From the Department of Anesthesiology, Mayo Clinic, Jacksonville, Florida, USA.
Exp Clin Transplant. 2021 Sep;19(9):986-989. doi: 10.6002/ect.2017.0339. Epub 2018 Oct 5.
Acute compartment syndrome is the physiologic consequence of increasing pressures within an enclosed anatomic space; if left untreated, it can subsequently cause irreversible necrosis, nerve injury, and tissue damage. A number of iatrogenic causes have been reported in the literature; however, to the best of our knowledge, there are no prior reports of upper extremity compartment syndrome in orthotopic liver transplant following arterial line placement. Here, we report a 52-year-old male with a history of end-stage liver disease secondary to primary sclerosing cho-langitis who presented for orthotopic liver transplant. A radial arterial line with 20-gauge catheter was placed atraumatically without complication. Intraoperatively, the patient developed severe coagulopathy. The cause was likely multifactorial, including dilution of factors from the massive blood loss during the dissection phase, a prolonged anhepatic period, and delayed graft function, resulting in decreased production of coagulation factors. This consumptive process likely subjected minor vascular injury to potential bleeding and caused a slow cumulative bleed into the right forearm, resulting in compartment syndrome. This case exemplifies the complications that can occur from arterial line placement in a liver transplant recipient who develops severe intraoperative coagulopathy. This can arguably be extrapolated to any situation caused by significant dilutional coagulopathy or a consumptive process, such as disseminated intra-vascular coagulation. As such, when large-volume blood transfusions are anticipated, we recommend that all central venous and arterial accesses be obtained under ultraso-nographic guidance and that frequent extremity physical examinations should be performed at a minimum of every hour. Correcting the underlying coagulopathy is imperative to resolve ongoing bleeding, a high index of suspicion is warranted, and immediate diagnosis and therapy are integral to improving patient outcomes.
急性间隔综合征是封闭解剖空间内压力增加的生理后果；如果不进行治疗，它随后可能会导致不可逆转的坏死、神经损伤和组织损伤。文献中有许多医源性原因的报道；然而，据我们所知，在原位肝移植后动脉置管后，上肢间隔综合征尚无先前报道。在这里，我们报告了一名 52 岁男性，因原发性硬化性胆管炎导致终末期肝病，他接受了原位肝移植。创伤性地放置了一根带有 20 号导管的桡动脉线，没有并发症。术中，患者出现严重凝血功能障碍。其原因可能是多方面的，包括在解剖阶段大量失血导致的因子稀释、无肝期延长和移植物功能延迟，导致凝血因子产生减少。这个消耗过程可能会使小血管损伤潜在出血，并导致右前臂缓慢累积性出血，导致间隔综合征。这个病例说明了在发生严重术中凝血功能障碍的肝移植受者中，动脉置管可能会发生的并发症。这可以说是由明显稀释性凝血功能障碍或消耗性过程引起的任何情况，例如弥散性血管内凝血。因此，当预计需要大量输血时，我们建议在超声引导下获得所有中心静脉和动脉通路，并至少每小时进行一次四肢体格检查。纠正潜在的凝血功能障碍对于解决持续出血至关重要，应保持高度怀疑，及时诊断和治疗对于改善患者预后至关重要。
