Intraoperative acute compartment syndrome of the upper limb secondary to extravasation

A woman in her 50s was undergoing a repeat liver resection surgery for recurrence of liver metastasis when the intravenous fluid flow was noted to be sluggish on multiple occasions. On the third examination of the right hand where the intravenous cannula was located, surgery was halted as there was extensive swelling from the hand to the biceps and the hand had started turning blue. A diagnosis of acute upper limb compartment syndrome secondary to extravasation exacerbated by metaraminol was made by the anaesthetist and surgeon. Fasciotomies of the right upper limb were performed, and perfusion was restored. A hand surgeon arrived shortly after and completed decompressing the upper limb compartments. A literature review revealed risk factors such as communication barriers, age and chemotherapy were present in this case. Enhanced monitoring is needed in the context of unsatisfactory infusion flow rates perioperatively.

Drug therapy related to surgery, Musculoskeletal and joint disorders, Colon cancer, Vascular surgery

Acute compartment syndrome is defined as an increase in interstitial tissue pressure within a closed fascial compartment, leading to compromised blood supply and function of the structures within that space.1 2 It is a surgical emergency which can potentially have devastating consequences.3 4 Clinical features such as extreme pain and pain on passive stretch of the muscles are signs of impending compartment syndrome, followed by neurovascular compromise.5 Rapid decision-making is then required to decompress the compartments, often using fasciotomies. There are many causes of acute compartment syndrome but extravasation of intravenous agents as a cause is rare, especially in the context of being under general anaesthetic. Here, we present a case report of acute upper limb compartment syndrome developing intraoperatively during liver resection surgery and discuss extravasation of intravenous agents as an aetiology. Case presentation A woman in her 50s with a history of liver resection and cholecystectomy for colorectal liver metastasis was scheduled to undergo a repeat liver resection for recurrence of liver metastasis. Other medical history included caesarean section, uterine fibroids, endometriosis, polycystic ovary syndrome, ovarian surgery and a loop ileostomy. Preoperatively, the patient had 20-gauge cannulas in both hands and a further 16-gauge cannula was also inserted in the dorsum of the right hand. Both arms were wrapped, and anaesthesia was induced using the intravenous cannula in the left hand. Intravenous fluids via the 16-gauge cannula were noted to be sluggish in the right arm and the arm was unwrapped to reveal a kink. This was corrected, the arm loosely rewrapped, and the flow was noted to be satisfactory. A similar check was performed again after the surgery had commenced and no abnormalities were found. Around this time, metaraminol was administered in the right hand. Fifteen minutes later however, the syringe pump indicated an occlusion downstream and the right arm was unwrapped and checked again. This revealed excessive forearm swelling up to the biceps which was also significantly more tense than the left arm. The palm and fingertips had also turned blue and black in colour. All infusions and cloth wrappings in the right arm were removed and the arm was maintained at the level of the heart for 5 min with no improvement. After reviewing the patient’s charts, the consultant anaesthetist and consultant surgeon made a diagnosis of compartment syndrome secondary to extravasation, exacerbated by metaraminol; the tension, swelling and colour of the arm, particularly the hand was diagnostic obviating the need for any compartment pressure measurements. Systemic blood pressure (110/80 mm Hg) had stayed normal and steady throughout the procedure. There were no constricting elements to be loosened. Metaraminol and other infusions in the affected arm were immediately stopped with no improvement. The nearest specialist was a hand surgeon who would take another hour to arrive as surgery involving the limb was not routinely done at the hospital. Compartment pressures were not measured as it would delay treatment. In the 15 min since diagnosis, the limb’s condition had not improved and the ischaemia in the fingertips had started to spread proximally. The consultant surgeon then decided to perform an S-shaped fasciotomy incision from the hand to the anterior cubital fossa with two further fasciotomies in the hand. The discolouration of the fingers immediately resolved and there were normal peripheral pulses in the right arm and normal capillary refill. A hand surgeon arrived an hour later, further decompressed the thenar compartment and later measured compartment pressures which were noted to be satisfactory. The patient remained stable and under anaesthetic throughout to enable completion of liver surgery thereafter. Outcome and follow-up Primary closure was attempted, and a vacuum dressing was applied where the defect could not be closed after the fasciotomies. The patient had three further surgeries on the right forearm before full closure was achieved. She attended multiple hand physiotherapy appointments over the next 4 months and eventually had full recovery with no complications.

