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Well Leg Compartment Syndrome: Pathophysiology, Prevention, and Treatment. J Clin Med 2022; 11:jcm11216448. [DOI: 10.3390/jcm11216448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 10/24/2022] [Accepted: 10/25/2022] [Indexed: 11/06/2022] Open
Abstract
The development of compartment syndrome involving the lower limb is a potentially devastating complication of prolonged surgery in patients held in the lithotomy position. Well leg compartment syndrome (WLCS) was recognized in 1953. The incidence of this condition has been reported to range from 0.20% to 0.03%. The mechanism of WLCS development in the absence of trauma appears to be related to prolonged hypoperfusion of the limb, pressure on the muscle compartments, and in some cases, reperfusion of the ischemic limb. This grave complication develops either during or immediately after prolonged surgery in which the patient was held in the Lloyd-Davies lithotomy or hemi-lithotomy position. Surgeons must be aware of the potential for WLCS development during prolonged surgery. Signs of developing WLCS include swelling, increased firmness of the muscle compartments, discoloration, and cooling of the limb. Preventive measures can be taken without contaminating the surgical field by returning the limb to the right atrium level. Once the diagnosis has been made, failure to prevent the development of WLCS requires extensile fasciotomy of each leg compartment to restore perfusion and relieve elevated intra-compartment pressures. This article reviews the pathophysiology, prevention, and treatment of WLCS.
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Fleisch MC, Bader W, Balzer K, Bennefeld L, Boeing C, Bremerich D, Gass P, Geissbuehler V, Koch MC, Nothacker MJ, Pietzner K, Renner SP, Römer T, Roth S, Schütz F, Schulte-Mattler W, Sehouli J, Lippach K, Tamussino K, Teichmann A, Tempfer C, Thill M, Tinneberg HR, Zarras K. The Prevention of Positioning Injuries During Gynecologic Surgery. Guideline of the DGGG, OEGGG and SGGG (S2k Level, AWMF Registry Number 015/077, October 2020). Geburtshilfe Frauenheilkd 2021; 81:447-468. [PMID: 33867563 DOI: 10.1055/a-1378-4209] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 01/29/2021] [Indexed: 10/21/2022] Open
Abstract
Purpose Positioning injuries are relatively common, forensically highly relevant complications of gynecologic surgery. The aim of this official AWMF S2k-guideline is to provide statements and recommendations on how to prevent positioning injuries using the currently available literature. The literature was evaluated by an interdisciplinary group of experts from professional medical societies. The consensus on recommendations and statements was achieved in a structured consensus process. Method The current guideline is based on the expired S1-guideline, which was updated by a systematic search of the literature and a review of relevant publications issued between February 2014 and March 2019. Statements were compiled and voted on by a panel of experts. Recommendations The guideline provides general and specific recommendations on the prevention, diagnosis and treatment of positioning injuries.
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Affiliation(s)
- Markus C Fleisch
- Landesfrauenklinik, HELIOS Universitätsklinikum Wuppertal, Wuppertal, Germany
| | - Werner Bader
- Zentrum für Frauenheilkunde, Klinikum Bielefeld Mitte, Bielefeld, Germany
| | - Kai Balzer
- Klinik für Gefäßchirurgie, GFO Kliniken, Bonn, Germany
| | - Luisa Bennefeld
- Landesfrauenklinik, HELIOS Universitätsklinikum Wuppertal, Wuppertal, Germany
| | - Carsten Boeing
- Klinik für Gynäkologie und Geburtshilfe, AMEOS Klinikum St. Clemens Oberhausen, Oberhausen, Germany
| | | | | | | | - Martin C Koch
- Frauenklinik, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Monika J Nothacker
- AWMF-Institut für Medizinisches Wissensmanagement, Universität Marburg, Marburg, Germany
| | - Klaus Pietzner
- Charité Frauenklinik, Universitätsmedizin Berlin, Berlin, Germany
| | | | - Thomas Römer
- Frauenklinik, Evangelisches Krankenhaus Weyertal, Köln, Germany
| | - Stephan Roth
- Klinik für Urologie, HELIOS Universitätsklinikum Wuppertal, Wuppertal, Germany
| | - Florian Schütz
- Klinik für Gynäkologie und Geburtshilfe, Diakonissen Krankenhaus Speyer, Speyer, Germany
| | | | - Jalid Sehouli
- Charité Frauenklinik, Universitätsmedizin Berlin, Berlin, Germany
