity of inciting event • Skin graft or primary closure? • Rhabdomyolysis causing kidney failure

  39. (2011). The Journal of Bone and Joint Surgery. American Volume, 93(10), 937–941. http://doi.org/10.2106/JBJS.J.00285

  40. 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

  41. 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

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