半切开位腿的肌内和血压:阐明好腿急性筋膜室综合征的危险因素

R. S. Meyer, K. White, J. Smith, E. Groppo, S. Mubarak, A. Hargens
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Intramuscular pressures were continuously measured with a slit catheter in all four compartments of the left leg with the subject supine, in the hemilithotomy position with the calf supported, and in the hemilithotomy position with the heel supported but the calf free. Blood pressure was measured intermittently with use of automated pressure cuffs. Results: Changing from the supine to the calf-supported position significantly increased the intramuscular pressure in the anterior compartment (from 11.6 to 19.4 mm Hg) and in the lateral compartment (from 13.0 to 25.8 mm Hg). Changing from the calf-supported to the heel-supported position significantly decreased intramuscular pressure in the anterior, lateral, and posterior compartments (to 2.8, 3.4, and 1.9 mm Hg, respectively). The mean diastolic blood pressure in the ankle averaged 63.9 mm Hg in the supine position, which significantly decreased to 34.6 mm Hg in the calf-supported position. Changing to the heel-supported position had no significant effect on the diastolic blood pressure in the ankle (mean, 32.8 mm Hg). The mean difference between intramuscular pressure and diastolic blood pressure in the supine position was approximately 50 mm Hg in each of the four compartments. This mean difference significantly decreased to <20 mm Hg in the calf-supported position and then, when the leg was moved into the heel-supported position, significantly increased to approximately 30 mm Hg in all compartments. Conclusions: The combination of increased intramuscular pressure due to external compression from the calf support and decreased perfusion pressure due to the elevated position causes a significant decrease in the difference between the diastolic blood pressure and the intramuscular pressure when the leg is placed in the hemilithotomy position in a well-leg holder on a fracture table. 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引用次数: 85

摘要

背景:在长时间的普外科、泌尿外科和妇科手术中,处于取石位的腿被广泛报道为急性筋膜室综合征。骨科文献中也有在半骨切开位置放置在骨折台上的腿部出现这种并发症的报道。本研究的目的是确定由这种腿位引起的急性筋膜室综合征的危险因素。方法:将8名健康志愿者置于骨折治疗台上。在受试者仰卧位、小腿支撑半骨切开位和小腿支撑半骨切开位时,用切开导管连续测量左腿所有四个腔室的肌内压力。使用自动压力袖带间歇测量血压。结果:从仰卧位改变为小腿支撑位,显著增加了前房室的肌内压力(从11.6到19.4 mm Hg)和侧房室的肌内压力(从13.0到25.8 mm Hg)。从小腿支撑到脚跟支撑体位的改变显著降低了前、外侧和后腔的肌内压力(分别降至2.8、3.4和1.9 mm Hg)。仰卧位踝关节舒张压平均值为63.9 mm Hg,小腿支撑位踝关节舒张压平均值为34.6 mm Hg。改变足跟支撑体位对踝关节舒张压无显著影响(平均32.8 mm Hg)。仰卧位时,四个心室肌内压和舒张压的平均差值约为50毫米汞柱。在小腿支撑的位置,这一平均差异显著降低到<20毫米汞柱,然后,当腿移动到脚跟支撑的位置时,所有隔室的平均差异显著增加到约30毫米汞柱。结论:小腿支架外压引起的肌内压升高和体位升高引起的灌注压降低,使得骨折手术台上小腿处于半截骨位时舒张压与肌内压的差值显著降低。加上手术时间延长,该体位可引起井腿急性筋膜室综合征。让小腿自由,而不是使用标准的井腿支架,增加了舒张压和肌内压之间的差异,并可能降低急性筋膜间室综合征的风险。
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Intramuscular and Blood Pressures in Legs Positioned in the Hemilithotomy Position: Clarification of Risk Factors for Well-Leg Acute Compartment Syndrome
Background: Acute compartment syndrome has been widely reported in legs positioned in the lithotomy position for prolonged general surgical, urologic, and gynecologic procedures. The orthopaedic literature also contains reports of this complication in legs positioned on a fracture table in the hemilithotomy position. The purpose of this study was to identify the risk factors for development of acute compartment syndrome resulting from this type of leg positioning. Methods: Eight healthy volunteers were positioned on a fracture table. Intramuscular pressures were continuously measured with a slit catheter in all four compartments of the left leg with the subject supine, in the hemilithotomy position with the calf supported, and in the hemilithotomy position with the heel supported but the calf free. Blood pressure was measured intermittently with use of automated pressure cuffs. Results: Changing from the supine to the calf-supported position significantly increased the intramuscular pressure in the anterior compartment (from 11.6 to 19.4 mm Hg) and in the lateral compartment (from 13.0 to 25.8 mm Hg). Changing from the calf-supported to the heel-supported position significantly decreased intramuscular pressure in the anterior, lateral, and posterior compartments (to 2.8, 3.4, and 1.9 mm Hg, respectively). The mean diastolic blood pressure in the ankle averaged 63.9 mm Hg in the supine position, which significantly decreased to 34.6 mm Hg in the calf-supported position. Changing to the heel-supported position had no significant effect on the diastolic blood pressure in the ankle (mean, 32.8 mm Hg). The mean difference between intramuscular pressure and diastolic blood pressure in the supine position was approximately 50 mm Hg in each of the four compartments. This mean difference significantly decreased to <20 mm Hg in the calf-supported position and then, when the leg was moved into the heel-supported position, significantly increased to approximately 30 mm Hg in all compartments. Conclusions: The combination of increased intramuscular pressure due to external compression from the calf support and decreased perfusion pressure due to the elevated position causes a significant decrease in the difference between the diastolic blood pressure and the intramuscular pressure when the leg is placed in the hemilithotomy position in a well-leg holder on a fracture table. Combined with a prolonged surgical time, this position may cause an acute compartment syndrome of the well leg. Leaving the calf free, instead of using a standard well-leg holder, increases the difference between the diastolic blood pressure and the intramuscular pressure and may decrease the risk of acute compartment syndrome.
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