Postoperatives bilaterales Kompartmentsyndrom der Unterschenkel nach ausgedehnten urologischen Eingriffen in Steinschnittlage

Abstract

We report two cases of compartment syndrome of the lower leg that occurred in male patients aged 62 and 57 years, respectively, after 10 and 12-h urological surgery in the lithotomy position. During sedation and mechanical ventilation creatine kinase (CK) activity of more than 8,000 U/l was found in both patients. After extubation, clinical symptoms of the compartment syndrome were found. On the 1st day after surgery patient 2 underwent fasciotomy of both lower legs (Fig. 2). No lasting neurologic defects were observed. Patient 1 was treated by fasciotomy on the 4th postoperative day after paresis of the peroneal nerve had developed in the left lower leg. This paresis had shown no tendency to regression when the patient left hospital. On phlebography, both patients showed blockage of the deep lower leg veins up to the knee. DISCUSSION. The compartment syndrome is a rare but serious complication resulting from prolonged surgery in the lithotomy position. Symptoms are neuromuscular lesions of the affected limb. Severe complications of the compartment syndrome are acute renal failure resulting from myoglobin residues in the tubules, electrolyte disturbances, and disorders of acid-base balance. A decrease in perfusion due to the elevated position of the legs, on the one hand, and the impeded venous back-flow due to the positioning on the other are discussed. While positioning the legs, it is important to ensure that the lower legs are lifted only slightly above left atrial level. When rehabdomyolysis occurs, serum CK activity increases. CK values of over 2,000 U/l after surgery may be considered a warning sign in ventilated and sedated patients, in whom early clinical symptoms of the compartment syndrome such as pain and paresthesias cannot be ascertained. Frequent and regular checks of these parameters starting shortly after surgery are recommended. A thorough examination of the lower legs and, if necessary, measurement of the tissue pressure in the compartment should follow. The deep veins of the legs should be checked by phlebography. In cases of verified compartment syndrome, early fasciotomy is the best choice of therapy, because neuromuscular defects are known to be irreversible after 12 to 24 h. Enforced diuresis is recommended in order to avoid renal complications.

Lower leg compartment syndrome following prolonged orthopedic surgery in the lithotomy position -A case report-

“…The maximum safe time length of the operation has not been clearly known, but it was reported that the compartment syndrome occurred after more than 4 hours of operation by Warner and Martin [9], 10-12 hours of operation by Lampert et al [10], and 13 hours and 15 minutes of operation by Kumamato et al [11]. These risk factors were not involved in the case report herein, but the operation took 6 hours and 20 minutes.…”

“…Since irreversible neuromuscular defects occur 12-24 hours after the operation [10], diagnosis is very important. Mar et al [15] reported that the pain is unreliable, as cardinal symptom and physical examination are also unreliable for the diagnosis.…”

Compartment Syndrome Following Lower Limb Arthroplasty: A Review

“…CK values of over 2,000 U/l after surgery may be considered a warning sign in ventilated and sedated patients, in whom early clinical symptoms of the compartment syndrome such as pain and paresthesias cannot be assessed [50]. The presence of myoglobinuria suggests an impending CS but the amount of myoglobinuria does not correlate with the degree of underlying tissue injury [51].…”

“…The presence of myoglobinuria suggests an impending CS but the amount of myoglobinuria does not correlate with the degree of underlying tissue injury [51]. Prophylactic use of mannitol may obviate the need for decompressive fasciotomy [41], however if myoglobinuria is established enforced diuresis is recommended in order to avoid renal complications [50]. …”

Diagnosing acute compartment syndrome—where have we got to?

“…Additionally, creatine kinase and lactate levels rise, due to muscle breakdown and anaerobic metabolism respectively. Creatinine kinase levels of > 2000 units/L can be a warning sign of compartment syndrome in a sedated and ventilated patient [65]. Similarly, ischaemia-modified albumin (IMA) has been shown to rise with reasonable sensitivity and specificity in the presence of critical limb ischaemia; however, its role in aiding the diagnosis of ACS remains unclear [66].…”