| | - Kristina Lippach
- Pflegewissenschaften und Praxisentwicklung, LMU München, München, Germany
| | - Karl Tamussino
- Klinik für Frauenheilkunde und Geburtshilfe, Universitätsklinikum Graz, Graz, Austria
| | - Alexander Teichmann
- Sichuan Center for Gynaecology and Breast Surgery, Dept. of Perinatal Medicine, Medical University of Southwest China, Luzhou (Sichuan), China
| | - Clemens Tempfer
- Klinik für Frauenheilkunde und Geburtshilfe, Marienhospital Herne, Universitätsklinikum Bochum, Bochum/Herne, Germany
| | - Marc Thill
- Klinik für Gynäkologie und Gynäkologische Onkologie, Agaplesion Markus Krankenhaus, Frankfurt am Main, Germany
| | | | - Konstantinos Zarras
- Abteilung für Allgemein-, Viszeral- und Minimalinvasive Chirurgie des VVKD Marienhospitals Düsseldorf, Düsseldorf, Germany
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Prevention of well-leg compartment syndrome following lengthy medical operations in the lithotomy position. Surg Open Sci 2020; 3:16-21. [PMID: 33305248 PMCID: PMC7709791 DOI: 10.1016/j.sopen.2020.10.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 09/26/2020] [Accepted: 10/17/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose Compartment syndrome that occurs after lengthy surgery in the lithotomy position is known as well-leg compartment syndrome. It has serious consequences for patients, including amyotrophic renal failure, limb loss, and sometimes even death. This study aimed to identify effective preventive measures against well-leg compartment syndrome using a retrospective cohort study of 1,951 patients (985 and 966 in the prevention and control groups, respectively). Material and methods The following preventive interventions were analyzed: (1) changing from the lithotomy position to the open-leg position, (2) removing lower leg pressure caused by the lithotomy position, (3) limiting leg elevation based on the height of the right atrium, (4) horizontally repositioning the operating table every 3 hours, and (5) decompressing the contact area of the lower leg in the lithotomy position during operation. Results Eight cases of well-leg compartment syndrome occurred in the control group, whereas no well-leg compartment syndrome occurred in the prevention group. Conclusion These findings suggest that the five interventions assessed can prevent the development of well-leg compartment syndrome.
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Mizuno J, Takahashi T. Male sex, height, weight, and body mass index can increase external pressure to calf region using knee-crutch-type leg holder system in lithotomy position. Ther Clin Risk Manag 2016; 12:305-12. [PMID: 26955278 PMCID: PMC4772916 DOI: 10.2147/tcrm.s86934] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Well-leg compartment syndrome (WLCS) is one of the catastrophic complications related to prolonged surgical procedures performed in the lithotomy position, using a knee-crutch-type leg holder (KCLH) system, to support the popliteal fossae and calf regions. Obesity has been implicated as a risk factor in the lithotomy position-related WLCS during surgery. In the present study, we investigated the relationship between the external pressure (EP) applied to the calf region using a KCLH system in the lithotomy position and selected physical characteristics. Methods Twenty-one young, healthy volunteers (21.4±0.5 years of age, eleven males and ten females) participated in this study. The KCLH system used was Knee Crutch®. We assessed four types of EPs applied to the calf region: box pressure, peak box pressure, contact pressure, and peak contact pressure, using pressure-distribution measurement system (BIG-MAT®). Relationships between these four EPs to the calf regions of both lower legs and a series of physical characteristics (sex, height, weight, and body mass index [BMI]) were analyzed. Results All four EPs applied to the bilateral calf regions were higher in males than in females. For all subjects, significant positive correlations were observed between all four EPs and height, weight, and BMI. Conclusion EP applied to the calf region is higher in males than in females when the subject is supported by a KCLH system in the lithotomy position. In addition, EP increases with the increase in height, weight, and BMI. Therefore, male sex, height, weight, and BMI may contribute to the risk of inducing WLCS.
