Síndrome compartimental no primeiro interósseo dorsal: relato de caso / Compartment syndrome in the first dorsal interosseous compartment: case report

Resumo O diagnóstico da síndrome compartimental em regiões que não são frequentemente afetadas, por possuírem uma boa relação continente-conteúdo, pode se tornar difícil, uma vez que o cirurgião terá dificuldades em alcançar um diagnóstico apenas por um sinal ou sintoma isolado. Assim, muitas vezes, pode-se protelar a conduta adequada, desencadeando danos ao paciente. A paciente era uma mulher, de 29 anos, que foi atendida com dor em mão esquerda por queimadura, com lesão em região anterior à tabaqueira anatômica de tamanho significativo. A paciente já havia sido submetida a cirurgia na sua cidade de origem com desbridamento de pele e tecido subcutâneo há 30 dias, com evolução sem melhora do quadro doloroso. Estava em uso de antibioticoterapia (ceftriaxona 1 g de 12 em 12 horas) e analgesia com dose terapêutica de morfina de 8 em 8 horas.

Abstract In areas that are not commonly affected by compartment syndrome because they have a good content/container ratio, diagnosis of the condition can be a challenge, since surgeons will find it difficult to make a diagnosis on the basis of an isolated sign or symptom. As a result, the correct treatment can very often be delayed, causing harm to the patient. In this case, the patient was a 29-year-old woman who was seen for a painful left hand secondary to a large burn injury to the area anterior of the anatomical snuffbox. She had already undergone surgery in her home town 30 days previously, with debridement of skin and subcutaneous tissue, but the pain had not improved. She was on antibiotic therapy (ceftriaxone, 1g every 12 hours) and analgesia, with therapeutic morphine doses every 8 hours.

A Case of Nonisland Pedicled Foot Fillet Flap for Below-Knee Amputation Stump Wound: Treatment Option for Compartment Syndrome after Fibular Free Flap Surgery

Despite the frequent use of the fibular free flap, there have been no reports of severe compartment syndrome of the donor leg that necessitated limb amputation. A 66-yr-old man had a fibular osseous free flap transfer from the left leg to the mandible that was complicated by postoperative compartment syndrome. An extensive chronic leg wound resulted, which was treated with multiple debridements and finally with below-knee amputation. Successful coverage of the below-knee amputation stump was accomplished with a nonisland pedicled foot fillet flap. Various foot fillet flaps may be used acutely as a free or an island pedicled flap, but dissection of the vascular pedicle may be difficult in a chronically inflamed wound because of inflammation and adhesions to surrounding tissue. The nonisland pedicled foot fillet flap may be considered as a useful option for treatment of a chronically inflamed stump wound after below-knee amputation.

[Comparison of intra-abdominal pressure measurement and physical exam for diagnosis of surgery indication in patients with abdominal compartment syndrome due to blunt trauma]

Increase in abdominal pressure can lead to the so-called intra-abdominal compartment syndrome [ACS] that is often observed during the first 24 hours after sever abdominal trauma and surgery. Measurement of the intra abdominal pressure through the bladder as a non-invasive measurement can provide a quick and accurate assessment of abdominal pressure changes. This study was performed to compare the diagnostic value of intra-abdominal pressure measurement through the bladder with that of physical exam in the diagnosis of surgery indication. This descriptive-analytical study was performed on patients with intra-abdominal compartment syndrome due to blunt abdominal trauma referred to Nemazee hospital, Shiraz, Iran. Tools for data collection included a check list consisting demographic information, and intra-abdominal pressure measurement instruments. Data analysis was done through SPSS software. Of 100 patients with abdominal trauma whose abdominal pressures were measured, 28 ones had abdominal compartment syndrome of whom, 21 ones [75 percent] were referred to the operation room by physician. Among all patients who were sent to the surgery room, 5 patients [23.80%] were survived and all those who were not sent to the surgery room died. Mean diagnosis time of measuring abdominal pressure for detection of operation indication was significantly lower than that of physical exam [P<0.01]. Age, sex, type of trauma and type of injury to internal organ had no significant relationship with the rate of abdominal compartment syndrome. Also, there was no significant difference between the two methods in finding surgery indication. Implementing education on methods of early diagnosis of intra-abdominal pressure increase for medical team especially nurses is one of the treatment priorities

