Romagnoli Anna N, Morrison Jonathan J, DuBose Joseph J, Feliciano David V
Department of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA, USA.
Department of Trauma Surgery and Surgical Critical Care, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD, USA.
Am Surg. 2020 Aug;86(8):1010-1014. doi: 10.1177/0003134820942138.
Failure to perform adequate fasciotomy for a presumed or diagnosed compartment syndrome after revascularization of an acutely ischemic limb is a potential cause of preventable limb loss. When required, outcomes are best when fasciotomy is conducted with the initial vascular repair. Despite over 100 years of experience with fasciotomy, the actual indications for its performance among acute care and trauma surgeons performing vascular repairs are unclear. The hypothesis of this study was that there are many principles of fasciotomy that are uniformly accepted by surgeons and that consensus guidelines could be developed.
A 20-question survey on fasciotomy practice patterns was distributed to trauma and acute care surgeons of a major surgical society which had approved distribution.
The response to the survey was 160/1066 (15 %). 92.5% of respondents were fellowship trained in trauma and acute care surgery, and 74.9% had been in practice for fewer than 10 years. Most respondents (71.9%) stated that they would be influenced to perform a preliminary fasciotomy (fasciotomy conducted prior to planned exploration and arterial repair) based upon specific signs and symptoms consistent with compartment syndrome-including massive swelling (55.6%), elevated compartment pressures (52.5%), delay in transfer >6 hours (47.5%), or obvious distal ischemia (33.1%). 20.6% responded that they would conduct exploration and repair first, regardless of these considerations. Prophylactic fasciotomies (fasciotomy without overt signs of compartment syndrome) would be performed by respondents in the setting of the tense compartment (87.5%), ischemic time >6 hours (88.1%), measurement of elevated compartment pressures (66.9%), and in the setting of large volume resuscitation requirements (31.3%). 69.4% of respondents selectively measure compartment pressures, with nearly three-fourths utilizing a Stryker needle device (72.5%). The most common sequence of repairs following superficial femoral artery injury with a >6-hour limb ischemia was cited as the initial insertion of a shunt, followed by fasciotomy, then vein harvest, and finally interposition repair.
While there is some general consensus on indications for fasciotomy, there is marked heterogeneity in surgeons' opinions on the precise indications in selected scenarios. This is particularly surprising in light of the long history with fasciotomy in association with major arterial repairs and strongly suggests the need for a consensus conference and/or meta-analysis to guide further care.
对急性缺血肢体进行血管再通术后，若未针对疑似或确诊的骨筋膜室综合征进行充分的筋膜切开术，可能导致可预防的肢体丧失。若有必要，在进行初始血管修复时同时进行筋膜切开术，效果最佳。尽管筋膜切开术已有100多年的应用经验，但在进行血管修复的急症和创伤外科医生中，其实际应用指征尚不清楚。本研究的假设是，存在许多外科医生普遍接受的筋膜切开术原则，并且可以制定共识指南。
向一个已批准进行调查分发的主要外科学会的创伤和急症外科医生发放了一份关于筋膜切开术实践模式的20个问题的调查问卷。
共收到160份回复，占1066名调查对象的15%。92.5%的受访者接受过创伤和急症外科专科培训，74.9%的受访者从业时间不到10年。大多数受访者（71.9%）表示，他们会根据与骨筋膜室综合征相符的特定体征和症状——包括严重肿胀（55.6%）、骨筋膜室内压力升高（52.5%）、转运延迟>6小时（47.5%）或明显的远端缺血（33.1%）——而受到影响进行初步筋膜切开术（在计划的探查和动脉修复之前进行的筋膜切开术）。20.6%的受访者表示，无论这些因素如何，他们都会先进行探查和修复。在出现紧张的骨筋膜室（87.5%）、缺血时间>6小时（88.1%）、测量到骨筋膜室内压力升高（66.9%）以及需要大量液体复苏（31.3%）的情况下，受访者会进行预防性筋膜切开术（在没有明显骨筋膜室综合征体征的情况下进行的筋膜切开术）。69.4%的受访者会选择性地测量骨筋膜室内压力，近四分之三（72.5%）的受访者使用史赛克针装置。股浅动脉损伤且肢体缺血>6小时后的最常见修复顺序被认为是首先插入分流管，然后进行筋膜切开术，接着进行静脉采集，最后进行血管移植修复。
虽然在筋膜切开术的指征方面存在一些普遍共识，但在某些特定情况下，外科医生对于确切指征的意见存在显著异质性。鉴于筋膜切开术与主要动脉修复相关的悠久历史，这一点尤其令人惊讶，强烈表明需要召开一次共识会议和/或进行荟萃分析以指导进一步的治疗。
