1 / 44

Compartment Syndrome Related to Infusion Therapy

Explore the pathophysiology, etiology, diagnosis, and treatment of compartment syndrome related to infusion therapy. Learn about tissue damage, symptoms, signs, and methods for measuring compartment pressure. Discover clinical insights on reliable early signs, pediatric considerations, and pressure measurement techniques.

lucillebean
Download Presentation

Compartment Syndrome Related to Infusion Therapy

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  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

More Related