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Table of Contents
LETTERS TO EDITOR
Year : 2019  |  Volume : 35  |  Issue : 3  |  Page : 403-404

Gluteal compartment syndrome a rare complication of lithotomy position and continuous postoperative epidural analgesia


1 Department of Trauma and Emergency, All India Institute of Medical Science, Bhubaneswar, Odisha, India
2 Department of Anaesthesia, All India Institute of Medical Science, Bhubaneswar, Odisha, India
3 Department of Orthopaedics, All India Institute of Medical Science, Bhubaneswar, Odisha, India

Date of Web Publication3-Sep-2019

Correspondence Address:
Dr. Chitta R Mohanty
Department of Trauma and Emergency, AIIMS, Bhubaneswar - 751 019, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/joacp.JOACP_146_18

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How to cite this article:
Mohanty CR, Sahoo AK, Panda R, Jain M. Gluteal compartment syndrome a rare complication of lithotomy position and continuous postoperative epidural analgesia. J Anaesthesiol Clin Pharmacol 2019;35:403-4

How to cite this URL:
Mohanty CR, Sahoo AK, Panda R, Jain M. Gluteal compartment syndrome a rare complication of lithotomy position and continuous postoperative epidural analgesia. J Anaesthesiol Clin Pharmacol [serial online] 2019 [cited 2019 Sep 20];35:403-4. Available from: http://www.joacp.org/text.asp?2019/35/3/403/265900



Madam,

Gluteal compartment syndrome is a rarely reported complication following posterior cruciate ligament repair during knee arthroplasty performed in lithotomy position under epidural anesthesia.[1],[2] A 27-year-old obese male with BMI 36 Kg/m2 was scheduled for arthroscopic posterior cruciate ligament tear repair under combined spinal-epidural anesthesia. Preoperative investigations were within the normal limit; there was no history of bleeding or coagulopathy. Combined spinal-epidural anesthesia was provided with 2.5ml(12.5mg) of bupivacaine heavy (0.5%) at the L3/ L4 level, the sensory level of T10 and motor blockade of T12 achieved. After positioning in the modified lithotomy position, the arthroscopic procedure was done with the tourniquet time (thigh) of 1 h and 30 min and the total intraoperative duration was 2 h and 30 min; the tourniquet pressure was 250 mm Hg. The procedure was uneventful and the patient was hemodynamically stable throughout the surgery. In the postoperative period, continuous epidural infusion of 0.2% ropivacaine was started after 1 h at the rate of 6 mL/h, for postoperative analgesia. After 6 h, the patient was evaluated and found that there was motor weakness and the dilution was changed to 0.1% and the infusion was reduced to 4 mL/h, with resolution of motor block after 4 h. After 18 h, the epidural infusion was stopped and the patient complained of severe pain in the right buttock whilst there was recovery of sensory block. On examination, we noticed a tense, tender swelling in the right buttock. Having a high suspicion for the compartmental syndrome, an immediate surgical decompression was done. During surgery, we found significant tissue edema without any evidence of muscle damage. The patient eventually had an uneventful recovery with a prolonged hospital stay.

Patient positions that are used for surgery result in undesirable physiological consequences including significant cardiovascular and respiratory compromise. Anesthetic agents blunt natural compensatory mechanisms, rendering surgical patients vulnerable to positional changes. Lower extremity compartment syndrome is a rare complication caused by inadequate tissue perfusion that is associated with the lithotomy position.[3] Compartment consists of the group of muscles separated by fascia which is a nonyielding space. Local arterial pressure decreases by 0.78 mm for each centimeter the leg is raised above the right atrium.[4] Compartment pressure initially increases in the lithotomy position for reasons that remain incompletely explained. This increase, combined with decrease perfusion pressure in elevated extremities, causes a vicious cycle of ischemia, edema, and further ischemia leading to inadequate tissue perfusion. Unrelieved pressure within the compartment can cause neuromuscular damage that results in rhabdomyolysis and multiorgan failure.

Decompression fasciotomy is generally performed if the tissue pressures are measured to be >30 mm Hg. Irreversible muscle damage occurs with pressure >50 mm Hg for several hours. Warner et a l. in a large retrospective review of 572,498 surgeries, observed higher incidence of compartment syndromes in a lithotomy (1 in 8720) and lateral decubitus (1 in 9711) positions as compared with the supine (1 in 92,441) position.[3] Long procedure time was only distinguishing characteristic of surgeries during which patients developed lower extremity compartment syndromes. Simms and Terry reported that compartment syndrome might occur 1 in 500 radical cystectomy procedures, which represent 78% of their cases; affected patients had undergone surgeries with a duration longer than 3.5 h.[5] Compartment pressure increases over time in the lithotomy position, and legs should be periodically lowered to the level of the body if surgery extends beyond 2 to 3 h.[1] Additional risk factors include high BMI and factors that compromise tissue oxygenation such as blood loss, peripheral vascular disease, hypotension, and reduced cardiac output. Gluteal compartment syndrome has been occasionally reported following posterior cruciate ligament repair, knee arthroplasty, and total hip arthroplasty; this is just report of 1997.[2] An association between the epidural anesthesia and gluteal compartment syndrome was reported in the literature.[2] In our patient, high BMI, intraoperative lithotomy position, continuous epidural with impaired sensation, and motor blockade were the risk factors that predispose to the development of compartment syndrome. Identifying patients at risk, intraoperative positioning with proper padding, evaluation for motor blockade during continuous epidural and appropriate dose adjustment, vigilant nursing, and change in posture intraoperatively in longer duration cases and postoperatively can prevent and help in early detection of this potentially devastating complication. Prompt intervention in clinically presented cases can lead to complete recovery without neuromuscular damage and patient morbidity. Anesthesiologists should be aware of the risk of this syndrome in patients operated in the lithotomy position under combined spinal-epidural anesthesia along with continuous epidural infusion for postoperative analgesia.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Krysa J, Lofthouse R, Kavanagh G. Gluteal compartment syndrome following posterior cruciate ligament repair. Injury 2002;33:835-8.  Back to cited text no. 1
    
2.
Kontrobarsky Y, Love J. Gluteal compartment syndrome following epidural analgesic infusion with motor blockage. Anaesth Intensive Care 1997;25:696-8.  Back to cited text no. 2
    
3.
Warner ME, LaMaster LM, Theming AK, Marienau ME, Warner MA. Compartment syndrome in surgical patients. Anesthesiology 2001;94:705-8.  Back to cited text no. 3
    
4.
Simms MS, Terry TR. Well leg compartment syndrome after pelvic and perineal surgery in the lithotomy position. Postgrad Med J 2005;81:534-6.  Back to cited text no. 4
    
5.
Turnbull D, Farid A, Hutchinson S, Shorthouse A, Mills GH. Calf compartment pressures in the Lloyd-Davies position. A cause for concern? Anaesthesia 2002;57:905-8.  Back to cited text no. 5
    




 

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