Acute compartment syndromes

Infiltration and extravasation

The Infusion Nurses Society's national standards of practice require that a nurse who administers IV medication or fluid know its adverse effects and appropriate interventions to take before starting the infusion. A serious complication is the inadvertent administration of a solution or medication into the tissue surrounding the IV catheter--when it is a nonvesicant solution or medication, it is called infiltration; when it is a vesicant medication, it is called extravasation. Both infiltration and extravasation can have serious consequences: the patient may need surgical intervention resulting in large scars, experience limitation of function, or even require amputation. Another long-term effect is complex regional pain syndrome, a neurologic syndrome that requires long-term pain management. These outcomes can be prevented by using appropriate nursing interventions during IV catheter insertion and early recognition and intervention upon the first signs and symptoms of infiltration and extravasation. Nursing interventions include early recognition, prevention, and treatment (including the controversial use of antidotes, and heat and cold therapy). Steps to manage infiltration and extravasation are presented.

Conservative treatment of an acute compartment syndrome of the thigh

Compartment syndromes of the thigh after blunt trauma without any fracture are rare. Most surgeons recommend operative treatment. There are different rules for compartment syndromes of the thigh in young athletes after blunt trauma compared to compartment syndromes at other locations [(1) the large volume of the quadriceps muscle, (2) its relatively elastic fascia, (3) the direct proximal contact to the hip muscles which allows extravasation of fluid out of the compartment)]. We present a case of conservative treatment of elevated intra-compartmental pressure (ICP) of the anterior thigh after blunt trauma and the follow-up until return to sport. Conservative treatment of a compartment syndrome of the thigh after blunt trauma in a young patient without fracture or vascular damage was successful without short-term sequelae. Recovery of muscle strength is delayed but return to sport is possible. Depending on the severity the diagnosis and follow-up with ICP measurements and MRI is necessary. There is a very good chance for excellent outcome without any risk of surgery. However, a long healing time is possible.

Acute limb compartment syndrome: a review

Acute limb compartment syndrome (LCS) is a limb-threatening and occasionally life-threatening condition caused by bleeding or edema in a closed muscle compartment surrounded by fascia and bone, which leads to muscle and nerve ischemia. Well-known causative factors are acute trauma and reperfusion after treatment for acute arterial obstruction. Untreated compartment syndrome usually leads to muscle necrosis, limb amputation, and, if severe, in large compartments, renal failure and death. Alertness, clinical suspicion of the possibility of LCS, and occasionally intracompartmental pressure (ICP) measurement are required to avoid a delay in diagnosis or missed diagnosis. Open fasciotomy, by incising both skin and fascia, is the most reliable method for adequate compartment decompression. The techniques of measuring ICP have advantages and disadvantages, whereas the pressure level that mandates fasciotomy is controversial. Increased awareness of the syndrome and the advent of measurements of ICP pressure have raised the possibility of early diagnosis and treatment. This review reports LCS, including etiology, pathophysiology, diagnosis, ICP measurement, management, and outcome.

Influence of Semi-Recumbent Position on Intra-Abdominal Pressure as Measured by Bladder Pressure

BACKGROUND

Intra-abdominal pressure (IAP) obtained by bladder pressure measurement is used to detect impending abdominal compartment syndrome (ACS), but, while it is recommended to use a supine position, the literature describes IAP measurement in varying positions. This study evaluated the impact of body position at differing head-of-bed (HOB) elevations on bladder pressure when planned to be used as a surrogate IAP measurement.

MATERIALS AND METHODS

Forty-five trauma patients admitted to a surgical intensive care unit underwent bladder pressure measurements at 0, 15, 30, 45 degrees HOB position and 30 degrees HOB position plus 15 degrees of reverse Trendelenburg tilt; these measurements were performed in counterbalanced fashion and assessed by built-in angle indicators on the bed rails of each bed. Study participants were connected to an IAP monitoring kit via their indwelling Foley catheter.