There are many causes of acute compartment syndrome, of which traumatic injuries such as fractures are the most common.1 6–8 Reperfusion injuries, snake bites and drug abuse have also been mentioned as causes of acute compartment syndrome in the limbs.5 Less well known are iatrogenic causes such as anticoagulation,9 intraoperative wrapping of the limbs10 and intravenous infiltration.11 Extravasation of fluids or drugs leading to acute compartment syndrome in the limb is a rare complication that has been infrequently documented in the available literature.11 A literature review using the keywords ‘compartment syndrome’ AND ‘upper limb’ OR ‘arm’ OR ‘forearm’ OR ‘hand’ OR ‘upper extremity’ from 2006 until September 2021 revealed 401 publications in English filtered for case reports. Papers without acute episodes, intravenous infiltrations or extravasations were then excluded. The remaining papers then had their references hand-searched to reveal a total of 30 cases detailed in table 1. The median age of presentation was 47 (IQR 29–60) with a 3:2 female preponderance. Thirteen (43%) cases were secondary to intravenous fluids given alone or with other agents while 11 (37%) cases were due to intravenous contrast (figure 1A). Other intravenous agents administered included three (10%) cases of blood products, three (10%) cases of propofol, two (7%) cases of vasopressors and one (3%) case each of rocuronium, sugammadex, heparin, platelets, N-acetylcysteine, remifentanil, mannitol, ceftriaxone, calcium gluconate and sodium bicarbonate given either alone or in conjunction with other intravenous agents mentioned. Table 1. | Reference | Age | Gender | Aetiology | Risk factors | Diagnosis | Onset | ACS location | Treatment | Outcome | | Hoefnagel et al, 202145 | 22 | M | Fluids, rocuronium, sugammadex | Difficult access, sedation | Doppler used | Intraoperative | Hand | Esmarch surgical compression bandaging +elevation | Good | | Tawfik et al, 202150 | 81 | F | Heparin, fluids | – | Clinical | Ward | Arm | Upper arm lateral fasciotomy | Paraesthesia | | Fisher and Jarrett, 202113 | 33 | F | Fluids, blood, phenylephrine, platelets | Sedation | Doppler used | Postoperative | Hand | Hand + distal forearm fasciotomy + carpal tunnel release + phentolamine injections | Sensory deficit | | Van Veelen et al, 202051 | 43 | M | Contrast, fluids | Difficult access | Clinical | CT | Forearm | Forearm fasciotomy + carpal tunnel release | Good | | Barber et al, 201848 | 47 | F | Fluids | Sedation | Clinical | Postoperative | Hand | Elevation + hand/distal forearm fasciotomy | Good | | Stavrakakis et al, 201852 | 72 | F | Contrast | Diabetes | Clinical | CT | Hand | Elevation + ice + hand fasciotomy + carpal tunnel release | Good | | Varacallo et al, 201853 | 52 | F | Propofol | Sedation | Pressure | Postoperative | Hand | Hand fasciotomy | – | | Wong, Hanwright and Manahan, 201749 | 5 months | M | Fluids | Child | Clinical | ITU | Hand | Hand fasciotomy | Good | | Thoppil et al, 201754 | 26 | M | N-acetylcysteine | – | Pressure | Ward/ED | Hand + mid forearm | Fasciotomy | – | | Chinn and Colella, 201755 | 57 | F | Fluids | Difficult access, diabetes, peripheral vascular disease | Pressure | ED | Forearm | Forearm fasciotomy + carpal tunnel release | Good | | Alexander, Ramseyer and Beatty, 20164 | 32 | M | Norepinephrine | Sedation | Doppler used | ITU | Forearm | Forearm fasciotomy + below elbow amputation | Amputation | | Vinod et al, 201656 | 63 | F | Contrast | – | Clinical | CT | Hand | Elevation + cold compress + hand fasciotomy | Good | | Araz et al, 201521 | 34 | F | Fluids, calcium gluconate, sodium bicarbonate | Difficult access, diabetes | Clinical | Postoperative | Hand | Hand fasciotomy | Good | | Kalraiya et al, 201557 | 18 | F | Propofol | Nil | Clinical | ITU | Forearm | Forearm fasciotomy | Good | | Yurdakul et al, 20142 | 60 | M | Contrast | Nil | Doppler, XRay used | CT | Hand | Ice + elevation + steroids + hand fasciotomy | Good | | Davies et al, 201358 | 28 | M | Fluids, ceftriaxone | Not well communicative | Doppler used | ED | Hand | Hand fasciotomy | – | | Bebawy, Gupta and Koht, 201159 | 43 | M | Fluids, propofol, remifentanil | Sedation | Doppler, pressure used | Intraoperative | Forearm | Forearm fasciotomy | Good | | Belzunegui et al, 201160 | 50 | F | Contrast | Active chemotherapy | XR used | CT | Hand | Ice + elevation + steroids + hand fasciotomy | Good | | Talbot and Rogers, 201161 | 10 months | M | Fluids | Child | Pressure | Ward | Hand + forearm | Hand/forearm fasciotomy + carpal tunnel release | Good | | D'Asero et al, 201062 | 81 | F | Contrast | – | Doppler used | CT | Hand | Bullous needle decompression + hirudoid cream + hand fasciotomy | – | | Noyes et al, 201019 | 56 | F | Blood | Hypertension | Doppler, pressure used | Postoperative | Hand + forearm | Elevation + warm compress + forearm fasciotomy | Residual paraesthesia of thumb | | Gerard et al, 200846 | 72 | M | Contrast | Not well communicative | Clinical | CT | Hand + forearm | Elevation + warm compress | – | | Grand, Yeager and Wollstein, 200863 | 48 | F | Contrast | – | Clinical | CT | Forearm | Forearm fasciotomy + carpal tunnel release | Good | | Selek et al, 200764 | 70 | F | Contrast | Active chemotherapy | Clinical | CT | Hand | Ice + elevation + steroids + hand fasciotomy + carpal tunnel release | Good | | Wang et al, 200765 | 48 | F | Contrast | – | Pressure | CT | Hand | Hand fasciotomy | Good | | Kanojia, Sharma and Kataria, 20073 | 7 months | F | – | Child, unconscious | Pressure | ITU | Forearm | Forearm fasciotomy | Necrosis, gross limb deformity, poor power | | Erickson et al, 200766 | 36 | F | Mannitol | Difficult access, intravenous drugs user, sedated, hypertension | Pressure | Postoperative | Forearm | Forearm fasciotomy | Good | | Chew, Boles and Mattern, 200667 | 66 | M | Contrast | – | – | CT | Arm—biceps bachii compartment | Arm fasciotomy | Good | | Scholtes, Loriau and Tombal, 200668 | 60 | F | Blood, fluids | Sedation | Pressure | Intraoperative | Forearm | Forearm + hand fasciotomy + carpal tunnel release | Good | ED, emergency department; ITU, intensive therapy unit. In the case presented, fluids and metaraminol were documented as being administered. Metaraminol could have contributed to compartment syndrome as it would have decreased arterial perfusion pressure via its vasoconstrictive effects. It acts on alpha-adrenergic receptors and when extravasated, can lead to local vasospasm and impair vessel wall integrity during extravasations.12 These agents are also directly toxic to tissues and can cause necrosis within 6 hours.4 There were two similar cases of vasopressor extravasation in the last 15 years, of which, one case had to undergo limb amputation4 and the other had sensory deficits at latest follow-up.13 However, both cases had significant lengths of time until surgical intervention; a few days in the former4 and 12 hours in the latter.13 The severe consequences of these two cases were not seen in the case presented, possibly because it was only minutes between onset of symptoms and surgical intervention. Although the volume of intravenous fluids administered was not documented, it was likely a significant contributing factor to compartment syndrome as it would have significantly increased compartment pressures.1 An infusion pump was used intraoperatively and the downstream occlusion alarm alerted the anaesthetic team to check the intravenous access. The use of infusion pumps with occlusion alarms were poorly documented in the cases reviewed. Their effectiveness in detecting extravasations has also been disputed with some papers describing increased pressures not being detected.14 15 Despite this, the occlusion alarm in the case presented likely prevented delayed diagnosis and prompted a check on the intravenous site which was not easily visible to the anaesthetic team. There are numerous possible risk factors involved in intravenous extravasations. Chemotherapy and age more than 50 years may cause veins to be particularly fragile while diabetes would compromise the ability of veins to tolerate extravasations.16–18 Intravenous access at the dorsum of the hand or near joints are sites most often implicated with extravasation injuries, possibly due to lesser soft tissue available to protect underlying structures.16 Other risk factors include compromised lymphatic or venous drainage, peripheral vascular disease, hypertension and radiation therapy.16 18 19 In our case, the patient was more than 50 years old