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Affiliation(s)
- Ju Mizuno
- Department of Anesthesiology and Pain Medicine, Juntendo University Faculty of Medicine, Bunkyo-ku, Tokyo
| | - Toru Takahashi
- Faculty of Health and Welfare Science, Okayama Prefectural University, Soja-shi, Okayama, Japan
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Fleisch MC, Bremerich D, Schulte-Mattler W, Tannen A, Teichmann AT, Bader W, Balzer K, Renner SP, Römer T, Roth S, Schütz F, Thill M, Tinneberg H, Zarras K. The Prevention of Positioning Injuries during Gynecologic Operations. Guideline of DGGG (S1-Level, AWMF Registry No. 015/077, February 2015). Geburtshilfe Frauenheilkd 2015; 75:792-807. [PMID: 26365999 PMCID: PMC4554497 DOI: 10.1055/s-0035-1557776] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Purpose: Official guideline published and coordinated by the German Society of Gynecology and Obstetrics (DGGG). Positioning injuries after lengthy gynecological procedures are rare, but the associated complications can be potentially serious for patients. Moreover, such injuries often lead to claims of malpractice and negligence requiring detailed medical investigation. To date, there are no binding evidence-based recommendations for the prevention of such injuries. Methods: This S1-guideline is the work of an interdisciplinary group of experts from a range of different professions who were commissioned by DGGG to carry out a systematic literature search of positioning injuries. Members of the participating scientific societies develop a consensus in an informal procedure. Afterwards the directorate of the scientific society approves the consensus. The recommendations cover.
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Affiliation(s)
| | - D. Bremerich
- Klinik für Anästhesiologie, Agaplesion Markus Krankenhaus Frankfurt am Main, Frankfurt am Main
| | - W. Schulte-Mattler
- Klinik und Poliklinik für Neurologie Universitätsklinikum Regensburg, Regensburg
| | - A. Tannen
- Institut für Gesundheits- und Pflegewissenschaften, Charité Universitätsmedizin Berlin, Berlin
| | | | - W. Bader
- Zentrum für Frauenheilkunde, Klinikum Bielefeld Mitte, Bielefeld
| | - K. Balzer
- Gefäß- und Endovaskulärchirurgie, GFO Kliniken Bonn, Betriebsstätte St. Marien, Bonn
| | - S. P. Renner
- Universitätsklinikum Erlangen-Nürnberg, Frauenklinik, Erlangen
| | - T. Römer
- Klinik für Gynäkologie und Geburtshilfe, Evangelisches Krankenhaus, Cologne
| | - S. Roth
- Urologische Klinik, Helios Klinikum Wuppertal, Wuppertal
| | - F. Schütz
- Allgemeine Frauenheilkunde und Geburtshilfe, Universitätsklinikum Heidelberg, Heidelberg
| | - M. Thill
- Klinik für Gynäkologie, Agaplesion Markus Krankenhaus, Frankfurt am Main
| | - H. Tinneberg
- Zentrum für Frauenheilkunde und Geburtshilfe, Universitätsklinium Gießen, Gießen
| | - K. Zarras
- Abteilung für Allgemein-, Viszeral- und Minimalinvasive Chirurgie, Marienhospital Düsseldorf, Düsseldorf
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Bauer EC, Koch N, Janni W, Bender HG, Fleisch MC. Compartment syndrome after gynecologic operations: evidence from case reports and reviews. Eur J Obstet Gynecol Reprod Biol 2014; 173:7-12. [DOI: 10.1016/j.ejogrb.2013.10.034] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2013] [Revised: 10/10/2013] [Accepted: 10/31/2013] [Indexed: 11/26/2022]
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Krite Svanberg E, Wollmer P, Andersson-Engels S, Åkeson J. Physiological influence of basic perturbations assessed by non-invasive optical techniques in humans. Appl Physiol Nutr Metab 2011; 36:946-57. [DOI: 10.1139/h11-119] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
