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 Table of Contents  
IMAGES FOR SURGEONS
Year : 2020  |  Volume : 53  |  Issue : 1  |  Page : 39-40

Acute compartment syndrome by improper postdialytic hemostasis


1 Department of Internal Medicine, Division of Nephrology, Ditmansion Medical Foundation Chia-Yi Christian Hospital, Chia-Yi; Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
2 Department of Surgery, Division of Cardiovascular Surgery, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan

Date of Submission20-Jun-2019
Date of Decision05-Sep-2019
Date of Acceptance21-Oct-2019
Date of Web Publication19-Feb-2020

Correspondence Address:
Dr. Cheng-Chieh Yen
No. 539, Zhongxiao Road, East Dist., Chia-Yi City
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/fjs.fjs_50_19

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How to cite this article:
Yen CC, Huang SM. Acute compartment syndrome by improper postdialytic hemostasis. Formos J Surg 2020;53:39-40

How to cite this URL:
Yen CC, Huang SM. Acute compartment syndrome by improper postdialytic hemostasis. Formos J Surg [serial online] 2020 [cited 2020 Apr 4];53:39-40. Available from: http://www.e-fjs.org/text.asp?2020/53/1/39/278672



A 61-year-old female presented to the emergency department with unusual pain and progressive numbness along the left forearm that had developed following her dialysis session 3 hours before. Diabetic nephropathy contributed to her end-stage renal disease and hemodialysis was maintained via her forearm arteriovenous fistula for more than 2 years. She received aspirin and clopidogrel for her coronary ischemia and had no known history of coagulation disorders. Her dialysis regimens were free of anticoagulants. Smooth cannulation was exhibited under area puncture technique.

At the emergency department, the area of cannulation was swollen, ecchymotic, and bullous, and the left hand was cyanotic and cold [Figure 1]a. Physical examinations showed tense left forearm muscle and paresthesias of the left hand. Her blood and coagulation parameters were within normal limit (leukocyte: 5.56 × 103/μL; hemoglobin: 11.3 g/dL; platelet: 174 × 103/μL; prothrombin time: 10 s; and activated partial thromboplastin time: 47.8s). She received computed tomographic angiography, which revealed a hematoma deriving from her arteriovenous fistula without other vascular abnormalities. We performed emergent fasciotomy for the acute compartment syndrome. A subcutaneous hematoma (the asterisk) originated from the dialysis cannulation hole was observed with the extension of the subfascial layer [Figure 1]b. Inappropriate postdialytic hemostasis led to this troublesome complication. Cyanosis and paresthesias of her hand recovered immediately after the fasciotomy. The arteriovenous fistula was ligated simultaneously. She discharged without sequelae 10 days after admission. Since the follow-up sonographies revealed insufficient blood flow of the arteriovenous fistula, an alternative artificial graft was reconstructed 3 months later.
Figure 1: (a) The appearance of left forearm and hand of the patient after a dialysis session. (b) A subcutaneous hematoma (the asterisk) derived from the cannulation site and extended to the subfascial layer

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Compartment syndrome occurs when elevated pressure within a muscle group compromises the circulation and function of the distal tissues. Given the bleeding diathesis resulting from uremia, polypharmacy affecting coagulation and frequent vascular procedures in patients undergoing hemodialysis,[1] vascular access surgeries, dialysis cannulations, and traumas have been reported causing acute compartment syndrome in this vulnerable population.[2],[3] It is a clinical diagnosis based on the patients' symptoms and signs rather than their compartment pressure measurements.[4] Missed or delayed diagnosis results in miserable outcomes. Surgeons could not only prevent this devastating situation by thorough preoperative evaluation and cautious access establishment, but also provide timely decompressive fasciotomy for the prevention of neuromuscular deficit and extremity loss.[5]

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sagripanti A, Barsotti G. Bleeding and thrombosis in chronic uremia. Nephron 1997;75:125-39.  Back to cited text no. 1
    
2.
Lin CT, Dai NT, Chen SG, Chang SC. Acute forearm compartment syndrome following haemodialysis access fistula puncture in uraemia. ANZ J Surg 2016;86:785-9.  Back to cited text no. 2
    
3.
Reddy SP, Matta S, Handa A. Forearm compartment syndrome following puncture of haemodialysis access fistula. Eur J Vasc Endovasc Surg 2002;23:458-9.  Back to cited text no. 3
    
4.
Nelson JA. Compartment pressure measurements have poor specificity for compartment syndrome in the traumatized limb. J Emerg Med 2013;44:1039-44.  Back to cited text no. 4
    
5.
von Keudell AG, Weaver MJ, Appleton PT, Bae DS, Dyer GS, Heng M, et al. Diagnosis and treatment of acute extremity compartment syndrome. Lancet 2015;386:1299-310.  Back to cited text no. 5
    


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