and had prior chemotherapy, increasing the likelihood of having particularly fragile veins. In the literature review, 13 (43%) cases had patients at least 50 years old of which two (7%) were having active chemotherapy (figure 1B). Furthermore, the cannula in the dorsum of the right hand would have increased the risk of extravasation injury. Weber et al also suggested extravasations could have been a result of incorrect cannula placement or damage in the vein wall structure during infusion.20 In the literature review, five (17%) cases documented some difficulty securing intravenous access and multiple attempts at intravenous cannulation could have resulted in extravasation from the existing punctures through the vein.20 21 In the present case, there was no documented difficulty in securing the intravenous access, although the repeated problems with the infusion flow rate could have indicated subsequent extravasation injury taking place. The use of the large 16-gauge intravenous cannula could also have contributed to extravasation injury. This is supported by a large prospective study which found increasing the size of intravenous cannulas increased the risk of extravasation.22 However, this is disputed in another study of similar cohort size.23 The gauge of cannulas used were poorly documented in the cases reviewed and it is also worth noting that factors related to the size of veins used and the different forms of injector or infusion systems would affect results. In any case, the use of large cannulas would have to be weighed against the need for them, such as in the unlikely event of major haemorrhage during surgery in the present case. Acute compartment syndrome is usually diagnosed clinically with disproportionately excessive pain and pain on passive stretching of the affected muscles, one of the first signs which should raise a high index of suspicion.6 24 Neurological signs and swelling of the affected compartment can also be present.24 25 Diagnosis can then be confirmed with the measurement of compartment pressures where normal is a value below 8–12 mm Hg.5 25 Only 11 out of 29 (38%) cases in the literature review used compartment pressures to make a diagnosis, highlighting the importance of clinical findings in making a diagnosis. In the case presented however, the patient was sedated and many of these signs involving pain could not be elicited. This communication barrier poses obstacles in making a diagnosis21 24 and a systematic review looking at compartment syndrome secondary to intravenous infiltration noted patients with communication barriers were particularly vulnerable.11 This concurs with the present literature review where 14 (47%) cases had patients with some form of communication barrier. Three (10%) of the cases occurred intraoperatively and six (20%) cases occurred postoperatively (figure 1C). It is unclear in some of these cases if compartment syndrome had started developing intraoperatively and was only detected postoperatively. A further four (13%) cases occurred in the intensive care unit. In these patients where communication might be restricted, it is often difficult to examine intravenous access sites, increasing the risk of extravasation injuries leading to compartment syndrome. Where compartment syndrome is suspected in an unconscious patient, measuring compartment pressures is the preferred method to aid diagnosis.26–28 An absolute compartment pressure measurement of between 30 and 40 mm Hg would generally be accepted as diagnostic for compartment syndrome.29–31 However, tissue ischaemia occurs when the compartment pressure approaches diastolic blood pressure, varying depending on clinical circumstances such as a hypertensive or hypotensive patient.32 33 Therefore, a delta pressure (difference between diastolic pressure and intracompartment pressure) of around 20–30 mm Hg has been suggested as being more accurate in diagnosing compartment syndrome and an indication for fasciotomy.29 34 35 In the case presented, a period of hypotension requiring metaraminol could have lowered the threshold for ischaemia to occur which could explain the discolouration in the fingertips. However, blood pressure recordings were not available in the case presented and there was little documentation