New non-invasive techniques enabling frequent or continuous assessments of various pathophysiological conditions might be used to improve in-hospital outcome by enabling earlier and more reliable bedside detection of medical deterioration. In this preclinical study, three modern non-invasive optical techniques, laser Doppler imaging (LDI), near-infrared spectroscopy (NIRS), and tissue viability imaging (TVI), were all evaluated with respect to the influence of basic physiological perturbations (including local changes in arm positioning, skin temperature, and regional blood flow conditions) on quasi simultaneously obtained values of skin perfusion, muscle tissue oxygenation (StO2), and skin blood volume, recorded in eighteen healthy volunteers. Skin perfusion measured by LDI responded prominently to changes in positioning of the arm, whereas muscle StO2 measured by NIRS did not change significantly. Total haemoglobin count (HbT) measured by NIRS and blood volume estimated by TVI both increased significantly on lowering of the limb. On local cooling, the perfusion and blood volume were both found to increase considerably, while StO2 and HbT did not change. Local heating induced a more than 10-fold increase in skin perfusion and a small increase in blood volume. On progressive venoarterial occlusion, the perfusion, StO2, HbT, and blood volume values decreased, after transient increases in HbT and blood volume before full arterial occlusion occurred, and all values approached the baseline level on release of the occlusion with a slight overshoot of the StO2. The results obtained have potential bearing on future utilization of these non-invasive techniques in the management of severely injured and (or) critically ill patients.
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Affiliation(s)
- Emilie Krite Svanberg
- Department of Anaesthesiology and Intensive Care Medicine, Lund University, Skåne University Hospital, entrance 42, 3rd floor, SE – 205 02 Malmö, Sweden
| | - Per Wollmer
- Clinical Physiology and Nuclear Medicine, Lund University, Skåne University Hospital, Malmö, Sweden
| | | | - Jonas Åkeson
- Department of Anaesthesiology and Intensive Care Medicine, Lund University, Skåne University Hospital, entrance 42, 3rd floor, SE – 205 02 Malmö, Sweden
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Abstract
AIM In spite of recent advances in technology and technique, laparoscopic colorectal surgery is associated with increased operating times when compared with open surgery. This increases the risk of acute lower limb compartment syndrome. The aim of this review was to gain a better understanding of postoperative lower limb compartment syndrome following laparoscopic colorectal surgery and to suggest strategies to avoid its occurrence. METHOD A MEDLINE search was performed using the keywords 'compartment syndrome', 'laparoscopic surgery' and 'Lloyd-Davies position' between 1970 and 2008. All relevant articles were retrieved and reviewed. RESULTS A total of 54 articles were retrieved. Of the 30 articles in English, five were reviews, six were original articles and 19 were case reports, of which only one was following laparoscopic colorectal surgery. The remaining 24 were non-English articles. Of these, two were reviews and 22 were case reports, of which only one was following laparoscopic colorectal surgery. The incidence of acute compartment syndrome following laparoscopic colorectal surgery is unknown. The following are believed to be risk factors for acute lower limb compartment syndrome: the Lloyd-Davies operating position with exaggerated Trendelenburg tilt, prolonged operative times and improper patient positioning. Simple strategies are suggested to reduce its occurrence. CONCLUSION Simple preventative measures have been identified which may help to reduce the incidence of acute lower limb compartment syndrome. However, if suspected, timely surgical intervention with four-compartment fasciotomy remains the standard of care.
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Affiliation(s)
- M M Rao
- The John Goligher Colorectal Unit, Leeds General Infirmary, Leeds, UK.
