What the Anesthesiologist Should Know before the Operative Procedure

Decompressive fasciotomy of the lower leg is most frequently performed to relieve acute compartment syndromes. Acute compartment syndromes in the lower extremity most frequently result from traumatic insult, but can also be associated with reperfusion after ischemic injury, burns, or prolonged surgical positioning (lithotomy). These are often true emergencies with the time from diagnosis to fasciotomy critical to help prevent muscle ischemia and necrosis. Muscle necrosis will occur within 3 hours of the onset of ischemia with irreversible muscle and nerve damage occurring within 5 hours.

Compartment syndromes of the lower extremity most frequently occur below the knee. The lower leg has four compartments: anterior, lateral, superficial posterior, and deep posterior. The fasciotomy of the lower leg can be done with either a single incision or two incisions. The two-incision technique is more common, with the latter incision made longitudinally approximately 2 cm anterior to the fibular shaft and the medial incision made longitudinally 1 to 2 cm posterior to the subcutaneous posteromedial border of the tibia.

Chronic exertional compartment syndromes have been described in young athletic patients. The treatment for these is elective minimally invasive fasciotomy of the lower leg.

Common causes of compartment syndromes

Fracture
Crush injury
Reperfusion injuries
Intracompartmental hemorrhage
Circumferential burns
Venous or arterial obstruction
Surgical positioning

1. What is the urgency of the surgery?

What is the risk of delay in order to obtain additional preoperative information?

Once compartment syndrome is diagnosed, surgical fasciotomy is the standard treatment. The mechanism and acuity of the compartment syndrome will directly relate to the urgency to go to the operating room. Frequently, this procedure is done in the setting of a traumatic injury and will be done in an emergent nature. The risk in delaying treatment is progressive muscle ischemia resulting in loss of limb and potentially loss of life depending on the extent of the compartment syndrome.

Emergent: Patients with acute traumatic compartment syndrome require emergent lower extremity fasciotomy.

Urgent: Patients with delayed or slowly developing compartment syndrome, secondary to reperfusion, burn or positioning injury may tolerate a delay in surgery.

Elective: Fasciotomies performed for increased compartment pressures secondary to intense exercise or decreased serum osmolarity.

2. Preoperative evaluation

Lower leg fasciotomies are usually performed in the setting of trauma. As such, preoperative evaluation will focus on other related injuries. In addition to related traumatic injuries, metabolic abnormalities must be evaluated. In severe compartment syndromes, rhabdomyolysis can lead to acute hyperkalemia and renal failure. Preoperative evaluation should include obtaining electrolytes, renal function tests, and acid-base status.

Medically unstable conditions warranting further evaluation: Patients coming for lower extremity fasciotomy frequently have been involved in trauma. As in any patient with trauma, an ATLS evaluation should have been performed to assess all patient injures. Based on the evaluation by the trauma team, injuries should be prioritized and corrected in the order of most critical to least critical. It will be up to the surgical teams to determine where lower extremity fasciotomies fall in relation the patient’s other injuries.

Delaying surgery: Lower extremity fasciotomy for acute compartment syndrome is most often a surgical emergency and should not be delayed. Elective lower extremity fasciotomy for exercise-induced increased compartment pressures should be delayed if the patient is not optimized for surgery. This would include any acute illness, new cardiac condition, or failure to meet NPO guidelines.

3. What are the implications of co-existing disease on perioperative care?

b. Cardiovascular system:

Acute/unstable conditions: Acute or unstable conditions should be evaluated and managed according to ACC/AHA guidelines for perioperative cardiovascular evaluation and care before proceeding with lower extremity fasciotomy. As with any unstable trauma patient, all injuries should be evaluated and prioritized with the injury presenting the greatest risk to the patient treated first.