RESULTS

A total of 675 bladder pressure measurements were obtained with 135 measurements at each of five HOB elevations (0 degrees , 15 degrees , 30 degrees , 45 degrees , 30 degrees +15 degrees tilt). Statistically significant differences occurred between all HOB elevations. Statistically significance differences also occurred at different BMI statuses.

CONCLUSIONS

Elevating HOB significantly increases bladder pressure measurement. Bladder pressure measurements in nonsupine positions may not provide valid interpretation for IAP, and more so in cases of increased body mass index.

Acute bilateral forearm compartment syndrome of unknown aetiology

This is the first reported case of non-traumatic, acute bilateral forearm compartment syndrome. Despite a delay of over 24 hours until surgical decompression and 50% muscle fibre necrosis in the histopathological examination, the clinical outcome was excellent after fasciotomy, delayed primary wound closure and early institution of a range of motion exercise programme. The literature on non-traumatic causes of compartment syndrome is reviewed.

[Abdominal compartment syndrome: significance, diagnosis and treatment]

A pathological increase of intraabdominal pressure (IAP) is frequently observed in severely ill patients suffering from surgical diseases. This may lead to the abdominal compartment syndrome (ACS) which is characterized by an IAP >20 mmHg (>2.67 kPa) and failure of one or more organ systems. The mortality of ACS exceeds 60%. Knowledge concerning the sequelae of ACS is abundant, however, measurement of IAP is not routinely performed even if patients present with corresponding risk factors. This is probably due to a variable incidence of ACS and scepticism regarding the results of bladder pressure measurement. However, measurement of IAP can now be performed semi-automatically, continuously and in a standardized fashion. The therapy of ACS, i.e. decompression laparotomy and laparostomy, is undisputed. Since a heterogeneous group of patients can be affected, monitoring of IAP is indicated in patients needing intensive care. A consistent registration of IAP will improve knowledge and guidelines regarding the therapy of a pathologically increased IAP. Nevertheless, patients in whom ACS is suspected should be decompressed as soon as possible.

Lower limb acute compartment syndrome after colorectal surgery in prolonged lithotomy position

PURPOSE

Acute compartment syndrome in patients undergoing prolonged colorectal procedures is uncommon but can have catastrophic consequences for the patient with the development of metabolic acidosis, myoglobinuric renal failure, Volkmann's contracture, limb loss, and death. The potential to produce long-term disability in a patient has important medicolegal implications, particularly if the complication is avoidable. Why only some patients develop acute compartment syndrome is not fully understood. The purpose of this study was to highlight current knowledge and suggested prevention strategies.

METHODS

A review of the relevant English language articles was performed on the basis of a MEDLINE search of the keywords: acute compartment syndrome, lithotomy position, reperfusion injury, and fasciotomy.

RESULTS

Different factors play a role: lithotomy position with or without head down, ankle and knee position, external compression for deep vein thrombosis prophylaxis, method of leg support, duration of surgery, and physiologic factors, such as gender, age, and body mass index. All efforts should be directed to prevent the establishment of acute compartment syndrome and there are accepted suggestions, such as limiting the time of leg elevation, positioning the leg below the atrium level, and monitoring postoperatively patients at risk. There is still debate on the intraoperative use of pulse oximetry to detect hypoperfusion and the appropriate use of sequential compression devices and antithromboembolic stockings.

CONCLUSIONS

Acute compartment syndrome is uncommon but cases have been reported after prolonged pelvic procedures in the lithotomy position and it is a preventable condition. More research is required to set clear guidelines on patient positioning during surgery.

Gluteal compartment syndrome

Gluteal compartment syndrome is uncommon and is often diagnosed late, resulting in muscle necrosis and sciatic nerve palsy. The mainstay of treatment is prompt diagnosis and early surgery. A high index of suspicion is essential, especially in the setting of major bleeding and excessive pain. Embolization and hyperbaric oxygen may be considered as adjuncts to surgery.

Results from the International Conference of Experts on Intra-abdominal Hypertension and Abdominal Compartment Syndrome. I. Definitions

OBJECTIVE

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) have been increasingly recognized in the critically ill over the past decade. The variety of definitions proposed has led to confusion and difficulty in comparing one study to another.