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Romero FR, Pilati R, Kulysz D, Canali FA, Baggio PV, Filho TB. Factores de riesgo combinados para síndrome compartimental de la pierna después de una prostatectomía radical laparoscópica. Actas Urol Esp 2009; 33:920-4. [DOI: 10.1016/s0210-4806(09)72883-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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11
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Epidemiology, Etiology, Pathophysiology and Diagnosis of the Acute Compartment Syndrome of the Extremity. Eur J Trauma Emerg Surg 2007; 33:576-83. [DOI: 10.1007/s00068-007-7151-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2007] [Accepted: 11/02/2007] [Indexed: 01/03/2023]
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Cohn SM. Near-infrared spectroscopy: potential clinical benefits in surgery. J Am Coll Surg 2007; 205:322-32. [PMID: 17660081 DOI: 10.1016/j.jamcollsurg.2007.02.024] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2006] [Revised: 01/31/2007] [Accepted: 02/06/2007] [Indexed: 10/23/2022]
Affiliation(s)
- Stephen M Cohn
- Department of Surgery, University of Texas Health Science Center, San Antonio, TX 78229-3900, USA
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13
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Abstract
Acute compartment syndrome is a surgical emergency requiring immediate intervention to limit tissue and nerve injury. Although the measurement of compartment pressure is frequently performed, there is controversy regarding the pressure at which fasciotomy should be performed. Near-infrared spectroscopy (NIRS) uses the same technology as pulse oximetry to estimate tissue oxygenation. To date, NIRS is used most commonly to estimate cerebral oxygenation during intraoperative anesthetic care. The authors present a 1-month-old infant who developed an acute compartment syndrome of the right lower extremity after cardiac surgery. In addition to the measurement of compartment pressures, the diagnosis of compartment syndrome was confirmed by NIRS with a value of 15% in the involved leg versus 40% to 50% in the noninvolved contralateral lower extremity. The potential use of this modality in identifying compartment syndrome is reviewed.
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Affiliation(s)
- Joseph D Tobias
- Department of Anesthesiology, University of Missouri, Columbia, MO 65212, USA.
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Beraldo S, Dodds SR. Lower limb acute compartment syndrome after colorectal surgery in prolonged lithotomy position. Dis Colon Rectum 2006; 49:1772-80. [PMID: 17036205 DOI: 10.1007/s10350-006-0712-1] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- Stefania Beraldo
- Department of Vascular Surgery, Good Hope Hospital NHS Trust, Rectory Road, Sutton Coldfield, B75 7RR, West Midlands, United Kingdom
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Wassenaar EB, van den Brand JGH, van der Werken C. Compartment syndrome of the lower leg after surgery in the modified lithotomy position: report of seven cases. Dis Colon Rectum 2006; 49:1449-53. [PMID: 16937229 DOI: 10.1007/s10350-006-0688-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- Eelco B Wassenaar
- Department of General Surgery, University Medical Center, Utrecht, The Netherlands
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Wassenaar EB, Van den Brand JGH. Reliability of Near-Infrared Spectroscopy in People With Dark Skin Pigmentation. J Clin Monit Comput 2005; 19:195-9. [PMID: 16244841 DOI: 10.1007/s10877-005-1655-0] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2004] [Revised: 02/01/2005] [Accepted: 02/01/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Near-infrared spectroscopy (NIRS) is a promising non-invasive technique for the continuous monitoring of tissue oxygen delivery. NIRS detects light absorbance of haemoglobin chromophores to determine tissue oxygen saturation (StO2). As skin colour is also determined by the presence of chromophores, it is plausible that NIRS signal quality may be affected by dark skin pigmentation. METHODS Tissue saturation in the anterior compartment of the lower leg during isometric contraction was measured using NIRS in 17 volunteers with dark skin pigmentation. Measurements were continued until StO2 was zero percent or until the signal disappeared. RESULTS The NIRS device failed to register tissue saturation values at some point in nine of seventeen volunteers. This occurred more often in individuals with darker skin. CONCLUSIONS In patients with a dark pigmented skin, NIRS StO2 measurements should be interpreted with caution, as melanin clearly interferes with the quality of the reflected NIRS signal.