Baseline coronary artery disease or cardiac dysfunction – Goals of management: As with acute or unstable cardiovascular conditions, preoperative evaluation and management should follow the ACC/AHA guidelines. Baseline cardiovascular treatment should be continued throughout the perioperative period, with the exception of platelet inhibitor therapy. Discontinuation of aspirin and gpiib iiia inhibitors (e.g., clopidogrel) for reduction in perioperative bleeding should be balanced against the risk of postoperative thrombotic complications (i.e., stent restenosis). If a coronary stent is involved, consultation with the patient’s cardiologist regarding the balance of risks and benefits is indicated.

c. Pulmonary:

COPD

Based on the timing of surgery, if possible COPD should be medically optimized according to ATS guidelines before proceeding to surgery. Baseline therapy should be continued throughout the perioperative period.

Reactive airway disease (asthma)

Patients with reactive airway disease are at increased risk of perioperative pulmonary complications. If time permits prior to surgery, baseline reactive airway disease should be medically optimized according to NHLBI guidelines before proceeding. Baseline therapy should be continued throughout the perioperative period.

d. Renal-GI:

Patients undergoing lower extremity fasciotomy for acute compartment syndrome are at increased risk for acute renal failure secondary to myoglobinemia. Preexisting renal disease will increase this risk. Preoperative evaluation of patients should include an assessment of electrolytes, renal function, and dialysis session (for patients with chronic end-stage renal disease). Renal function should be closely monitored in the perioperative period. Patient’s renal function may deteriorate over time. In patients who are nonoliguric, aggressive fluid administration should be considered.

e. Neurologic:

Lower extremity fasciotomy is frequently performed in the setting oftrauma. A careful evaluation of neurologic function should be performedto rule out head trauma.

Acute issues: Intracranial bleeds, cerebral edema, or other trauma-related neurosurgical conditions should be evaluated and managed prior to lower extremity fasciotomy. In addition, any acute or unstable neurologic disorders (e.g., stroke, seizure) should be evaluated and managed prior to surgery.

Acute nerve injury to the involved extremity is also a potential in the trauma situation, and careful preoperative neurologic examination is indicated.

Chronic disease: Baseline treatment for chronic neurologic conditions should be continued throughout the perioperative period.

f. Endocrine:

Lower extremity fasciotomy is not associated with any endocrine diseases. Patients with preexisting endocrine abnormalities should be continued on their baseline treatments during the perioperative period. In patients with diabetes, glucose levels should be monitored closely.

g. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (e.g., musculoskeletal in orthopedic procedures, hematologic in a cancer patient)

There are none.

4. What are the patient's medications and how should they be managed in the perioperative period?

In the setting of traumatic lower compartment syndrome requiring emergency fasciotomy, the patient’s medications should be evaluated and a decision made on a medication-by-medication basis of whether to continue, substitute, or hold the medication, based on the patient’s condition and the patient’s comorbidities.

h. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?

N/A

i. What should be recommended with regard to continuation of medications taken chronically?

Cardiac: If possible, based on the patient’s condition, all cardiac medication should be continued throughout the perioperative period.

Pulmonary: Based on the patient’s condition, all pulmonary medication should be continued throughout the perioperative period.

Renal: Renal function should be monitored closely and renal medications should be held until baseline renal function is established.

Neurologic: Neurologic medications should be continued throughout the perioperative period.

Antiplatelet: Discontinuation of aspirin and gpIIbIIIa inhibitors should be balanced against the risk of perioperative thrombotic complications.

Psychiatric: Based on the patient’s condition, psychiatric medication should be continued throughout the perioperative period.

j. How to modify care for patients with known allergies

Avoid medications to which there are documented allergies.

k. Latex allergy – If the patient has a sensitivity to latex (e.g., rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.

Normal, nonlatex precautions are appropriate.

l. Does the patient have any antibiotic allergies

N/A

m. Does the patient have a history of allergy to anesthesia?

Malignant hyperthermia (MH)

Documented: Avoid all trigger agents such as succinylcholine and inhalational agents. Follow a proposed general anesthetic plan: total intravenous anesthesia with propofol ± opioid infusion ± nitrous oxide. Ensure an MH cart is available [MH protocol].

Family history or risk factors for MH: Nontriggering general anesthetic.

Local anesthetics/muscle relaxants: Avoid succinylcholine (possible hyperkalemia).

