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Teaching flbreoptic nasotracheal intubation via the laryngeal mask airway

I describe a case of bilateral compartment syndrome in a 45-year-old male following prolonged positioning in the lithotomy position during reconstruction prostatectomy. A routine general anaesthetic was supplemented with epidural analgesia, which was stopped at the end of the operation. The operation lasted 7 h 45 min. Four h postoperatively he was drowsy, hypotensive, anuric and hyperkalaemic. Antibiotics, fluids and insulin were given. After 8.5 h he complained of painful calves which on examination were tense, swollen and painful to stretch. Serum creatine kinase was 50000 U.1-’ (normal range 0-130 U.1-I). Compartment syndrome was diagnosed and fasciotomy to the three compartments of each lower limb was performed. His subsequent care was on intensive care where he needed treatment for acute renal failure. Eleven days later he was discharged to the ward with neurosensory dysfunction of both lower limbs and dependent on renal dialysis. Four weeks later there was no improvement. The recurring nature of this problem suggests the lithotomy position results in a degree of ischaemia in the compartments. How this is tolerated depends on a variety of factors, the most important being time in the lithotomy position, no cases being reported under 5 h duration [ l , 21; this may be the critical time limit. In animal studies of compartment changes during ischaemia, irreversible damage to muscle and nerve occurs between 3 4 h [ 3 4 ] . Less important are type of leg support, age and operation performed. Some patients have an increased risk, e.g. large muscle bulk, peripheral vascular disease, haemodynamic instability. Intra-operatively, the developing compartment syndrome is difficult to treat. Intermittently lowering the legs to restore perfusion to leakly vessels within a compartment exacerbates the end result. Actively limiting time in the lithotomy position to where it is required for surgical access is the best way to reduce the ischaemic insult. Experimentally, intra-operative infusions of oxygen free radical scavengers, e.g. desferrioxamine or the capillary ‘plugger’ pentafraction of hydroxyethyl starch have successfully limited the increase in compartment pressure postoperatively [7,8]. However, no work has been done on humans. Therefore, more care should be directed into early detection postoperatively by frequent limb examination, especially in high risk cases, allowing early treatment and thus preventing long-term complications. The diagnosis is confirmed by direct measurement of compartment pressure using a side port needle and a pressure measuring device [9]; fasciotomy is considered at pressures of 30-40 mmHg. Compartment syndrome can present as acute renal failure before pain is felt. In these cases urinary myoglobin and creatine kinase must be added to the routine investigation of postoperative renal failure. Finally, does epidural analgesia mask the pain of compartment syndrome? Of the cases reported in the literature, eight had working epidurals. In six cases the pain broke through, but in two lack of pain contributed to delayed diagnosis [ 10-121. When using epidurals frequent examination and early investigation of compartment pressure is mandatory.