Compartment syndromes Dr Tultul K Sangma Fellow- ICU Maharaja Agrasen Hospital, Delhi

Overview Introduction Etiology Disease progression Diagnosis Conclusion

Introduction Compartment syndrome Mainly a disorder of the extremities and is most common in lower leg and forearm However, can also occur in other locations eg, upper arm, abdomen, thoracic, buttock It is the increased tissue pressure within a closed fascial space, resulting in tissue ischemia The earliest symptom is pain out of proportion to the severity of injury Abdominal compartment syndrome significantly contribute to the morbidity and mortality of both medical and surgical patients alike in ICU

Etiology: extremity compartment syndrome Crush Ischaemia Arterial injury Vascular ligation Fracture Direct blunt trauma with hematoma/oedema Prolonged external pressure Electrical injury

Etiology: Secondary extremity compartment syndrome Hypotension Massive volume resuscitationwhole body oedema including muscles (post resuscitation systemic inflammatory response syndrome)

Disease progression Begins with tissue edema that normally occurs after injury (eg, soft-tissue swelling or a hematoma). Edema within a closed fascial compartmentlittle room for tissue expansion interstitial (compartment pressure) increases. If >8 mm Hg which exceeds normal capillary pressure, cellular perfusion slows and may ultimately stop. Because 8 mm Hg is much lower than arterial pressure, cellular perfusion can stop long before pulses disappear. Resultant tissue ischemia further worsens edema in a vicious circle. As ischemia progresses, muscles necrose, sometimes leading to rhabdomyolysis, infections, and hyperkalemia; these complications if untreated, can result in death. Hypotension or arterial insufficiency can compromise tissue perfusion with even mildly elevated compartment pressures, causing or worsening compartment syndrome. In limbs, contractures may develop after necrotic tissue heals.

Diagnosis Pain disproportionate to injury Neurologically compromised patient Tense or tight compartments to touch Increased pain with passive muscle stretch, classical for anterior calf compartment-dorsiflexion of great toe Hypoesthesia/muscle weakness

Abdominal compartment syndrome (ACS) Etiology: Primary ACS Abdominal injury or disease Post operative abdominal surgery Ascites in critically ill cirrhotic patients Secondary ACS massive volume resuscitation Sepsis, multiple organ failure Space occupying fluid in the abdomen Oedematous tissue in abdomen Space occupying hematoma in retroperitoneum

Diagnosis Tensely distended abdomen, however often normal, with oliguria Decreased cardiac output, decreased pulmonary function, raised ICP Intra-abdominal pressure measurement Bladder pressure measurement Inferior vena cava pressure measurement Organ dysfunction

How to measure bladder pressure? Clamp foley Instill 20-100ml NS Measure pressure at level of symphysis Normally 5-7mmHg in critically ill adults. Increased in increased body mass index >12mmHg intra- abdominal hypertension >20mmHg abnormal 25-35mmHg needs operative decompression

Complications Multiorgan failure: renal, pulmonary, cardiovascular Physiological impairment: splanchnic, neurological Death: 100% if not treated, 40-70% if treated

Treatment Urgent decompression laparotomy. Avoid reperfusion syndrome Temporary abdominal fascial closure Close abdomen Gastric and colonic decompression Neostigmine or other prokinetic drugs Neuromuscular blockade Diuresis Avoid head elevation > 30 degrees Avoid prone position Ultrafiltration Percutaneous drainage of intraperitoneal fluid or gas

Thoracic compartment syndrome May occur after trauma and after mediastinal and cardiac procedures. Cl features: Elevated airway pressure, low cardiac output, worsening acidosis May result in cardiopulmonary collapse Treatment: opening the chest, and often pericardium, through median sternotomy

Conclusion Identification of patients at risk, early recognition, and timed intervention is key to effective management of compartmental syndrome. If left untreated, abdominal compartment syndrome is almost uniformly fatal