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he fixed-walled compartments
of the human body separate
and protect vital organs. The
walls of the compartments can
be fascia/connective tissue (muscle compartments, pericardium, and capsulated
visceral organs) or bone and connective
tissue (brain, spinal cord, and orbit).
Connective tissues with high collagen
content are less tensile than muscle or
skin and key determinants of the volume
of the compartments. In broad terms,
compartment syndrome is defined as the
dysfunction of organs/tissues within the
compartment due to limited blood supply
caused by increased pressure within the
compartment. Without timely intervention, compartment syndromes cause permanent and irreversible damage to the
tissues within the compartment. In the
case of vital organs, they cause rapid
physiologic deterioration and death. Prevention, timely recognition, and immediate intervention are the strategies of the
management of patients with potential
General Pathophysiology
The underlying pathophysiology of all
compartment syndromes is the inadequate perfusion and oxygenation of the
organs/tissues within the confined space
Individual Compartments
Thoracic/mediastinal
compartment syndrome
A syndrome of tight mediastinum
after prolonged cardiac surgery was described by Riahi et al (8) in 1975. The
condition, known as thoracic or mediastinal compartment syndrome, has been
described in almost 200 reported cases of
adult and pediatric patients undergoing
cardiac surgical procedures. Open chest
management has gained acceptance as a
technique in the management of hemodynamically unstable patients where cardiac compression by sternal closure is not
tolerated. Early concerns to use this technique were related to the potential increased risk of mediastinitis after prolonged open sternotomy; however,
infectious complications and sternal
morbidity have been less frequent than
first anticipated in the late 1970s (9 12).
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Although thoracic compartment syndrome is well known in the cardiac surgical literature, it is hardly mentioned in
the noncardiac surgical and trauma literature (13).
Etiology. Research into cardiac function after cardiac surgery has found that
restriction of diastolic filling is the main
point at which compression or tamponade
develops in the thoracic cavity. Both the
pericardium and the sternum act to increase diastolic stiffness; however, a larger
decrease in cardiac output noted after sternal closure suggests that the latter may
exert a greater effect than pericardial closure, particularly in patients with fluid
overload (14). The decrease in blood
pressure and the increased end-diastolic pressure can result in subendocardial ischemia, leading to a cycle of
progressive deterioration (13). Low cardiac output can be improved by opening
the sternum (15).
Thoracic compartment syndrome is
an infrequent occurrence, even in the
busiest cardiac and trauma centers. Prolonged open sternotomy with delayed
sternal closure has been illustrated as
useful after cardiac surgery in the setting
of severe myocardial dysfunction, marked
myocardial edema, coagulopathy with
uncontrolled bleeding, and relentless arrhythmias (16 18). Patients with decreased lung compliance, acute pulmonary edema, or congestive cardiac failure
are also at a significant risk for a delayed
sternal closure.
There are two case reports in the literature describing thoracic compartment
syndrome after noncardiac thoracic procedures (13, 19).
With regard to the trauma patient,
Kaplan et al (20) reported a patient with a
gunshot wound causing thoracic and cardiac injuries that was treated with delayed sternal closure. This is the only case
reported in the literature of thoracic
compartment syndrome with the etiology
of trauma. The lack of further data to
support prolonged open sternotomy in
trauma patients (more than anecdotal evidence) is due largely to the limited survival of patients whose injuries are significant enough to result in massive tissue
edema after resuscitation from thoracic
trauma. In this context, it is important to
note that thoracic compartment syndrome can also occur after thoracotomy
with packing for trauma.
Diagnosis. In the poststernotomy
state, massive resuscitation and acute
mediastinal swelling/bleeding should
Abdominal compartment
syndrome
Abdominal compartment syndrome
(ACS) is the most frequently cited compartment syndrome after ECS. The clinical consequences of elevated intraabdominal pressure (IAP) were described
as early as the mid-19th century (22).
Pediatric surgeons became aware of the
catastrophic consequences of attempted
closure of omphaloceles, and vascular
surgeons described the problem after surgical management of ruptured abdominal
aortic aneurysms (23, 24). Damage control surgery improved the chances of survival of patients with hemorrhagic shock
and severe abdominal trauma. The fact
that the patients survived and some of the
practices of damage control (abdominal
packing and aggressive fluid resuscitation) led to the emergence of the epidemic of postinjury ACS (25). The expoCrit Care Med 2010 Vol. 38, No. 9 (Suppl.)
The clinically most relevant classification is to describe the acuity of the syndrome (acute, subacute, or chronic), the
etiology (e.g., postinjury, sepsis, burn, abdominal aortic aneurysm), and the primary or secondary nature of the problem.
Etiology. The acutely increased IAP,
the IAH, and the ACS can be due to a
variety of abdominal and extra-abdominal
factors (Table 1) (27). Considering the
size of the abdominal cavity, its central
location in the body, and the number of
vital organs located within, it is not surprising that ACS has symptoms related to
extra-abdominal organs (Table 2) (28,
29). In patients with already marginal
organ function, the characteristic IAH/
ACS-related organ dysfunctions tend to
be apparent at lower IAP.
