POSTOPERATIVE BILATERAL COMPARTMENT SYNDR OME RESULTING FROM PROLONGED UROLOGICAL SURGERY IN LITHOTOMY POSITION - SERUM CREATINE-KINASE AS AN EARLY MARKER IN MECHANICALLY VENTILATED AND SEDATED PATIENTS

We report two cases of compartment syndrome of the lower leg that occu rred in male patients aged 62 and 57 years, respectively, after 10 and 12-h urological surgery in the lithotomy position. During sedation an d mechanical ventilation creatine kinase (CK) activity of more than 8, 000 U/l was found in both patients. After extubation, clinical symptom s of the compartment syndrome were found. On the Ist day after surgery patient 2 underwent fasciotomy of both lower legs (Fig. 2). No lastin g neurologic defects were observed. Patient 1 was treated by fasciotom y on the 4th postoperative day after paresis of the peroneal nerve had developed in the left lower leg. This paresis had shown no tendency t o regression when the patient left hospital. On phlebography, both pat ients showed blockage of the deep lower leg veins up to the knee. Disc ussion. The compartment syndrome is a rare but serious complication re sulting from prolonged surgery in the lithotomy position. Symptoms are neuromuscular lesions of the affected limb. Severe complications of t he compartment syndrome are acute renal failure resulting from myoglob in residues in the tubules, electrolyte disturbances, and disorders of acid-base balance. A decrease in perfusion due to the elevated positi on of the legs, on the one hand, and the impeded venous back-flow due to the positioning on the other are discussed. While positioning the l egs, it is important to ensure that the lower legs are lifted only sli ghtly above left atrial level. When rhabdomyolysis occurs, serum CK ac tivity increases. CK values of over 2,000 U/l after surgery may be con sidered a warning sign in ventilated and sedated patients, in whom ear ly clinical symptoms of the compartment syndrome such as pain and pare sthesias cannot be ascertained. Frequent and regular checks of these p arameters starting shortly after surgery are recommended. A thorough e xamination of the lower legs and, if necessary, measurement of the tis sue pressure in the compartment should follow. The deep veins of the l egs should be checked by phlebography. In cases of verified compartmen t syndrome, early fasciotomy is the best choice of therapy, because ne uromuscular defects are known to be irreversible after 12 to 24 h. Enf orced diuresis is recommended in order to avoid renal complications.