DESIGN

An international consensus group of critical care specialists convened at the second World Congress on Abdominal Compartment Syndrome to standardize definitions for IAH and ACS based upon the current understanding of the pathophysiology surrounding these two syndromes.

METHODS

Prior to the conference the authors developed a blueprint for the various definitions, which was further refined both during and after the conference. The present article serves as the final report of the 2004 International ACS Consensus Definitions Conference and is endorsed by the World Society of Abdominal Compartment Syndrome (WSACS).

RESULTS

IAH is redefined as an intra-abdominal pressure (IAP) at or above 12 mmHg. ACS is redefined as an IAP above 20 mmHg with evidence of organ dysfunction/failure. ACS is further classified as either primary, secondary, or recurrent based upon the duration and cause of the IAH-induced organ failure. Standards for IAP monitoring are set forth to facilitate accuracy of IAP measurements from patient to patient.

CONCLUSIONS

State-of-the-art definitions for IAH and ACS are proposed based upon current medical evidence as well as expert opinion. The WSACS recommends that these definitions be used for future clinical and basic science research. Specific guidelines and recommendations for clinical management of patients with IAH/ACS are published in a separate review.

Compartment syndrome of the lower leg after surgery in the modified lithotomy position: report of seven cases

PURPOSE

Acute compartment syndrome is known to develop after trauma or after postischemic revascularization. It also can occur when a patient has been lying in the lithotomy position during prolonged surgery. Methods were searched for the prevention of this iatrogenic complication after a series of seven patients who developed compartment syndrome after surgery at our hospital.

METHODS

A series of seven consecutive patients who developed compartment syndrome of the lower leg(s) after abdominoperineal surgical procedures from 1997 to 2002 is presented and so are the lessons learned to prevent this problem.

RESULTS

When comparing our experiences with data from literature, the seven patients had the usual risk factors for development of a compartment syndrome: lengthy procedure (>5 hours); decreased perfusion of the lower leg because of Trendelenburg positioning combined with the lithotomy position; and external compression of the lower legs (because of positioning, stirrups, or antiembolism stockings). Measures have been taken to prevent compartment syndrome from developing after prolonged surgery in the lithotomy position. This complication has not occurred again after the introduction of these measures two years ago.

CONCLUSIONS

Acute compartment syndrome can be prevented if adequate measures are taken, but after lengthy surgery, maximum alertness for emerging acute compartment syndrome remains indicated. Early diagnosis and treatment by four-compartment fasciotomy is still the only way to prevent irreversible damage.

Changes in muscle compartment pressure after cardiopulmonary bypass

PURPOSE

Hemodilution and inflammation lead to edema and increased muscle compartment pressure after cardiac surgery. The aim of this study was to find whether muscle compartment pressure was affected by the addition of albumin and mannitol to the pump prime, heparin coating or leukocyte depletion. Additionally, we studied the relationship between intraocular pressure and lower leg muscle compartment pressure. Edema during and following cardiac surgery is due to hemodynamic, osmotic and inflammatory changes, according to Starling's Law. We attempted to influence the osmotic balance and reduce the inflammatory response in order to reduce the edema.

METHODS

Thirty-six patients who underwent cardiac surgery were randomly allocated into four groups. Group A received albumin and mannitol into the pump prime. Group B had an, heparin-coated perfusion system, Group C had a leukocyte-depletion arterial line filter and Group D was the control group, where intraocular pressure was also measured.

RESULTS

Lower leg muscle compartment pressure increased significantly during and after cardiac surgery in all groups, but this increase was significantly less in Group A than in the control group 24 h after surgery. No correlation was found between muscular compartment pressure and intraocular pressure. The intraocular pressure profile is different from the muscular compartment pressure and recovers much faster.

CONCLUSION

Lower leg muscle compartment pressure and intraocular pressure behave differently during and after cardiac surgery. Albumin and mannitol added to the pump prime decreases muscle compartment pressure after cardiac surgery.

