Compartment+Syndrome

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Compartment syndrome is permanent damage to muscle, nerves, blood vessels or other organs caused when pressure within a compartment exceeds perfusion pressure. It is a rare complication of surgery. The main sites are the limbs and abdomen. Unless recognized and treated early compartment syndrome can lead to permanent loss of function or death.

=Etiology= Compartment syndrome can occur in any compartment where the compartment pressure > perfusion pressure for a prolonged period. The main sites and common causes are:

n Upper limb Lower limb Abdomen
 * Fractures and crush injury
 * Burns
 * Intra-arterial injection
 * Fractures and crush injury
 * Burns
 * Patient position (so called “well leg" compartment syndrome)
 * Intra-abdominal sepsis
 * AAA
 * Ileus
 * Ascites

=Pathophysiology= Compartment syndrome occurs when **Compartment Pressure > Perfusion Pressure**. Perfusion pressure can be measured clinically as the MAP for that limb or organ. Reduced perfusion (below that required for normal oxygenation of the tissues) results in release of inflammatory factors causing dilatation and tissue edema. This in turn results in further swelling, increased compartment pressure and reduced perfusion. Compartment syndrome resulting from patient positioning - as seen in the OR - tends to result from a more insidious rise in compartment pressure compared with traumatic causes.

Compartment syndrome can occur hours post surgery as a result of re-perfusion and hyperemia, secondary to prolonged hypoxia of a limb compartment.

=Patient positioning= Anything that increases compartment pressures or reduces perfusion increase the risk of compartment syndrome. ==Increased compartment pressure== Pressure points Use of compression stockings of Flotrons

Decreased perfusion (MAP)
Calf / limb elevation (Lloyd Davies, lithotomy) Trendelenburg Hypotension/hypovolemia

Other
Hypoxia Surgical duration <5 hours

=Diagnosis= The key to diagnosis is clinical suspicion in the postoperative period.

Clinical
Compartment Syndrome is a clinical diagnosis. Diagnosis of compartment syndrome is classically described in terms of the 6 Ps: **P**ain (on passive movement, out of proportion to stimulus), **P**aresthesia, **P**aralysis, **P**ulseless, **P**allor and **P**erishing cold.

Compartment pressure measurement
Compartment pressure of >30 mmHg can be diagnostic, but a low compartment pressure measurement in the light of clinical presentation should not be reassuring because of a lack of reliability these measurements.

Confounding factors in diagnosis.
Epidural or spinal anesthesia can mask postoperative lower limb pain In some circumstances, compartment syndrome in the hand may not be painful certain compartments do not have nerves running within them. Delayed presentation: compartment pressures may only build after the limb is returned to its normal position and a period of hyperemia ensues.

=Treatment= Treatment of compartment syndrome is emergent fasciotomy.

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