Síndrome compartimental abdominal / Abdominal compartment syndrome

JUSTIFICATIVA E OBJETIVOS: Recentemente, aumentou o interesse no reconhecimento e na importância clínica da síndrome compartimental abdominal em pacientes críticos já que o aumento da pressão intra-abdominal resulta em uma progressiva disfunção de órgãos. O objetivo deste estudo foi fornecer atualização clínica para um diagnóstico preciso, manuseio e intervenção adequados na síndrome compartimental abdominal, com particular ênfase em cuidados intensivos. CONTEÚDO: Foram selecionados 43 artigos, capítulos de livros nas bases de dados MedLine, SciElo e LILACS (1969-2009), por meio das palavras-chave: hipertensão abdominal, síndrome compartimental abdominal, fisiopatologia, diagnóstico, manejo e tratamento. Adicionalmente, referências desses artigos, capítulos de livros e artigos históricos foram fornecidos pelo arquivo pessoal dos próprios autores e avaliados. São apresentados os dados de artigos, sem a interferência direta da análise pessoal dos autores. CONCLUSÃO: O impacto negativo do aumento progressivo da pressão intra-abdominal, evoluindo para síndrome compartimental abdominal é reconhecido tanto nas unidades de cuidados intensivos clínicos quanto nas cirúrgicas. Devido à sua incidência, o manejo diário da pressão intra-abdominal deve ser rotina nos pacientes de alto risco, na unidade terapia intensiva (UTI). A descompressão cirúrgica continua sendo o padrão-ouro para o tratamento rápido e definitivo da síndrome compartimental abdominal, masas medidas clínicas podem ser efetivas para minimizar os níveis de pressão intra-abdominal e síndrome compartimental abdominal.

Abdominal compartment syndrome--an old syndrome, a new perspective.

The abdominal compartment syndrome is a life threatening condition resulting from pathologic elevation of the intraabdominal pressure. Prompt diagnosis is required to avoid significant sequelae. Diagnosis of this syndrome is based on clinical findings and intra abdominal pressure monitoring. Treatment consists of decompressive laparotomy, which corrects the pathology. Various surgical techniques are described to manage the open abdomen. Despite considerable attention accorded to this disorder, it is still associated with high morbidity and mortality. This review article deals with the identification of risk factors, pathophysiology, diagnostic criteria and treatment of critically ill patients with the abdominal compartment syndrome.

Abdominal compartment syndrome monitoring in major burn patients with Siriraj device catheter.

Abdominal compartment syndrome (ACS) is consistently reported to have significant morbidity and mortality. Major burn patients who receive massive fluid resuscitation are at high-risk for this condition. Close monitoring of ACS is necessary for these patients. Prolonged unrelieved intra-abdominal pressure (IAP) at greater than 20 mmHg can produce significant morbidity and mortality. The most widely accepted and feasible way to measure IAP is via the draining port of a standard urinary catheter Siriraj burn unit developed its own device from simple equipment that can be found easily in the hospital. It proved to be useful, cheap, and effective in monitoring intra-abdominal pressure. The present study described techniques of using this device for monitoring and early detection of ACS. Five major burn patients > or = 40% Total body surface area (TBSA) was measured by IAP measurement via foley catheter using the Siriraj device catheter compared to direct measurement via peritoneal catheter. There was no difference of IAP between the two methods (p = 0.48). This suggested that Siriraj device catheter was useful, not invasive, and effective in reflection of actually IAP Siriraj burn unit suggested IAP measurement in all major burns > or = 40% TBSA to early recognize and treat intra-abdominal hypertension(IAH) that can lead to ACS. Early detection of this syndrome might decrease the adverse effects after increasing abdominal pressure that can cause organ dysfunction.