Safety of Power Injector Use in Children as Measured by Incidence of Extravasation

OBJECTIVE

The purpose of this study was to assess the safety of power injector use in peripheral IV injections for CT examinations of children by measuring the incidence of contrast extravasation and to review the management of extravasation as reported in the literature.

SUBJECTS AND METHODS

At a tertiary pediatric center, we prospectively collected data on 557 children undergoing CT with IV contrast injection by power injector through a peripheral venous line. Data collected included age, weight, angiocatheter size, location of venous access, flow rate, total contrast volume, maximum injector pressure, and incidence of extravasation. Adverse effects such as emesis, sensation of warmth, hives, and allergies and anaphylaxis also were recorded.

RESULTS

The patients' ages ranged from 13 days to 20 years (mean, 9.8 years). The size of angiocatheter most commonly used was 22 gauge (n = 443). The dorsum of the hand was the most common site of venous access (n = 373). The mean flow rate was 1.48 mL/s. When the patients were divided into groups on the basis of reaction or no reaction, statistical differences between the groups were found with respect to flow rate (p = 0.016) and pressure (p = 0.017) needed for injection. There were two episode of extravasation (0.3%), which were treated conservatively.

CONCLUSION

The use of power injectors through 18- to 24-gauge angiocatheters in children is safe when meticulous technique is used and personnel are appropriately trained. Our study showed a similar rate of extravasation as has been reported in other studies.

Some current controversies in paediatric regional anaesthesia

PURPOSE OF REVIEW

Controversial topics in paediatric regional anaesthesia are discussed.

RECENT FINDINGS

The performance of blocks under general anaesthesia, new local anaesthetics, adjuvants, location techniques, and risks of masking compartment syndromes are contemplated.

SUMMARY

The performance of regional blocks in anaesthetized patients is generally contra-indicated in adults but accepted in children. Levobupivacaine displays the same pharmacokinetic profile as racemic bupivacaine with possibly less cardiac toxicity. Ropivacaine undergoes slower absorption and, in some studies, concomitant increase in peak plasma concentration in infants. Conversely, continuous infusion of ropivacaine offers the safest therapeutic index. Many adjuvants have been used but only epinephrine, clonidine, and preservative-free ketamine offer clear advantages. Midazolam and neostigmine are effective but have potential drawbacks and raise safety questions. Needle and catheter positioning is critical. Electrocardiogram guidance and electrical stimulation occasionally help identify the migration of epidural catheters. Stimulating catheters might be useful for continuous peripheral blockade. Ultrasonography will probably become the reference technique for peripheral catheter placement. Patients at risk of compartment syndrome must be monitored (measurement of compartmental pressures); adequate pain management does not 'hide' this complication but, on the contrary, can facilitate early diagnosis since the increase in requirement for pain medication precedes other clinical symptoms by an average of 7.3 h.

Decompression not escharotomy in acute burns

The concept of escharotomy has long been associated with acute burns care. Nevertheless the practice of escharotomy is frequently flawed and there is considerable diversity in the teaching of the procedure. It is proposed that there should be a fundamental change in the teaching of acute burn management and the concept of decompression should be promoted. The justification for this change comes from a review of the present knowledge base using indexed, library and web-based information sources and also a review of a series of patients transferred to a regional burns unit over a five-year period which revealed that 37% of patients who required surgical decompression had not been appropriately treated prior to transfer. Based on relevant compartmental anatomy a change in the surgical decompression of limbs is proposed to allow safer and more effective management.

Risk factors for acute renal failure: inherent and modifiable risks

PURPOSE OF REVIEW

Our purpose is to discuss established risk factors in the development of acute renal failure and briefly overview clinical markers and preventive measures.