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Affiliation(s)
- E B Wassenaar
- Department of General Surgery, University Medical Centre, Utrecht, The Netherlands
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17
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Wang TL, Hung CR. Role of tissue oxygen saturation monitoring in diagnosing necrotizing fasciitis of the lower limbs. Ann Emerg Med 2004; 44:222-8. [PMID: 15332062 DOI: 10.1016/j.annemergmed.2004.03.022] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
STUDY OBJECTIVE We determine the utility of tissue oxygen saturation monitoring in diagnosing necrotizing fasciitis of the lower extremities. METHODS We prospectively studied patients who met the criteria of soft tissue infection throughout the lower extremities by tissue oxygen saturation monitoring (with near-infrared spectroscopy) over the middle third of possible involved areas. Cases with evidence of chronic venous stasis, peripheral vascular disease, shock, and systemic hypoxia were excluded. Biceps and contralateral unaffected leg areas were measured as references. The tissue oxygen saturation reading for each area was compared with those finally diagnosed as necrotizing fasciitis and those with only simple soft tissue infection. The tissue oxygen saturation reading was presented as mean+/-SD. Receiver operating characteristic (ROC) curves were used to determine a cutoff value of tissue oxygen saturation reading for early diagnosis of necrotizing fasciitis. RESULTS Two hundred thirty-four consecutive patients were enrolled. Nineteen patients (group N) were confirmed to have necrotizing fasciitis, whereas the remaining 215 patients (group C) had only cellulitis. The tissue oxygen saturation reading measured over the biceps muscle was 86%+/-11% in group N and 85%+/-12% in group C. In group N, the leg with necrotizing fasciitis had a tissue oxygen saturation reading of 52%+/-18% throughout the involved site, whereas the tissue oxygen saturation reading measured in the comparative values found in group C was 84%+/-7% (difference 95% confidence interval [CI] 22% to 29%). After fasciotomy, the tissue oxygen saturation reading of the leg with necrotizing fasciitis returned to 82%+/-17% (95% CI 23% to 28% compared with prefasciotomy value) in group N. At the cutoff value of a tissue oxygen saturation reading less than 70% (area under the curve 0.883; 95% CI 0.817 to 0.949) defined by ROC curve, the test revealed a sensitivity of 100% (95% CI 82% to 100%), a specificity of 97% (95% CI 94% to 99%), and an accuracy of 97% (95% CI 95% to 99%). CONCLUSION The low tissue oxygen saturation reading values measured by near-infrared spectroscopy throughout the involved areas of the lower extremities are of value in identifying necrotizing fasciitis. This method may offer a reliable noninvasive method of assessing lower extremities at risk for necrotizing fasciitis, at least for a selected patient population.
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Affiliation(s)
- Tzong-Luen Wang
- Department of Emergency Medicine, Shin-Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan.
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Turnbull D, Mills GH. Compartment syndrome associated with the Lloyd Davies position. Three case reports and review of the literature. Anaesthesia 2001; 56:980-7. [PMID: 11576100 DOI: 10.1046/j.1365-2044.2001.02221.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The Lloyd Davies position was developed to facilitate access to the pelvis for gynaecological, urological and colorectal procedures. Previous case reports have demonstrated that prolonged adoption (> 4 h) of this position has been associated with the development of bilateral compartment syndrome of the calves. All three patients reported here suffered severe bilateral calf pain despite the use of thoracic epidurals. All three cases required three-compartment fasciotomies and, 6 months after surgery, were all still severely disabled as a consequence of the compartment syndrome. These case reports stress the dangers of use of the Lloyd Davies position for prolonged procedures and demonstrate that some patients are at risk after relatively short periods (< 3 h). Previous case reports and clinical studies have focused on the effect of limb elevation in stirrups on the arterial pressure in the lower limb. We review the pathophysiology of compartment syndrome and consider factors other than a decrease in arterial pressure that may predispose to compartment syndrome during adoption of the Lloyd Davies position.
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Affiliation(s)
- D Turnbull
- Department of Anaesthetic Sciences, K Floor, Royal Hallamshire Hospital, Sheffield S10 2JF, UK.
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Nakayama M, Iwasaki S, Ichinose H, Yamamoto S, Kanaya N, Namiki A. Intraoperative acute lower extremity ischemia detected by near-infrared spectroscopy. J Cardiothorac Vasc Anesth 2001; 15:624-5. [PMID: 11688006 DOI: 10.1053/jcan.2001.26544] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- M Nakayama
- Division of Anesthesia, Obihiro Kosei Hospital, Obihiro, Japan.