Effect of hemodialysis on intra-abdominal pressure

OBJECTIVE: To study the effect of hemodialysis on intra-abdominal pressure. METHODS: Five patients admitted between July and November of 2003 were evaluated in the intensive care unit. Intra-abdominal pressure was measured before and after hemodialysis, maintaining the ventilatory parameters except for PEEP (positive-end expiratory pressure). RESULTS: Intra-abdominal pressure was significantly reduced by hemodialysis in all the 5 patients. CONCLUSION: Hemodialysis significantly reduced intra-abdominal pressure in the 5 patients, an effect which could have influence over other organic systems. This reduction is related to the weight variation before and after hemodialysis, as well as to the loss of volume caused by this procedure.

OBJETIVO: Pesquisar o efeito da hemodiálise sobre a pressão intra-abdominal. MÉTODOS: Foram avaliados cinco pacientes internados entre julho e novembro de 2003, na Unidade de Terapia Intensiva do Serviço de Nefrologia do Hospital das Clínicas de São Paulo. Mensurou-se a pressão intra-abdominal antes e após a hemodiálise, mantendo os parâmetros ventilatórios exceto a PEEP (positive end expiratory pressure). RESULTADOS: Constatou-se que a hemodiálise foi capaz de reduzir significativamente a PIA em cinco pacientes na Unidade de Terapia Intensiva CONCLUSÃO: A hemodiálise reduziu a pressão intra-abdominal numa amostra de cinco pacientes, de maneira significativa, o que poderia influenciar os demais sistemas orgânicos. Essa redução está relacionada com a variação de peso pré e pós-hemodiálise, e com a perda de volume promovida pelo procedimento.

Síndrome compartimental del abdomen en el paciente crítico / Abdominal compartment syndrome in critically ill patients

En la última década se ha observado un incremento de la literatura disponible sobre hipertensión intrabdominal (HIA) y síndrome compartimental del abdomen. Dado las importantes implicancias fisiopatológicas del aumento de la presión intrabdominal (PIA) en la función de órganos dentro y fuera del abdomen, este tópico es y será trascendente en los próximos años para una población de pacientes críticamente enfermos tanto neonatales, pediátricos como adultos. El objetivo de la presente revisión es efectuar una puesta al día sobre definiciones, epidemiología, metodología de medición, implicancias fisiopatológicas, hallazgos radiológicos y opciones terapéuticas. Mensajes claves a conocer por el lector son: (1) el índice de masa corporal y la resucitación con volumen predicen el desarrollo de HIA; (2) la HIA aumenta las presiones intratorácicas, intracraneana y de llenado cardíaco, y disminuye la compliance ventricular izquierda, de la pared torácica y total del sistema respiratorio; (3) la HIA causa atelectasia y aumenta el contenido de agua extravascular pulmonar; (4) la mejor presión positiva de fin de espiración (PEEP) debe ser indicada para contrarrestar la HIA; (5) estrategias de ventilación protectora deben de estar orientadas por DPpl (presión plateau-PIA); (6) presiones transdiafragmáticas e indicadores volumétricos reflejan mejor la precarga; (7) la HIA es un predictor independiente de falla renal aguda; (8) la HIA gatilla translocación bacteriana y desarrollo de síndrome de falla orgánica múltiple; (9) se recomienda la monitorización de la presión de perfusión abdominal en casos seleccionados.

Rabdomiólise por síndrome compartimental glútea após cirurgia bariátrica: relato de caso / Rhabdomyolysis secondary to gluteal compartment syndrome after bariatric surgery: case report

JUSTIFICATIVA E OBJETIVOS: A cirurgia bariátrica tornou-se rotineira e muitas complicações têm sido relatadas. O objetivo deste relato foi apresentar um caso de síndrome compartimental glútea que evoluiu para insuficiência renal aguda após cirurgia bariátrica e discutir aspectos do diagnóstico e condutas profilática e terapêutica. RELATO DO CASO: Paciente do sexo masculino, 42 anos, branco, índice de massa corporal (IMC) 43, estado físico ASA II, submetido à cirurgia bariátrica tipo duodenal switch, sob anestesia geral associada à anestesia peridural. O procedimento transcorreu sem intercorrências. O tempo anestésico-cirúrgico foi de 3 horas e 30 minutos. No primeiro dia do pós-operatório o paciente apresentou dor na região lombossacral e nas nádegas, além de parestesia nos membros inferiores na distribuição do nervo isquiático. Durante o exame, as nádegas apresentavam discreta palidez, tensas, edemaciadas, dolorosas à palpação e à movimentação. Foi diagnosticada síndrome compartimental glútea que evoluiu com rabdomiólise e insuficiência renal aguda. Houve recuperação da função renal e nenhuma seqüela motora ou sensitiva foi detectada. CONCLUSÕES: Os pacientes obesos mórbidos submetidos à cirurgia bariátrica podem apresentar síndrome compartimental glútea. Quando não diagnosticada e tratada precocemente, podem evoluir com rabdomiólise e insuficiência renal aguda que representam grave ameaça à vida.