5. What laboratory tests should be obtained and has everything been reviewed?

Hemoglobin levels: Potential for blood loss secondary to trauma; should evaluate preoperatively.

Electrolytes: Important to evaluate. Patient could have significant hyperkalemia and increased creatinine.

Coagulation panel: Not critical, unless massive traumatic blood loss suspected.

Imaging: If other injuries suspected, radiographs for fractures, and CT for other suspected injury locations.

Other tests: CPK levels to evaluate muscle breakdown and arterial blood gases for acid-base status.

Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?

In isolation, anesthesia for lower extremity fasciotomy could include general anesthesia, neuraxial anesthesia, and peripherial regional anesthesia. In most cases the cause of the lower extremity acute compartment syndrome will in part dictate the anesthetic used.

In the case of the exertionally induced compartment syndrome requiring elective lower extremity fasciotomy, any method of anesthesia can be used. This surgery is usually performed in an outpatient setting using a minimally invasive surgical approach. Anesthesia for this can be accomplished using multiple approaches including: sedation and surgical local topicalization, TIVA with an LMA, neuraxial regional anesthesia or general anesthesia.

In the case of trauma induced acute lower extremity compartment syndrome, the anesthetic choice can be limited by the patients co-existing injures and the extent of the hematologic and electrolyte abnormalities. Frequently, the patient’s condition will require general anesthesia with endotracheal intubation and arterial monitoring. If the patient has an isolated lower extremity injury requiring lower extremity fasciotomy, neuraxial or regional anesthesia can be considered, but frequently the surgical service will want to monitor lower extremity pain and neurologic function and will not want neuraxial or regional anesthesia.

a. Regional anesthesia

Neuraxial

Benefits: Lower risk of PONV, better short-term analgesia, possible shorter recovery and dismissal, avoidance of airway instrumentation.
Drawbacks: inability to assess pain and nerve and motor function. May not be an option depending on the patient’s other injures and/or the patient’s acid-base status
Issues: Surgeons may request general anesthesia in order to follow the symptoms of compartment syndrome (pain, neuropathy).

Peripheral nerve block

Benefits: Improved pain control in the postoperative period. Lower risk of PONV. Possible shorter recovery and dismissal. Avoidance of airway instrumentation
Drawbacks: Need to wait for block onset. Risk of incomplete block and need to convert to GA. inability to assess pain or nerve and motor function.
Issues: Surgical service is not able to follow and assess pain and neurologic function in the postoperative period

b. General anesthesia

Benefits: General anesthesia with a secure airway is most frequently used for traumatic acute compartment syndrome. GA allows control of the patient’s ventilation, which may be beneficial if the patient has significant acid-base changes from the compartment syndrome or from other traumatic injuries.

Drawbacks: As with general anesthesia for any procedure, one must be mindful of the potential risk for PONV, POCD, allergic reactions, MH, airway trauma during intubation, or lost airway.

Other issues: Additional access and monitoring may be necessary depending on the patient’s additional injuries and/or the patient’s acid-base status.

Airway concerns: Any trauma patient has risk for cervical spine injury or potential facial trauma making direct laryngoscopy challenging. In securing the airway in these patients, alternative methods for securing the airway should be immediately available and the ASA difficult airway algorithm should be followed.

c. Monitored anesthesia care

Benefits:Can avoid airway management, can assist with discharge for patient undergoing outpatient procedure.

Drawbacks: Frequently will not provide adequate anesthetic depth for the patient to tolerate the procedure.

6. What is the author's preferred method of anesthesia technique and why?

Frequently, patients present to the operating room for fasciotomy following trauma resulting in acute compartment syndrome. These patients frequently require a general anesthetic with endotracheal intubation.

