Complications associated with intermittent pneumatic compression
ABSTRACT The intermittent pneumatic compression device (IPCD) is prophylaxis for prevention of deep-venous thrombosis (DVT). This pneumatic leg sleeve has been used extensively in high-risk surgical patients, without complication. We describe two cases, one with peroneal neuropathy and the other with compartment syndrome, associated with IPCD use during surgery. Case 1 involves a patient with pancreatic cancer and weight loss who developed bilateral peroneal nerve palsies during surgery. Case 2 involves a patient with bladder cancer who developed lower leg compartment syndrome during prolonged surgery in the lithotomy position. These cases are unusual for several reasons. First, patients wearing IPCDs during surgery are at increased risk of neurovascular compression. Second, significant weight loss may predispose the peroneal nerve to injury from intermittent compression garments. Third, patients undergoing surgery in the lithotomy position are at risk of compartment syndrome. Therefore, physicians may wish to use another method of DVT prophylaxis in surgical patients with cancer or significant weight loss, or those who are undergoing procedures in the lithotomy position.
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ABSTRACT: Fragestellung und Ziel der Studie: Ziel der Arbeit ist, durch Messung des intramuskulären Sauerstoffpartialdrucks den kritischen Bereich des pneumatischen Drucks der Antischockhose (ASH) zu definieren, ab dem sich eine Muskelischämie an der unteren Extremität entwickelt. Bei gleichzeitiger intrakompartimenteller Druckmessung sollte neben der Gewebeoxygenation auch die auf Druck empfindlich reagierende Impulsfortleitung im N. peronaeus profundus beurteilt werden. Methodik: Bei 22 normotensiven gesunden Freiwilligen wurden mit einem ASH-Beinsegment im M. tibialis anterior Druckwerte zwischen 0 und 100 mm Hg erzeugt. Über einen Zeitraum von bis zu 6 h erfolgte die Messung des Muskelgewebedrucks, der Sauerstoffspannung und des Muskelsummenaktionspotentials (MSAP) des N. peronaeus profundus. Ergebnisse: Ausgangsdruckwert im M. tibialis anterior im Median 12,0 mm Hg (Q25%/Q75%: 8,9/17,3), pO2: 14,8 mm Hg (Q25%/Q75%: 11,5/22,0). Übertragung des pneumatischen Drucks zu 97,7% (Q25%/Q75%: 89,2/99,8) auf den Extremitätenmuskel. Bereits bei niedrigen ASH-Druckwerten (20–40 mm Hg) trat im Einzelfall eine schwere Hypoxie auf. Eine Reduktion des MSAP war ab einem ASH-Druck von 10 mm Hg zu beobachten. ASH-Druckwerte von 60 mm Hg (n = 6) führten in 5 Fällen innerhalb von 5–20 min zum Abfall des pO2 auf pathologische Werte. Inflationsdruckwerte über 60 mm Hg resultierten nahezu ausnahmslos in einer Anoxie des Muskels und im Verlust des MSAP. Schlußfolgerungen: Der Einsatz der ASH sollte nur mit Modellen erfolgen, bei denen der Inflationsdruck manometrisch kontrolliert werden kann. Der ASH-Einsatz erscheint dann gerechtfertigt, wenn bei einem Polytraumatisierten im schweren hämorrhagischen Schock das Risiko einer sich auch systemisch auswirkenden lokalen Gewebeischämie bewußt in Kauf genommen werden muß. Object of the study: The aim of the study was to assess, whether the pneumatic pressure of an antishock-trouser (AST) of 20–40 mm Hg induces a decreased oxygenation of the anterior tibial muscle and attenuates muscular response potential (MRP) of n. peronaeus profundus? Methods: Among 22 normotensive, healthy volunteers the AST were tested by applying pressure values between 0 and 100 mm Hg and measuring the intracompartmental pressure, the muscular oxygen pressure as well as the MRP by electroneurographic means within a period of 6 hours. Results: The median initial intracompartmental pressure value of the m. tibialis anterior was 12.0 mm Hg (Q25%/Q75%: 8.9/17.3), the muscular oxygen pressure 14.8 mm Hg (Q25%/Q75%: 11.5/22.0). Transmission of the pneumatic AST-leg segment pressure to the muscle: 97.7% (Q25%/Q75%: 89.2/99.8). Already in the low AST pressure field (20–40 mm Hg) a severe hypoxia occurred in one case. A reduction of MRP was noticed at an AST pressure rate of 10 mm Hg. In 5 of 6 cases AST pressure values of 60 mm Hg led to pathological pO2-values within 5–20 minutes. Almost without exception AST-pressure rates < 60 mm Hg resulted in an anoxia of the muscle and loss of the MRP. Conclusions: We should demand that the AST are only applied with models where the pressure generated within the single segments can be controlled by pressure gauge. The application of the AST seems to be justified for polytraumatised in severe haemorrhagic shock where the risk of a local tissue ischemia with systemical consequences must deliberately be accepted.Der Anaesthesist 47(7):571-580. DOI:10.1007/s001010050598 · 0.74 Impact Factor