RECENT FINDINGS

Findings from the literature support the role of older age, diabetes, underlying renal insufficiency, and heart failure as predisposing factors for acute renal failure. Diabetics with baseline renal insufficiency represent the highest risk subgroup. An association between sepsis, hypovolemia, and acute renal failure is clear. Liver failure, rhabdomyolysis, and open-heart surgery (especially valve replacement) are clinical conditions potentially leading to acute renal failure. Increasing evidence shows that intraabdominal hypertension may contribute to the development of acute renal failure. Radiocontrast and antimicrobial agents are the most common causes of nephrotoxic acute renal failure. In terms of prevention, avoiding nephrotoxins when possible is certainly desirable; fluid therapy is an effective prevention measure in certain clinical circumstances. Supporting cardiac output, mean arterial pressure, and renal perfusion pressure are indicated to reduce the risk for acute renal failure. Nonionic, isoosmolar intravenous contrast should be used in high-risk patients. Although urine output and serum creatinine lack sensitivity and specificity in acute renal failure, they remain the most used parameters in clinical practice.

SUMMARY

There are identified risk factors of acute renal failure. Because acute renal failure is associated with a worsening outcome, particularly if occurring in critical illness and if severe enough to require renal replacement therapy, preventive measures should be part of appropriate management.

Recognition and management of abdominal compartment syndrome in the United Kingdom

OBJECTIVE

Abdominal compartment syndrome(ACS) is a condition associated with high mortality if undiagnosed and untreated. ACS is seen in patients managed in intensive care units. Very little is known on the causes, diagnosis and treatment of this condition in the United Kingdom.

DESIGN

Questionnaire study.

SETTINGS

222 intensive care units in the UK dealing with acute abdominal condition.

RESULTS

127 (57.2%) questionnaires were returned (32 from teaching hospitals and 95 from district general hospitals. Among these, 96.9% of teaching hospitals and 72.6% of district general hospitals had seen cases of ACS. The conditions most frequently associated with ACS were small and large bowel surgery (67%), vascular surgery (62%) and trauma (60%). ACS was suspected mainly when there was a distended abdomen (98.6%), oliguria (94.5%) and increased ventilatory support (72.2%). The diagnosis was confirmed either clinically (68.4%) or by measuring intra-abdominal pressure (83.7%). The commonest method for measuring intra-abdominal pressure was the intra-vesical route. The pressure threshold for diagnosing the condition was variable, with a range of 11-50 mmHg. There was a large variation in the number of patients who were decompressed.

CONCLUSION

Fewer patients are diagnosed with ACS in district general hospitals compared with teaching hospitals. The threshold for the diagnosis of ACS is variable in the UK, as were the numbers of patients who were decompressed, suggesting that many doctors are still reluctant to accept this condition. This study would suggest that there is a need for standardisation of diagnostic threshold and protocols regarding decompression in ACS.

Acute compartment syndrome secondary to diabetic muscle infarction: case report and literature review

Acute compartment syndrome has a multitude of aetiologies. Unfortunately, the diagnosis is often delayed, resulting in permanent functional loss. Although spontaneous muscle infarction is an uncommon, yet well-recognized complication of diabetes mellitus, subsequent development of compartment syndrome appears to be rare, with only five case reports identified in the literature. This condition has not been reported in the emergency medicine literature. We report a case of a diabetic gentleman who presented with lower limb pain significantly out of proportion to any obvious injury and had a subsequent diagnosis of acute compartment syndrome. Despite fasciotomies, he had a persistent foot drop. Nontraumatic acute compartment syndrome secondary to diabetic muscle infarction should be considered in any diabetic patient presenting with pain out of proportion to sustained injury.

Abdominal Compartment Syndrome

BACKGROUND

Abdominal compartment syndrome (ACS) is a systemic syndrome involving derangement in cardiovascular haemodynamics, respiratory and renal functions as a result of sustained increase in intra-abdominal pressure (IAP) ending in multi-organ failure. It is a life threatening emergency and requires prompt action and treatment. For the last 20 years, there has been more awareness among surgeons and intensivists of ACS being a distinct disease entity but still widespread ignorance prevails. Presentation can be acute, chronic and acute on chronic. Initial diagnosis is clinical, confirmed by measurement of IAP. Treatment is abdominal decompression by laparostomy and delayed abdominal closure. Despite prompt treatment mortality remains high. Awareness among surgeons has increased because laparoscopy has resulted in determination of IAP as a readily measurable quantity and also they have been able to appreciate the benefit of abdominal decompression by performing repeated planned laparotomies for trauma.