ACS can be caused by many pathologic
conditions but the high-risk patients al-
Secondary
Ascites
Abdominal trauma
Damage control laparotomy
Ruptured abdominal aortic aneurysm
Abdominal aortic cross-clamping
Intestinal obstruction
Ileus
Severe constipation
Major abdominal surgery
Abdominal sepsis
Large abdominal tumors
(especially ovarian)
Pancreatitis
Liver transplantation
Symptoms/Signs
Increased intracranial pressure
Increased airway pressures, decreased compliance, poor oxygenation,
CO2 retention
Increased intrathoracic pressure, elevated diaphragms
Elevated filling pressures, decreased cardiac output, increased systemic
vascular resistance
Decreased intestinal pH, intolerance of enteral nutrition, bowel edema,
compromised intestinal barrier function, ileus
Decreased urine output, decreased glomerular filtration rate
Venous congestion, edema, increased risk for deep vein thrombosis
and extremity compartment syndromes
citation. When the abdominal compartment is already on the steep phase of its
pressure-volume curve, a decrease in
compliance and even small increases in
volume can lead to sharp elevations
in IAP. In most critically ill patients, continuous IAP monitoring is recommended
via the irrigation port of the previously
inserted three-way catheter (35). The diagnosis of ACS is confirmed if the deteriorated organ functions improve after
the IAP is decreased by either operative or
nonoperative means.
Based on a retrospective study,
Cheatham et al (7) have recommended
abdominal perfusion pressure (abdominal
perfusion pressure mean arterial pressure IAP) as a potentially superior and
more physiology-oriented definition of
IAH and ACS. Abdominal perfusion pressure was recommended to be kept at 60
mm Hg; however, this therapeutic goal
remains to be proven by higher-level evidence.
Treatment. The treatment of ACS entails the resolution of the underlying
problem simultaneously with measures
to decrease IAP. The authors believe that
medical methods to decrease IAP (diuretics, skeletal muscle paralysis, motility
agents, gastric and colonic decompression) can have a role in less acutely developing IAH, especially without surgical
causes (36). In the acute setting, especially postinjury, ACS deteriorates the already critically ill patients physiology to
organ failure within hours. This fulminant process prevents the opportunity to
reassess and titrate medical treatment before the condition becomes irreversible.
Thus, in the acute ACS, abdominal decompression is recommended. In cases of
primary ACS, this means usually abdominal reexploration in the operating room
for continued bleeding or for major septic
source. In secondary ACS, decompressive
laparotomy can be performed at the bedside as a lifesaving measure, because no
further surgical intervention is necessary
within the abdomen (37).
There are promising preliminary reports on percutaneous drainage of the
intraperitoneal fluid (especially in burns)
and subcutaneous linea alba fasciotomy
(pancreatitis) (38 40). However, these
techniques always require careful reassessment of the potential need for formal
decompression (full midline laparotomy).
The limitation of percutaneous decompression is the fact that, apart from burns
injury, secondary ACS is rarely caused by
free intraperitoneal fluid alone and withS448
the disease, does not rule out a compartment syndrome; thus, serial or continuous measurements can be important in
high-risk patients, especially in conditions where clinical examination is unreliable. The normal pressure of a tissue
compartment falls between 0 and 8
mm Hg, with symptoms and signs of
compartment syndrome developing with
pressures above approximately 20
mm Hg. However, the pressure necessary
for permanent damage varies. McQueen
and Court-Brown (57) performed a prospective cohort study of continuous monitoring of the anterior compartment pressure in 116 diaphyseal tibia fracture
patients. Forty-three percent and 23%
patients had compartment pressures of
30 mm Hg and 40 mm Hg, respectively.
The authors decompressed only those
who had a pressure (diastolic blood
pressure compartment pressure) of
30 mm Hg. This strategy resulted in
only three fasciotomies but prevented 50
unnecessary decompressions. No patients
had missed compartment syndrome. This
study highlights the need to consider the
general condition of the individual patients and questions the need for extensive monitoring, especially in awake oriented patients.
Compartment pressures can be measured with proprietary handheld devices
or with a simple ICU pressure transducer
set-up connected to the bedside or operating room monitor. Pressures should be
measured in all compartments of the
limb by inserting a needle, which is connected to the pressure measuring device.
The manometer needs to be zeroed at the
level of the measured compartment.
Treatment. The treatment of an ECS
is dermatofasciotomy (fasciotomy). Subcutaneous fasciotomy is not recommended in trauma/critical care scenarios.
Fasciotomy is performed preferably in the
operating room but, in critically ill patients, it should not be delayed because of
lack of operating room access or a patients general condition. Apart from its
therapeutic role, fasciotomy may also be
preventive in situations that are known to
be high risk for compartment syndrome.
In this case, avoiding the procedure carries a higher risk than managing the
complications of the fasciotomy itself.
These scenarios include major (proximal)
reimplantation, arterial repair with long
ischemic time, and combined arterial and
venous repair on the ipsilateral limb.
Prevention. Prehospital atraumatic
splinting and timely reduction (open or
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Polycompartment syndrome
More recently, the multiple compartment syndrome or poly-compartment syndrome was described as a result
of a futile attempt to optimize critical
trauma patients circulation with preload-driven resuscitation with crystalloid
solutions. The authors described a vicious cycle of increasing intracranial
pressure, intrathoracic pressure, and IAP
secondary to fluid therapy to optimize
cerebral perfusion and the aggressive
ventilatory management to treat acute
lung injury (58). Simultaneously, other
researchers (59) described the potential
interactions among different compartments. We believe most of these complications, including the secondary ECS, are
results of the previously described salty
water vicious cycle of futile crystalloid
loading.
CONCLUSIONS
Compartment syndromes are serious
limb, organ, or life-threatening conditions.
Clinicians need to be familiar with their
etiology and the frequently elusive presentation (especially secondary compartment
syndrome) in critically ill patients. Prevention of compartment syndrome with preemptive open management of compartments (primary syndromes) in high-risk
patients and/or careful resuscitation (both
primary and secondary syndromes) is the
recommended approach.
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