1. Compartment Syndrome Related to Infusion Therapy
Scott McKay, MD
Texas Children’s Hospital
Baylor College of Medicine
Houston TX

2. Outline
Pathophysiology
Etiology
Diagnosis
Treatment

3. Definition
Tissue necrosis in a muscular compartment resulting from increased intra-compartment pressure

4. Pathophysiology Certain muscles are bounded by rigid fascial linings
Fascia cannot expand to accommodate increased tissue pressure.
Sustained increased pressure leads to irreversible tissue damage.

5. Anatomy – lower leg 4 major compartments
Vessels
Nerves
Muscles
Subcutaneous space is separate from muscle compartment

6. Anoxic positive feedback loop
Venule compression
Increased vascular resistance
Blood shunted away from system
Cellular ischemia
Interstitial edema
Increased interstitial pressure

7. Arteriovenous gradient
Compartment syndrome is higher resistance system
Blood preferentially flows towards lower resistance systems

8. Tissue Damage Nerves Muscle 1 hour to reversible damage
4-6 hours irreversible damage
Muscle
Reversible up to 6-8 hours

9. Etiology Tissue trauma Ischemia/reperfusion Compression
Post vascular repair/injury
Compression
Chemical tissue damage
What causes swelling?

10. Trauma Fractures Crush injuries Elbow, forearm, tibia
Falls, ATV, MVA, industrial accidents, earthquakes

11. Chemical Tissue Damage
Burns
Bites
Medication extravasation

12. External compression Intoxication/overdose “found down”
Tight casts/splints/dressings
IV fluid infiltration

13. Ann Plast Surg 2011;67: 531–533

14. Pediatric Compartment Syndrome Caused by Intravenous Infiltration
Simon G. Talbot, MD, and Gary F. Rogers, MD, JD, MBA, MPH
Ann Plast Surg 2011;67: 531–533
A 10-month-old child was readmitted for dehydration after a hypospadias repair. He was rehydrated through a dorsal hand IV catheter through a pressure monitoring pump. The patient was noted by the incoming morning nurse to have an edematous arm. On further examination, he had blanching of the hand, mottling of the skin, and the fingers were held in an intrinsic minus position. The infant was unable to actively flex or extend the fingers, and passive motion caused pain (Fig. 2).
The patient was taken urgently to the operating room. Under anesthesia, the wrist and fingers were stiff. Compartment pressures were measured at 40 to 55 mm Hg. The dorsal and volar forearm compartments were released through a single incision, and the hand compartments and carpal tunnel were released. The wounds were dressed with moist dressings and closed within a week. The child has had a full functional recovery.
Case 2

15. A 7 month-old was admitted to the intensive care unit for observation after biopsy of a palatal lesion. Fluids were delivered through a dorsal foot IV catheter using a pressure monitoring pump. The patient’s family wrapped him for comfort. The infant became increasingly fussy in the morning, requiring narcotics. During the morning shift change, the incoming nurse removed the body cover and discovered swelling of the leg. The skin was tense with mottling and blistering. There was no active motion of the extremity, and passive motion was restricted, eliciting pain. Capillary refill was decreased but pulses remained (Fig. 3).
He was taken urgently to the operating room. Compartment pressures were elevated at 40 to 53 mm Hg. Decompressive fas- ciotomies were performed on the thigh, medial and lateral leg, and foot. The muscle appeared pale on compartment opening, but rapidly returned to normal. The wounds were managed initially with a Vacuum Assisted Closure dressing and were closed in the oper- ating room a week later. The child has no functional consequences.

16. 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
Greene AK, Hergrueter CA. Intravenous extravasation injuries. In: Manual of Neonatal Surgical Intensive Care. Hamilton, ON, Canada: BC Decker; 2006.
Noonan C, Quigley S, Curley MA. Skin integrity in hospitalized infants and children: a prevalence survey. J Pediatr Nurs. 2006;21:445–453.