A first-generation cephalosporin should be administered prior to skin incision, unless contraindicated. If the patient has additional injuries, another antibiotic may be indicated. Vancomycin or clindamycin may be used alternatively for patients with severe penicillin or cephalosporin allergies.
Lower extremity fasciotomy can be done through a single incision or with two incisions. The two-incision approach is more common because it provided better surgical exposure to all four compartments. Both approaches can be done with the patient in the supine position. Neither approach has any specific anesthetic concerns.
There is nothing specific to the anesthetic that will assist the surgeon.
Depending on the duration and degree of the lower extremity compartment syndrome prior to arrive in the operating room, the patient’s degree of acidosis could result in significant management during the intraoperative period. This could include aggressive management of hyperkalemia and metabolic acidosis.

Complications

Cardiac:None specific to this procedure or anesthetic technique.

Pulmonary: None specific to this procedure or anesthetic technique.

Neurologic: Within 6 hours of the onset of acute compartment, the patient can experience permanent neurologic damage. Releasing the increased compartment pressure with urgent lower extremity fasciotomy will improve blood flow into the compartment and reduce the risk of permanent neurologic damage. Generally, unless other injures require continued sedation, the anesthetic should be tailored to allow rapid return to a level of consciousness that allows neurologic assessment.

a. Neurologic:

Depending on the duration and severity of the compartment syndrome, nerve injury can occur. Additionally, the patient is at slight risk of surgical nerve injury if the surgeons fail to identify the nerves during fasciotomy and debridement.

b. If the patient is intubated, are there any special criteria for extubation?

Extubation will follow the standard criteria for extubation following surgery. This includes the return of neuromuscular function and the return of respiration. In the case of lower extremity fasciotomy performed in the setting of acute compartment syndrome, the patient’s acid-base status should be normalized prior to extubation, and in the setting of trauma, comorbidities should be assessed prior to extubation.

c. Postoperative management

What analgesic modalities can I implement?

Postoperative analgesia will be highly dependent on the patient’s condition. Frequently, PCA narcotics will be the primary analgesic modality. In patients who need to remain intubated and sedated, a continuous narcotic infusion can be implemented. In patients undergoing fasciotomy as an outpatient procedure, oral narcotics and NSAIDS can be used.

The patient’s postoperative location will depend on the patient’s additional injuries and level of electrolyte and acid-base disturbances. In patients with few additional injuries and normal electrolytes, floor care is appropriate. In patients with additional serious injuries or significant electrolyte and/or acid/base changes, ICU care is needed.

The most common postoperative complication is wound infection. Close observation and continued antibiotic therapy are common to help prevent wound infection.

What's the Evidence?

Mannion, S, Capdevila, X. “Acute compartment syndrome and the role of regional anesthesia”. Int Anesthesiol Clin. vol. 48. 2010. pp. 85-105. (This report describes the use of regional anesthesia in the management of lower extremity compartment syndrome.)

Frink, M, Hildebrand, F, Krettek, C, Brand, J, Hankemeier, S. “Compartment syndrome of the lower leg and foot”. Clin Orthop Relat Res. vol. 468. 2010. pp. 940-50.

Gourgiotis, S, Villias, C, Germanos, S, Foukas, A, Ridolfini, MP. “Acute limb compartment syndrome: a review”. J Surg Educ. vol. 64. 2007. pp. 178-86.

Tumbarello, C. “Acute extremity compartment syndrome”. J Trauma Nurs. vol. 7. 2000. pp. 30-6.

“Acute compartment syndrome of the limb”. Injury. vol. 36. 2005. pp. 992-8. (The authors describe the common mechanisms leading to compartment syndrome, as well as the anatomy of the lower extremity compartments, including surgical management.)

Konstantakos, EK, Dalstrom, DJ, Nelles, ME, Laughlin, RT, Prayson, MJ. “Diagnosis and management of extremity compartment syndromes: an orthopaedic perspective”. Am Surg. vol. 73. 2007. pp. 1199-209. (This information helps the anesthesiologist understand the orthopedic concerns involved in compartment syndrome.)

Gonzalez, D. “Crush syndrome”. Crit Care Med. vol. 33. 2005. pp. S34-41. (Compartment syndrome is a significant component of crush syndrome. In taking care of compartment syndrome, the anesthesiologist should be familiar with crush syndrome and the physiologic/metabolic changes it involves.)

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