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Compartment Syndrome in Surgical Patients Mary E Ⅵ CASE REPORTS Anesthesiology 2001; 94:705 © 2001 American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc. Compartment Syndrome in Surgical Patients Mary E. Warner, M.D.,* Lisa M. LaMaster, B.A.,† Amy K. Thoeming, B.S.N.,† Mary E. Shirk Marienau, M.S., C.R.N.A.,* Mark A. Warner, M.D.‡ COMPARTMENT syndrome is a potentially devastating curred in traumatized limbs or limbs that were subject to postoperative complication that can occur during or ischemia from vascular surgical procedures were ex- after surgery. It is a tissue injury that causes pain, ery- cluded. All surgical episodes must have been performed thema, edema, and hypoesthesia of the nerves in the while patients underwent general or regional anesthesia affected area. In general, fasciotomy must follow clinical or local anesthesia with or without sedation. A single Downloaded from http://pubs.asahq.org/anesthesiology/article-pdf/94/4/705/330517/0000542-200104000-00026.pdf by guest on 01 October 2021 diagnosis quickly to prevent permanent tissue damage.1 trained reviewer abstracted all records. Outcomes of If undiagnosed or diagnosed late, it may cause severe these patients at least 2 yr after the index surgeries were rhabdomyolysis, irreversible nerve deficits, loss of limb, obtained. A survey of the impact of the syndrome on or even death. A high proportion of cases have been daily activities, rated as mild, moderate, or major, was reported to occur in patients undergoing surgical proce- obtained from all patients with persistent neurologic dures while in the lithotomy position.1–12 dysfunction of at least 2 years’ duration. Mild impact was Perioperative compartment syndrome for which there defined as “often noticeable but not associated with any is no readily apparent cause (e.g., secondary to trauma or limitation of activities of daily living.” Moderate impact arterial embolism after vascular surgery) is not well- was defined as “always noticeable and associated with understood. Therefore, we reviewed the outcomes of a some limitation of one or more activities of daily living.” large number of surgical procedures to determine this Major impact was defined as “always noticeable and complication’s frequency and to further characterize its associated with significant limitation of multiple activi- natural history and outcomes. ties of daily living.” Statistical Analysis Methods The frequency of compartment syndrome was calcu- With Mayo Institutional Review Board approval, the lated along with the corresponding 95% confidence in- medical database at Mayo Medical Center, Rochester, terval. The frequencies of compartment syndrome for Minnesota, was reviewed to glean the data of all patients various patient positions were compared with the fre- who had undergone an index (i.e., initial) surgical epi- quency of this event in patients in the supine position sode and, within 5 days, a subsequent fasciotomy during using the Fisher exact test. Because less than 20 cases the 10-yr study period from July 1, 1989 to June 30, were identified, a case–control evaluation for risk factors 1999. Each unique anesthetic was considered to repre- was not performed. sent a single surgical episode, regardless of the number of procedures performed during that anesthesia. We attempted to glean only cases in which perioperative Results positioning or some unrecognized characteristic or During the study period, 499,214 patients underwent event may have caused the compartment syndrome. 572,498 surgical episodes. Nineteen percent (95,269) Therefore, cases of compartment syndrome that oc- underwent more than one surgical episode. The anes- thetic care provided during the 572,498 surgical epi- Additional material related to this article can be found on the sodes included general or combined general and re- c ANESTHESIOLOGY Web site. Go to the following address, click on gional anesthetics in 401,567 episodes (70.1%), regional Enhancements Index, and then scroll down to find the appro- anesthetics in 62,133 episodes (10.9%), and local anes- priate article and link. http://www.anesthesiology.org thetics or sedation in 108,798 episodes (19.0%). The predominant patient position during these 572,498 sur- gical episodes was supine in 462,204 episodes (80.1%), * Assistant Professor of Anesthesiology, Mayo Medical School, Rochester, lithotomy in 52,319 episodes (9.1%), lateral decubitus in Minnesota. † Student Registered Nurse Anesthetist, Mayo School of Health Related Sciences, Mayo Clinic, Rochester, Minnesota. ‡ Professor of Anesthesi- 19,422 episodes (3.4%), and either prone, other posi- ology, Mayo Medical School, Rochester, Minnesota. tions, or unknown in 38,553 episodes (6.7%). Just over Received from the Department of Anesthesiology, Mayo Foundation, Roches- half of the 499,214 patients were female (52.2%, n ϭ ter, Minnesota. Submitted for publication June 2, 2000. Accepted August 31, 2000. Supported by the Mayo Foundation, Rochester, Minnesota. 