Identification and management of Abdominal Compartment Syndrome in the Pediatric Intensive Care Unit

OBJECTIVE: Asses if Abdominal Compartment Syndrome (ACS) increases the morbidity and mortality of the Pediatric Intensive Care Unit patients and if early recognition and intervention with decompressive therapy will alter outcome and decrease mortality. SETTING: Pediatric Intensive Care Unit of the University Pediatric Hospital-UPR. PATIENTS: All patients admitted to the PICU from July 1, 1999 to June 30, 2002 were enrolled in the study. Those having a distended and/or tense abdomen on physical examination were identified at risk for intra-abdominal hypertension (IAH). IAH was diagnosed if the intra-abdominal pressure (IAP) was above 10 mmHg and with ACS if the IAH was accompanied by: hemodynamic instability, oliguria or anuria, metabolic acidosis and respiratory deterioration. MEASUREMENTS AND MAIN RESULTS: 1052 patients were admitted to PICU. Ten patients with evidence of ACS were identified with an incidence of 0.9. Ages ranged from 6 weeks to 12.3 years. Peak intravesical pressure measurements ranged from 17 to 39 mmHg. Inspiratory pressure was raised from a mean of 21.2 to 32.0 cmH2O. The PCO2 increased from a mean of 35.1 to 63 torr and the pH decreased from a mean of 7.40 to 7.12. Overall mortality was 40for this patient population. CONCLUSIONS: The outcome of pediatric critical care patients depends on multiple variables. Now there is evidence that in a select group of patients IAH and ACS play a significant role in their morbidity and mortality. This makes it mandatory for clinicians taking care of this population to be increasingly aware of this condition.

Síndrome compartamental abdominal en pacientes oncológicos: presentación de dos casos clínicos / Abdominal compartment syndrome in oncology patients: presentation of two clinical cases

Abdominal compartment syndrome is a multiple organ dysfunction ascribed to a sharp increase in intra-abdominal pressure.It is observed in new-borns with abdominal or diaphragmatic wall defects (omphalocele and gastroschisis) and in adults in events triggering a sharp increase in volume of abdominal cavity liquid (closed or penetrating traumas, intraperitoneal or retroperitoneal bleeding, very aggressive reanimation. Diagnosis arises from clinical signs, abdominal distension and measurement of intra-abdominal pressure as well as renal, respiratory and cardiovascular involvement. Measurement of intra-abdominal pressure is based on inferior vena cava or intravesical vein pressure. Treatment consists of evacuation by abdominal puncture maintained and adequately monitored during 8 to 15 days.

Diagnosis and management of severe acute pancreatitis complicated with abdominal compartment syndrome / 华中科技大学学报（医学）（英德文版）

Presented in this paper is our experience in the diagnosis and management of abdominal compartment syndrome during severe acute pancreatitis. On the basis of the history of severe acute pancreatitis, after effective fluid resuscitation, if patients developed renal, pulmonary and cardiac insufficiency after abdominal expansion and abdominal wall tension, ACS should be considered. Cystometry could be performed to confirm the diagnosis. Emergency decompressive celiotomy and temporary abdominal closure with a 3 liter sterile plastic bag must be performed. It is also critical to prevent reperfusion syndrome. In 23 cases of ACS, 18 cases received emergency decompressive celiotomy and 5 cases did not. In the former, 3 patients died (16.7%) while in the later, 4 (80%) died. Total mortality rate was 33.3% (7/21). In 7 death cases, 4 patients developed acute obstructive suppurative cholangitis (AOSC). All the patients who received emergency decompressive celiotomy 5 h after confirmation of ACS survived. The definitive abdominal closure took place mostly 3 to 5 days after emergency decompressive celiotomy, with longest time being 8 days. 6 cases of ACS at infection stage were all attributed to infected necrosis in abdominal cavity and retroperitoneum. ACS could occur in SIRS stage and infection stage during SAP, and has different pathophysiological basis. Early diagnosis, emergency decompressive celiotomy and temporary abdominal closure with a 3L sterile plastic bag are the keys to the management of the condition.