METHODS

A medline, pubmed and Cochrane database search was performed and the articles found were cross referenced.

RESULTS AND CONCLUSION

Clinical diagnosis is not easy and serial urinary bladder pressure (UBP) monitoring leads to early diagnosis. Treatment is by laprostomy to decompress the abdomen followed by delayed abdominal closure.

The use of regional anaesthesia in patients at risk of acute compartment syndrome

A delay in the diagnosis of an acute compartment syndrome can be devastating to the patient. The increasing use of regional anaesthesia in the management of orthopaedic and trauma patients raises concerns about the potential for delay in the diagnosis of acute compartment syndrome. We undertook a postal survey to assess the usage of regional anaesthesia in patients with lower limb fractures. The study showed that regional anaesthesia is being used in patients at risk of compartment syndrome and without compartment pressure monitoring equipment being available. The anaesthetists questioned had seen cases of acute compartment syndrome being masked by regional anaesthesia. We recommend that there is an urgent need to establish joint guidelines between the orthopaedic and anaesthetic communities on the usage of regional anaesthesia in patients with lower limb fractures to reduce further morbidity from delays in the diagnosis of compartment syndrome.

Biceps Brachii Compartment Contrast Media Extravasation with Surgical Correlation

We describe a case in which 120 ml of contrast media was extravasated into the biceps brachii compartment with a power injector during the course of an attempted CT angiogram. The patient underwent surgical fasciotomy and drainage. The radiographic appearance and clinical implications of this event are discussed.

Acute compartment syndrome of the foot caused by a hemangioma

Acute compartment syndrome is most commonly caused by trauma. Although it has been well described in adults, few have addressed this condition in the pediatric patient. The most common causes of acute compartment syndrome of the foot in children are crush syndromes with or without fractures. We present the case of an 8-year-old girl who had a congenital hemangioma on the second toe of her right foot, with persistent pain and swelling of her right lower extremity. On exploration, the limb was cold and swollen, and pulses were timidly palpable. She was admitted with a working diagnosis of cavernous hemangioma with a hematoma that affected the blood flow of the foot. After measuring the compartment pressures, acute compartment syndrome of the right foot was diagnosed and fasciotomy was performed. The current medical literature was reviewed for acute compartment syndromes secondary to hemangiomas. It appears that this could be a new complication of hemangiomas located in limbs with severe consequences if not detected in time.

Mandibular advancement decreases pressures in the tissues surrounding the upper airway in rabbits

The pharyngeal airway can be considered as an airway luminal shape formed by surrounding tissues, contained within a bony enclosure formed by the mandible, skull base, and cervical vertebrae. Mandibular advancement (MA), a therapy for obstructive sleep apnea, is thought to increase the size of this bony enclosure and to decrease the pressure in the upper airway extraluminal tissue space (ETP). We examined the effect of MA on upper airway airflow resistance (Rua) and ETP in a rabbit model. We studied 11 male, supine, anesthetized, spontaneously breathing New Zealand White rabbits in which ETP was measured via pressure transducer-tipped catheters inserted into the tissues surrounding the lateral (ETPlat) and anterior (ETPant) pharyngeal wall. Airflow, measured via surgically inserted pneumotachograph in series with the trachea, and tracheal pressure were recorded while graded MA at 75 degrees and 100 degrees to the horizontal was performed using an external traction device. Data were analyzed using a linear mixed-effects statistical model. We found that MA at 100 degrees increased mouth opening from 4.7 +/- 0.4 to 6.6 +/- 0.4 (SE) mm (n = 7; P < 0.004), whereas mouth opening did not change from baseline (4.0 +/- 0.2 mm) with MA at 75 degrees . MA at both 75 degrees and 100 degrees decreased mean ETPlat and ETPant by approximately 0.1 cmH2O/mm MA (n = 7-11; all P < 0.0005). However, the fall in Rua (measured at 20 ml/s) with MA was greater for MA at 75 degrees (approximately 0.03 mmH2O.ml(-1).s.mm(-1)) than at 100 degrees (approximately 0.01 mmH2O.ml(-1).s.mm(-1); P < 0.02). From these findings, we conclude that MA decreases ETP and is more effective in reducing Rua without mouth opening.