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Giannotti G, Cohn SM, Brown M, Varela JE, McKenney MG, Wiseberg JA. Utility of near-infrared spectroscopy in the diagnosis of lower extremity compartment syndrome. THE JOURNAL OF TRAUMA 2000; 48:396-9; discussion 399-401. [PMID: 10744275 DOI: 10.1097/00005373-200003000-00005] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine the utility of near-infrared spectroscopy in the diagnosis of lower extremity compartment syndrome (CS). METHODS Nine patients with CS confirmed by physical examination and elevated compartment pressures (64 +/- 17 mm Hg) were evaluated before and after fasciotomy. Control readings were also performed on 33 surgical patients who had no evidence of CS. The deltoid muscle was used as a reference value. RESULTS The deltoid muscle oxygen saturation (StO2) readings revealed a mean = 84 +/- 17% prefasciotomy and mean = 83 +/- 12% postfasciotomy in the CS group. The control group had a mean StO2 of 83 +/- 11%. In the CS group, the leg compartment with the highest pressure had a StO2 mean = 56 +/- 27% before fasciotomy. This value was statistically significantly lower (p < 0.05) than either the postfasciotomy mean StO2 in that compartment (82 +/- 16%) or the values found in matched control patients with no evidence of CS (87 +/- 7%). CONCLUSION Near-infrared spectroscopy-derived StO2 values in the lower extremities of trauma patients with CS were diminished relative to the control patients and usually normalized after fasciotomy. Near-infrared spectroscopy evaluation may offer a rapid, noninvasive method of assessing extremities at risk for CS.
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Affiliation(s)
- G Giannotti
- Finch University of Health Sciences/The Chicago Medical School, Illinois, USA
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21
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Abstract
Near-infrared (IR) light easily penetrates biological tissue, and the information offered by in vivo spectroscopy of cerebral oxygenation is detailed and comes with a high temporal resolution. Near-IR light spectroscopy (NIRS) reflects cerebral oxygenation during arterial hypotension, hypoxic hypoxaemia and hypo- and hypercapnia. As determined by dual-wavelength NIRS, the cerebral O2 saturation integrates the arterial O2 content and the cerebral perfusion, and as established for skeletal muscle, NIRS obtains information on tissue oxygenation and metabolism beyond that obtained by venous blood sampling. Caveats of cerebral NIRS include insufficient light shielding, optode displacement and a sample volume including muscle or the frontal sinus mucous membrane. The relative influence from the extracranial tissue is minimized by optode separation and correction for an extracranial sample volume, or both. The natural pigment melatonin and also water are of little influence to spectroscopic analysis of cerebral oxygenation, whereas bilirubin systematically lowers ScO2 and attenuates the detection of changes in cerebral oxygenation. By NIRS, reduction of cytochrome oxidase is demonstrated during hypoxic hypoxaemia and head-up tilt-induced arterial hypotension, but the changes are small. In the clinical setting, NIRS offers useful information in patients with both systemic and local cerebral circulatory impairment, for example, during cranial trauma, surgery on the cerebral arteries, orthostasis and acute heart failure. Whereas mapping of the brain circulation is needed for jugular venous sampling to reflect either global or local oxygenation, the determination of cerebral oxygenation by NIRS has the advantage of localized monitoring of the cerebral cortex.
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Affiliation(s)
- P L Madsen
- Department of Anaesthesia, the Copenhagen Muscle Research Centre, Rigshospitalet 2041, Denmark
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Duflo F, Allaouchiche B, Mathon L, Chassard D. [Bilateral anterior tibial compartment syndrome from prolonged surgery in the lithotomy position]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 1999; 18:779-82. [PMID: 10486631 DOI: 10.1016/s0750-7658(00)88457-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
We report a case of bilateral lower extremity compartment syndrome in a 52-year-old patient complicating surgery of 8h30 duration in the lithotomy position. Two months later, a bilateral foot drop was persisting. The pathophysiology and the prevention of this complication are discussed.
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Affiliation(s)
- F Duflo
- Département d'anesthésie-réanimation, hôpital de l'Hôtel-Dieu, Lyon, France
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