Compartment syndrome of the thigh. A case report and review of the literature

A case of compartment syndrome of the thigh following a gunshot injury that resulted in significant morbidity is presented. Early diagnosis of this uncommon condition requires a high index of suspicion in order to reduce morbidity and mortality. Timely diagnosis, emergency three-compartment decompression, prophylaxis against reperfusion syndrome and aggressive rehabilitation are necessary for a favourable outcome.

Síndrome compartimental abdominal / Abdominal compartment syndrome

El SCA es un acomplicación grave en pacientes con HIA que trae por resultado alteraciones cardiovasculares, renales, pulmonares, intraabdominales y de la pared. Aunque este síndrome se caracteriza por los síntomas clínicos, existen parámetros de laboratorio, que ayudan al disgnóstico del SCA (Presión Intravesical PIV >20 mmHg; Indice de Aporte de Oxígeno DO2 <600 ml/min/m²; Presión Vía Aérea Máxima >45 cm H2O; Diuresis <015 ml/Kg/h). La PIV medida a través de una sonda Foley en la vejiga, muestra buena correlación con la PIA y sirve como control y monitoreo durante el tratamiento del SCA. De la misma manera, su empleo profiláctico permite el diagnóstico precoz en pacientes postoperados, ya que la HIA produce alteraciones fisiopatológicas antes de presentarse los primeros síntomas de SCA. Cambios fisiopatológicos leves pueden ser corregidos mediante el incremento del volumen intravascular a base de soluciones cristaloides. En pacientes con un SCA establecido, hay que descomprimir y eventualmente reexplorar la cavidad abdominal. En la mayoría de los casos, el cuadro clínico se corrige a través de la disminución de la PIA como tratamiento de la causa, apoyado por el tratamiento sintomático de las alteraciones hemodinámicas y metabólicas. Más importante que el tratamiento sintomático es la profilaxis: para evitar un SCA no se debe cerrar la pared abdominal bajo gran tensión. En vez de cerrar la fascia se debe adaptar solamente la piel sobre las vísceras mediante pinzas de Backhaus, lo cual facilita la reexploración de la cavidad abdominal en caso necesario. Si esta maniobra no es posible de llevar a efecto, se sugiere el uso de una malla o de la llamada bolsa de Bogotá para cubrir la evisceración programada, por pocos días, hasta que se haya corregido el cuadro agudo y permita la reconstrucción transitoria y/o definitiva de la pared abdoninal. Varios estudios demostraron la eficacia de estos métodos, con lo cual se mejoró el cuadro crítico en un 95 por ciento de los casos estudiados

The abdominal compartment syndrome: a report of 3 cases including instance of endocrine induction

Three patients with the abdominal compartment syndrome are presented and discussed. In one of the patients the condition was induced in an endocrine fashion, since trauma was sustained exclusively by the middle third of the left leg. The development of the syndrome as a remote effect of local trauma has never been reported previously. In all three instances only insignificant amounts of intraperitoneal fluid was found and the increase in abdominal pressure was due to severe edema of the mesentery and retroperitoneum. Since the condition is highly lethal, early diagnosis is imperative, and this starts by carrying a high index of suspicion. Measurement of the intraperitoneal pressure easily confirms this diagnosis. It is emphasized that measurements at various sites, like bladder and stomach, in each patient is essential to confirm the diagnosis, since one of the sites may be rendered unreliable due to intraperitoneal processes impinging on the affected site and affecting its distensibility