Case report: compartment syndrome after a suspected black widow spider bite

Widow spider envenomations generally produce systemic neurologic syndromes without significant local injury. We report a patient who sustained a black widow spider bite to the left forearm and presented to the emergency department with rhabdomyolysis and compartment syndrome. We documented a decrease in symptoms and compartment pressure after administration of antivenom. No surgical intervention was performed. We believe this report to be the first documenting compartment syndrome associated with black widow spider bite.

Acute compartment syndrome of the limb

In this review the aetiology, clinical signs, diagnosis and therapy of the acute compartment syndrome of the limb is discussed. It is a limb- and untreated life threatening emergency. For good results, early detection is necessary. It is important to educate those taking care of patients of risk, especially in the early symptoms and signs. In uncooperative, unconscious and sedated patients pressure monitoring is recommended. The critical level of the absolute intracompartmental pressure is unclear. It is recommended to use a delta p pressure of 30 mm Hg. Below this pressure in the presence of clinical signs a fasciotomy of all compartments is the treatment of choice.

Rhabdomyolysis and compartment syndrome with coadministration of risperidone and simvastatin

We report a case of rhabdomyolysis and acute compartment syndrome of the lower extremity in a schizophrenic patient taking risperidone following the addition of simvastatin to treat hyperlipidemia. We suspect that disrupted drug metabolism, resulting from interactions with cytochrome P450 enzymes, rapidly elevated drug plasma levels, which then led to muscle toxicity. Clinicians who pharmacologically treat medical comorbidities in patients receiving atypical antipsychotics must be proactive in anticipating potential drug-drug interactions.

Diagnosis and management of severe acute pancreatitis complicated with abdominal compartment syndrome

Presented in this paper is our experience in the diagnosis and management of abdominal compartment syndrome during severe acute pancreatitis. On the basis of the history of severe acute pancreatitis, after effective fluid resuscitation, if patients developed renal, pulmonary and cardiac insufficiency after abdominal expansion and abdominal wall tension, ACS should be considered. Cystometry could be performed to confirm the diagnosis. Emergency decompressive celiotomy and temporary abdominal closure with a 3 liter sterile plastic bag must be performed. It is also critical to prevent reperfusion syndrome. In 23 cases of ACS, 18 cases received emergency decompressive celiotomy and 5 cases did not. In the former, 3 patients died (16.7%) while in the later, 4 (80%) died. Total mortality rate was 33.3% (7/21). In 7 death cases, 4 patients developed acute obstructive suppurative cholangitis (AOSC). All the patients who received emergency decompressive celiotomy 5 h after confirmation of ACS survived. The definitive abdominal closure took place mostly 3 to 5 days after emergency decompressive celiotomy, with longest time being 8 days. 6 cases of ACS at infection stage were all attributed to infected necrosis in abdominal cavity and retroperitoneum. ACS could occur in SIRS stage and infection stage during SAP, and has different pathophysiological basis. Early diagnosis, emergency decompressive celiotomy and temporary abdominal closure with a 3L sterile plastic bag are the keys to the management of the condition.

Acute compartment syndrome of the legs after colorectal surgery

This review considers the causes, diagnosis and management of compartment syndrome affecting the legs after colorectal surgery.

Unusual presentation and complication of the prone position for spinal surgery

Patient positioning for operative procedures has long been associated with perioperative complications. We present a case report of shoulder dislocation, which occurred following positioning in the prone position, and was detected by axillary artery occlusion resulting in the loss of the radial artery blood pressure line waveform. We discuss the diagnosis and consequences of this complication.

Elevated intramuscular compartment pressures do not influence outcome after tibial fracture

BACKGROUND

Although the importance of monitoring differential compartment pressures (Delta P) after tibial fractures has been established, many surgeons continue to use intramuscular pressures in diagnosing compartment syndrome, despite the limitations of this strategy. The cited reason for this is concern over leaving high intramuscular pressures untreated.