260,591). The mean age (Ϯ SD) of the surgical popu- Address reprint requests to Dr. Warner: Department of Anesthesiology, Mayo lation was 49.2 Ϯ 18.3 yr, with ages ranging from 0 to Clinic, 200 First Street SW, Rochester, Minnesota 55905. Address electronic mail to: [email protected]. Individual article reprints may be purchased 108 yr. through the Journal Web site, www.anesthesiology.org. Overall, 485 of the 499,214 patients (0.1%) underwent Anesthesiology, V 94, No 4, Apr 2001 705 706 CASE REPORTS a fasciotomy. Just over half of these patients (51.3%, n ϭ Postfasciotomy surveillance was obtained for all pa- 249) underwent this procedure secondary to trauma. tients, either until resolution of their neurologic symp- Compartment syndrome developed in 173 patients toms or, for those who had persistent symptoms, for at (35.7%), necessitating fasciotomy within 48 h of a vas- least 2 yr. The symptoms of six patients resolved within cular surgical procedure. Eighteen patients (3.7%) expe- the first year, including two who had complete neuro- rienced the syndrome after an arterial embolic event logic recoveries within 2 weeks of fasciotomy. Six of the associated with recent onset of atrial fibrillation, 12 patients remaining seven patients had persistent neurologic def- (2.5%) had a perfusion-limiting lower extremity cancer of icits and pain of at least 2 years’ duration. One patient, a the bone or vasculature, and 20 patients had a variety of 36-yr-old man who underwent a 6.3-h craniotomy in a miscellaneous conditions. There was no apparent preexist- lateral decubitus position, had development of compart- ing cause for compartment syndrome in 13 patients (2.7%). ment syndromes in his left forearm and hand, resulting Downloaded from http://pubs.asahq.org/anesthesiology/article-pdf/94/4/705/330517/0000542-200104000-00026.pdf by guest on 01 October 2021 The patient and procedure characteristics and outcomes of in arterial thrombosis and eventual forearm amputation these 13 patients are described in table 1. on the fourth postoperative day. In a surveillance survey The frequency (and 95% confidence interval) for com- of the seven patients with persistent deficits of at least 2 partment syndrome requiring fasciotomy in the absence years’ duration, one patient reported that her disability of apparent preexisting causes was 2.3 per 100,000 mildly impacted her daily living functions, three re- surgical episodes overall (1.2–3.9 per 100,000). The ported a moderate impact on daily functions, and three same figures for this event in only those patients to described the impact as major. whom general anesthetics were administered during their surgical episodes were 3.2 per 100,000 patients (1.7 to 5.5 per 100,000). It was more likely to occur in patients Discussion who underwent procedures while in the lithotomy or lat- eral decubitus positions than in a supine position. This Compartment syndrome is considered to occur primar- problem developed in 5 of the 462,204 patients in a supine ily in patients who undergo procedures while in the position (1 per 92,441). In contrast, it developed in 6 of lithotomy position. Our data confirm that compartment 52,319 patients in the lithotomy position (1 per 8,720) and syndrome is more likely to develop with no apparent 2 of 19,422 patients in the lateral decubitus position (1 per cause when the patient is in the lithotomy position than 9,711). The event frequencies for patients in the lithotomy in a supine position. However, we were surprised by and lateral decubitus positions were much higher (P Ͻ three of our findings: (1) patients in lateral decubitus 0.001 and P ϭ 0.03, respectively) than the frequency for positions unexpectedly had a high frequency of com- patients in a supine position. partment syndrome, (2) compartment syndromes neces- There were few characteristics that distinguished the sitating fasciotomies of the upper extremities developed 13 patients in whom compartment syndrome developed in three patients (23%), and (3) nearly half of the patients with no apparent preexisting cause. Their ages ranged in whom compartment syndromes developed in the from 17 to 67 yr; they underwent a variety of proce- lower extremities underwent procedures while in the dures, ranging from reimplantation of fingers to hemipel- supine position. There are few case reports of upper vectomy; and they were positioned in a variety of surgi- extremity compartment syndrome with causes other cal configurations. All underwent procedures during than trauma or vascular surgery. With the exception of a administration of general anesthetics. The one notewor- few reports of compartment syndrome developing in the thy characteristic was their relatively long surgical pro- lower extremities of patients who were positioned cedures. These ranged from 3.2 to 15.7 h, with an prone in “tucked,” “kneeling,” or “knee-chest” positions average duration of 7.2 h. In contrast, the average dura- for lumbar spine surgery,13–15 nearly all other reports of tion of procedures for all patients during this 10-yr study position-related compartment syndrome of the lower period was 2.7 h.
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