compartment syndrome related to infusion therapy scott mckay, md texas children’s hospital baylor...
TRANSCRIPT
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Compartment Syndrome Related to Infusion
TherapyScott McKay, MD
Texas Children’s HospitalBaylor College of Medicine
Houston TX
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Outline
• Pathophysiology• Etiology• Diagnosis• Treatment
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Definition
• Tissue necrosis in a muscular compartment resulting from increased intra-compartment pressure
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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.
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Anatomy – lower leg
• 4 major compartments– Vessels– Nerves– Muscles
• Subcutaneous space is separate from muscle compartment
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Anoxic positive feedback loop
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Arteriovenous gradient• Compartment
syndrome is higher resistance system
• Blood preferentially flows towards lower resistance systems
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Tissue Damage
• Nerves– 1 hour to
reversible damage– 4-6 hours
irreversible damage
• Muscle– Reversible up to
6-8 hours
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Etiology
• Tissue trauma
• Ischemia/reperfusion– Post vascular repair/injury
• Compression
• Chemical tissue damage
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Trauma
• Fractures– Elbow, forearm, tibia
• Crush injuries– Falls, ATV, MVA, industrial accidents,
earthquakes
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Chemical Tissue Damage
• Burns• Bites• Medication extravasation
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External compression
• Intoxication/overdose “found down”
• Tight casts/splints/dressings
• IV fluid infiltration
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Ann Plast Surg 2011;67: 531–533
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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
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Ischemia/Reperfusion
•4 year old girl fell from playground equipment
•Pulseless supracondylar humerus fracture
•Fracture fixation, vascular reconstruction, prophylactic compartment release
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Excellent outcome
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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
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DO NOT USE 5 P’s!
• Pallor• Pulselessness• Paralysis
• Pain• Paresthesias
• These are signs of severely decreased perfusion, not unique to compartment syndrome
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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.
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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
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The 3 As
• Children not little adults
• “Anxiety, Agitation, increasing Analgesia requirement”
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(2001). Journal of Pediatric Orthopedics, 21(5), 680–688.
• 3 A’s of Compartment Syndrome in children– Anxiety– Agitation– Increasing
Analgesia requirement
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Compartment pressures
• So why not measure the compartment pressure?
30-35 mmHg
10-15mmHg
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How high is too high?
• Absolute pressure >30mmHg
• Within 30mmHg of Diastolic pressure (ΔP)
• Within 20mmHg of Diastolic (ΔP)
• Within 30mmHg of MAP
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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
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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.
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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
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• 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
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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
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Most common method
• Kit with clear directions
• Found in OR and ER
• Orthopaedic Surgeons are the most familiar
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Or use older manometer
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Or, just use arterial line set-up
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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.
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Calculates end-organ tissue perfusion
Infrared Near-infrared
Venous blood
Arterial blood
NIS device
StO2 = difference between oxygenated and deoxygenated blood
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NIS uses
• Shock patients• Subarachnoid hemorrhage• Cerebral monitoring during CV
surgery• Stroke management• Compartment Pressure monitoring
– * readings affected by hematomas and subcutaneous fluid collections*
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Treatment
• Nonsurgical– Remove Tight dressings– Elevation ?????– Stop infusions– Supplemental O2
• Surgical treatment– fasciotomy
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Surgery
• Emergent fasciotomy
• Delayed closure
• +/- Skin graft
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Factors to predict outcome
• Early diagnosis and treatment
• Severity of inciting event
• Skin graft or primary closure?
• Rhabdomyolysis causing kidney failure
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(2011). The Journal of Bone and Joint Surgery. American Volume, 93(10), 937–941. http://doi.org/10.2106/JBJS.J.00285
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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
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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