Lampert R, Weih E H, Breucking E, Kirchhoff S, Lazica B, Lang K
Institut für Anästhesie, Intensivmedizin und Schmerztherapie, Universität Witten-Herdecke.
Anaesthesist. 1995 Jan;44(1):43-7. doi: 10.1007/s001010050131.
We report two cases of compartment syndrome of the lower leg that occurred in male patients aged 62 and 57 years, respectively, after 10 and 12-h urological surgery in the lithotomy position. During sedation and mechanical ventilation creatine kinase (CK) activity of more than 8,000 U/l was found in both patients. After extubation, clinical symptoms of the compartment syndrome were found. On the 1st day after surgery patient 2 underwent fasciotomy of both lower legs (Fig. 2). No lasting neurologic defects were observed. Patient 1 was treated by fasciotomy on the 4th postoperative day after paresis of the peroneal nerve had developed in the left lower leg. This paresis had shown no tendency to regression when the patient left hospital. On phlebography, both patients showed blockage of the deep lower leg veins up to the knee. DISCUSSION. The compartment syndrome is a rare but serious complication resulting from prolonged surgery in the lithotomy position. Symptoms are neuromuscular lesions of the affected limb. Severe complications of the compartment syndrome are acute renal failure resulting from myoglobin residues in the tubules, electrolyte disturbances, and disorders of acid-base balance. A decrease in perfusion due to the elevated position of the legs, on the one hand, and the impeded venous back-flow due to the positioning on the other are discussed. While positioning the legs, it is important to ensure that the lower legs are lifted only slightly above left atrial level. When rehabdomyolysis occurs, serum CK activity increases. CK values of over 2,000 U/l after surgery may be considered a warning sign in ventilated and sedated patients, in whom early clinical symptoms of the compartment syndrome such as pain and paresthesias cannot be ascertained. Frequent and regular checks of these parameters starting shortly after surgery are recommended. A thorough examination of the lower legs and, if necessary, measurement of the tissue pressure in the compartment should follow. The deep veins of the legs should be checked by phlebography. In cases of verified compartment syndrome, early fasciotomy is the best choice of therapy, because neuromuscular defects are known to be irreversible after 12 to 24 h. Enforced diuresis is recommended in order to avoid renal complications.
我们报告两例小腿骨筋膜室综合征，分别发生于62岁和57岁男性患者，他们在膀胱截石位接受泌尿外科手术10小时和12小时后出现该症状。在镇静和机械通气期间，两名患者的肌酸激酶（CK）活性均超过8000 U/l。拔管后，发现了骨筋膜室综合征的临床症状。术后第1天，患者2接受了双下肢筋膜切开术（图2）。未观察到持久的神经功能缺损。患者1在术后第4天，左下肢腓总神经麻痹后接受了筋膜切开术。患者出院时，这种麻痹没有恢复的趋势。静脉造影显示，两名患者小腿深部静脉直至膝关节均有阻塞。讨论：骨筋膜室综合征是膀胱截石位长时间手术导致的一种罕见但严重的并发症。症状为受累肢体的神经肌肉损伤。骨筋膜室综合征的严重并发症包括肾小管中肌红蛋白残留导致的急性肾衰竭、电解质紊乱和酸碱平衡失调。一方面，腿部抬高导致灌注减少，另一方面，体位导致静脉回流受阻。在摆放腿部位置时，重要的是要确保小腿仅略高于左心房水平。发生横纹肌溶解时，血清CK活性会增加。术后CK值超过2000 U/l，对于接受通气和镇静的患者可能被视为一个警示信号，因为在这些患者中无法确定骨筋膜室综合征的早期临床症状，如疼痛和感觉异常。建议术后不久就频繁定期检查这些参数。随后应彻底检查小腿，必要时测量骨筋膜室内的组织压力。应通过静脉造影检查腿部深部静脉。在确诊骨筋膜室综合征的情况下，早期筋膜切开术是最佳治疗选择，因为已知神经肌肉缺损在12至24小时后不可逆转。建议进行强制利尿以避免肾脏并发症。