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ABSTRACT: The background risk of neurological injury from ‘natural’ causes is small and imprecisely known. The evolution of interventional pain management has exacted its own toll of side-effects and neurological risk. When these two are superimposed it is often difficult, or impossible, to discern the separate parts of the final picture and it is only through a knowledge of both sets of side-effects that the viewer can glimpse the true part played by each. To catch that glimpse and to avoid potential complications requires vigilance, and vigilance must be sustained from the time the patients is seen until the remote effects of the analgesic procedure have completely dissipated. In the case of intraspinal steroids this implies a time span of up to 6 weeks (Bromage, 1993a).Next in importance to vigilance comes speed of appropriate therapeutic response, since the period of grace to rescue a compromised spinal cord is in the range of 6–12 h. Extraordinarily rapid advances in imaging techniques have made a tremendous contribution to the speed, safety and precision of neurological diagnoses when complications do arise. Today, MRI, with or without gadolinium enhancement, has virtually replaced ionized radiography as the premier imaging technique, and it has supplanted myelography except in cases where MRI is unavailable, or when patients are unable to undergo MRI because of claustrophobia or an implanted cardiac pacemaker (Sze et al, 1989; Byrne, 1992). MRI is now moving towards motion images that will provide dynamic capabilities comparable to those of cineradiography (Sze, 1992). While MRI is expensive, the savings achieved by eliminating earlier diagnostic procedures have made it a cost-effective instrument, well suited to the current era of rigorous cost containment (du Boulay et al, 1990).Baillière s Clinical Anaesthesiology 01/1993; 7(3-7):793-815. DOI:10.1016/S0950-3501(05)80282-X
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ABSTRACT: Determine the prevalence of proximal deep venous thrombosis (DVT) among acquired brain injury patients on admission to rehabilitation and assess cost-effectiveness of routine ultrasound screening for proximal DVT in those patients. Prospective study, sequential case series. University tertiary care rehabilitation center. One hundred sixteen traumatic brain injury patients (TBI) and 48 nontraumatic brain injury patients were admitted to our brain injury (BI) unit over a 21-month period and screened for a DVT on admission to rehabilitation utilizing real time, Doppler, and color Doppler ultrasound. Patients with a previous clinically recognized and treated DVT were excluded. No patients had been treated with prophylactic anticoagulation or intermittent anticoagulation since their BI and all patients were within 4 months of the original injury. Fourteen patients in total (8.5%) were found to have a DVT in the thigh or popliteal area, 9 of the 116 patients in the TBI group (7.8%), and 5 of the 48 patients in the nontraumatic BI group (10.4%). Statistically, there was no significant difference in the total number of detected proximal lower extremity DVTs between the TBI and the nontraumatic BI groups (Fisher's exact test). In the TBI group 22 patients had associated lower extremity or pelvic fractures, but this factor appeared not to be significant, because only 1 of the 22 patients was discovered to have a DVT. The average admission Glascow Coma Score (GCS) of the TBI group was 8.6 but there was no correlation with the GCS and prevalence of DVT. The additional cost of screening for and treating the additional DVTs utilizing color Doppler ultrasound is conservatively estimated to be $674.84 per patient admitted to the BI rehabilitation unit. It can be estimated the cost of saving one life is $129,527.83. DVT screening in this patient population appears to be more cost-effective than mass screening programs for either breast cancer or colorectal cancer. The cost per year of life saved, estimated at only $2,977.65 ($129,527.83/43.5 years) for DVT screening for brain injury patients on admission to rehabilitation, is lower than those costs proposed for comparable programs with significant social support.Archives of Physical Medicine and Rehabilitation 02/1996; 77(1):1-5. DOI:10.1016/S0003-9993(96)90210-5 · 2.44 Impact Factor