METHODS

One hundred one patients with tibial fractures with satisfactory Delta P were studied. Forty-one patients had elevated intramuscular pressures of over 30 mm Hg for more than 6 hours continuously. These patients were compared with a control group of 60 patients who had pressures of less than 30 mm Hg throughout. Outcome was measured prospectively in terms of muscular power and return to function over the year after injury.

RESULTS

No significant differences were found.

CONCLUSION

Provided Delta P remains satisfactory, patients with elevated intramuscular pressures after tibial fracture do not have a greater incidence of complications than those with low pressures. These patients can therefore be observed safely.

The Impact of Intra-abdominal Hypertension on Gene Expression in the Kidney

BACKGROUND

Intra-abdominal hypertension (IAH) has been recognized as a source of morbidity and mortality in the injured patient. Research concerning this entity has focused predominantly on the pathophysiology. We developed a model of IAH to determine whether gene expression is altered in the presence of this condition.

METHODS

Using general anesthesia, adult Sprague-Dawley rats were intubated and instrumented with a carotid and jugular catheter. Three pairs of rats (three control; three IAH 25 mm Hg) were used at each time interval. Continuous measurements of heart rate, blood pressure, cardiac output, and temperature were recorded. Arterial blood gases were measured every 30 minutes. A catheter was placed in the peritoneum and warm saline was infused up to a pressure of 25 mm Hg that was measured through this catheter continuously. At 30 and 60 minutes, the kidneys were harvested and standard protocols were used to extract nucleic acid and perform cDNA microarray analysis screening for 4,000 genes. Each experimental rat was paired with a control rat and each set underwent individual cDNA array analysis.

RESULTS

Hemodynamic changes occurred that were consistent with IAH, including depression of cardiac output and acidosis. Although widespread changes in gene expression were identified, only genes that were up-regulated and down-regulated by a ratio of fivefold, a difference in magnitude of 150 molecular dynamic counts, and p < 0.05 were considered significant. When comparing IAH of 25 mm Hg at 30 and 60 minutes, there was a surprising decrease in up-regulated genes from 10 to 1. In addition, there was an increase in down-regulated genes from zero to five genes.

CONCLUSION

IAH causes changes in gene up- and down-regulation in the kidney. The number and types of genes change in magnitude and type over time. Further investigation into renal gene expression may offer insight into the molecular pathophysiology of IAH.

Temporary closure of open abdominal wounds by the modified sandwich-vacuum pack technique

BACKGROUND

A 5-year experience with the modified sandwich-vacuum pack technique, using an opened 3-litre urological irrigation bag and continuous high-pressure suction, for temporary abdominal wall closure is presented.

METHODS

The records of all patients who underwent temporary abdominal wall closure using this method from January 1996 to December 2000 were examined.

RESULTS

The modified sandwich-vacuum pack was used 139 times in 55 patients. Forty patients sustained penetrating trauma while 15 patients sustained blunt trauma. The mean Injury Severity Score was 19 (range 9-34). Intra-abdominal sepsis (51 per cent) was the commonest indication, followed by visceral oedema (18 per cent), abdominal compartment syndrome (16 per cent), intra-abdominal packing (11 per cent) and abdominal wall defects (4 per cent). The overall mortality rate was 45 per cent. Three patients (5 per cent) developed enterocutaneous fistula. Of the 30 survivors, 16 patients underwent primary fascial closure.

CONCLUSION

The modified sandwich-vacuum pack technique of temporary abdominal wall closure is easy and rapid, cost effective and provides an effective means of containing abdominal wall contents.

Acute limb ischemia secondary to myositis-induced compartment syndrome in a patient with human immunodeficiency virus infection

Myositis, while uncommon, develops more frequently in patients with human immunodeficiency virus infection. We report a case of acute lower leg ischemia caused by myositis in such a patient. Urgent four-compartment fasciotomy of the lower leg was performed, which decompressed the compartmental hypertension and reversed the arterial ischemia. This case underscores the importance of recognizing compartment syndrome as a cause of acute limb ischemia.