of the patients’ vitals in the cases reviewed. A relatively new diagnostic modality is near-infrared spectroscopy which measures tissue hypoxia and could detect compartment syndrome.36 37 This non-invasive method however, is still the subject of much research to determine the threshold level to make a diagnosis.38 Similarly, the use of ultrasound to assess the fascial wall and detect an increase in compartment pressures has been reported but also requires further research.39 Using ultrasound to assess blood flow can be useful when assessing the severity of compromised blood flow and has also been reported to rule out other vascular conditions such as deep vein thrombosis.40 The study of tissue hardness has also been investigated and showed promising results but is associated with limitations such as site of measurement and muscle contraction.38 41 Biomarkers such as creatine kinase or myoglobin can also be useful to aid diagnosis but requires a period of time before muscle injury causes a rise in levels.38 While there are other less prominent diagnostic aids for compartment syndrome, clinicians have to bear in mind that relying on a single diagnostic modality would be insufficient to make a firm diagnosis and correlation with the clinical picture is crucial. Treating acute compartment syndrome involves decompression as early as possible to prevent irreversible changes in the tissues which can occur within 6–8 hours.42 43 Initial measures such as loosening of constrictive dressings and maintaining limb elevation to the level of the heart should be undertaken to maintain arterial perfusion.1 6 25 44 The British Orthopaedic Association guidelines dictate that re-evaluation should occur within 30 min and surgery should occur within the hour when a decision has been made to operate.44 There were only two (7%) cases of successful conservative treatment of compartment syndrome in the literature review,45 46 indicating the high likelihood of proceeding to surgery once a diagnosis has been made. Fasciotomies of the forearm and hand are commonly achieved by a curvilinear incision on the volar aspect, which extends into the hand for a carpal tunnel release.47 A dorsal forearm incision can also be used to achieve complete decompression of all three forearm compartments. Decompression of the 10 hand compartments involves two dorsal incisions and further incisions over the hypothenar, thenar and adductor compartments.48 49 Patient’s perspective. Obviously, at the time of the incident I was sedated and therefore unaware of what was happening around me. I am however, incredibly grateful that action was taken in a timely manner, by both the anaesthetist to detect the cause of the sluggish intravenous fluid flow and by the surgeon who performed the emergency fasciotomy, the speed of both actions I believe saved my hand and arm in the first instance. The subsequent three surgeries performed by both a hand surgeon and a plastic surgeon allowed full closure of my arm without the need for a skin graft. But also, importantly, the intensive physiotherapy sessions which followed with a hand therapist, over the course of the following 3–4 months, plus daily practice of those exercises at home, allowed me to regain full use of my hand and arm. Learning points. Enhanced monitoring is required for sedated patients with unsatisfactory infusion flow rates to prevent delayed diagnosis of compartment syndrome. Acute compartment syndrome can develop within minutes in the presence of extravasation and vasopressor administration. Patients with communication barriers, difficult intravenous access, chemotherapy, cardiovascular disease and age above 50 are at risk of developing extravasation injury which can lead to acute compartment syndrome. Footnotes Contributors: AA and AM performed literature search and co-wrote the manuscript with leadership from AA. SH and HMK supervised the writing and were critical to management of the patient. Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy. Competing interests: None declared. Provenance and peer review: Not commissioned; externally peer reviewed. Ethics statements Patient consent for publication Consent obtained directly from the patient(s).

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