17. Ischemia/Reperfusion
4 year old girl fell from playground equipment
Pulseless supracondylar humerus fracture
Fracture fixation, vascular reconstruction, prophylactic compartment release

18. Excellent outcome

19. 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

20. DO NOT USE 5 P’s! Pallor Pulselessness Paralysis Pain Paresthesias
These are signs of severely decreased perfusion, not unique to compartment syndrome
The classic “five P’s” of ischemia: pallor, pain, pulselessness, paresthesias, and paralysis, have been historically mentioned as diagnostic criteria for Compartment Syndrome. However, Compartment Syndrome is usually present long before these signs of severe limb ischemia are apparent, and the 5-P’s should therefore NOT be used for its timely diagnosis.
Recent Lancet article: “If the patient is awake, the 5 Ps to consider are pain, pain, pain, pain, and pain.”

21. Reliable Early Signs Pain out of proportion
Pain with passive stretch of muscles
Pain with muscle activation
Abnormal sensation in compartment nerves
Kalyani BS, Fisher BE, Roberts CS, Giannoudis PV: Compartment syndrome of the forearm: A systematic review. J Hand Surg Am 2011;36(3):
J Hand Surg Am 2011;36(3):

22. Not as reliable “Firm” or “Tense” compartments “Paralysis”
Due to pain or guarding? Or true paralysis
Shuler FD, Dietz MJ: Physicians’ ability to manually detect isolated elevations in leg intracompartmental pressure. J Bone Joint Surg Am 2010;92(2):
J Bone Joint Surg Am 2010;92(2):

23. The 3 As Children not little adults
“Anxiety, Agitation, increasing Analgesia requirement”

24. 3 A’s of Compartment Syndrome in children
Anxiety
Agitation
Increasing Analgesia requirement
(2001). Journal of Pediatric Orthopedics, 21(5), 680–688.

25. Compartment pressures
So why not measure the compartment pressure?
30-35 mmHg
10-15
mmHg

26. How high is too high? Absolute pressure >30mmHg
Within 30mmHg of Diastolic pressure (ΔP)
Within 20mmHg of Diastolic (ΔP)
Within 30mmHg of MAP

27. 48 tibial shaft fractures WITHOUT compartment syndrome
35% false positive rate (ΔP<30)
22% absolute pressure >45mmHg
The Journal of Trauma and Acute Care Surgery (2014) 76(2), 479–483.

28. 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”
Mars, M., & Hadley, G. P. (1998). Raised compartmental pressure in children: a basis for management. Injury, 29(3), 183–185.
(1998) Injury, 29(3), 183–185.

29. 20 healthy children (2m-6y) & 20 adults Absolute Pressures
13-16mmHg in children
5-9mmHg in adults
Staudt, J. M., Smeulders, M. J. C., & van der Horst, C. M. A. M. (2008). Journal of Bone and Joint Surgery - British Volume, 90(2), 215–219.

30. 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.

31. 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.

32. Most common method Kit with clear directions Found in OR and ER
Orthopaedic Surgeons are the most familiar

33. Or use older manometer

34. Or, just use arterial line set-up

35. 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.
Near infrared spectroscopy: clinical and research uses. (2013). Near infrared spectroscopy: clinical and research uses. Transfusion, 53 Suppl 1, 52S–58S.

36. Calculates end-organ tissue perfusion
NIS device
Infrared
Near-infrared
Venous blood
Arterial blood
StO2 = difference between oxygenated and deoxygenated blood

37. NIS uses Shock patients Subarachnoid hemorrhage
Cerebral monitoring during CV surgery
Stroke management
Compartment Pressure monitoring
* readings affected by hematomas and subcutaneous fluid collections*
Near infrared spectroscopy: clinical and research uses. (2013). Near infrared spectroscopy: clinical and research uses.Transfusion, 53 Suppl 1, 52S–58S.

38. Treatment Nonsurgical Surgical treatment Remove Tight dressings
Elevation ?????
Stop infusions
Supplemental O2
Surgical treatment
fasciotomy

39. Surgery
Emergent fasciotomy
Delayed closure
+/- Skin graft

40. Factors to predict outcome
Early diagnosis and treatment
Severity of inciting event
Skin graft or primary closure?
Rhabdomyolysis causing kidney failure

41. (2011). The Journal of Bone and Joint Surgery
(2011). The Journal of Bone and Joint Surgery. American Volume, 93(10), 937–941.

42. 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

44. 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