Abdominal compartment syndrome after hip arthroscopy.

Abdominales Kompartmentsyndrom nach Hüftarthroskopie

Die Hüftarthroskopie gilt als ein Verfahren mit geringen perioperativen Risiken. Während einer minimal-invasiven Resektion von periartikulären Verkalkungen an der linken Hüfte bei Zustand nach Endoprothese vor vielen Jahren kommt es bei einem 72-jährigen Mann zur Verschiebung von großen Mengen Spülflüssigkeit nach retroperitoneal und intraabdominal. In der Folge entwickelt sich ein akutes abdominales Kompartmentsyndrom mit Low-output-Kreislaufversagen. Symptomatik, notfallmäßige Diagnostik und zielgerichtete Therapie werden in dieser Kasuistik dargestellt. Der obstruktive Schock muss zeitnah erkannt und kausal behandelt werden. Die direkte, respektvoll kollegiale Kommunikation zwischen Anästhesist und Operateur ist Voraussetzung, um einen fatalen Verlauf für den Patienten zu verhindern.

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Case

A 72-year-old male (168 cm, 81 kg, American Society of Anesthesiologists, ASA risk class 2) was scheduled for an arthroscopic procedure of the left hip under general anesthesia. The procedure was indicated because of painful calcifications of the bursa iliopectinea (Fig. 1a, b) after a total hip replacement several years ago. After an uneventful induction of general anesthesia (endotracheal intubation, invasive arterial blood pressure measurement), the patient was placed in a right lateral position. No traction was applied to the limb. The iliopectineal bursa was approached through an anterior portal and the optic was advanced into the area of the iliopectineal bursa. A second portal was established approximately 5 cm proximal to the first portal and the guide wire was introduced under visual control. This enabled good visualization of the iliopectineal bursa, psoas tendon and the anterior rim of the acetabular component of the hip replacement. Ringer’s lactate was used as an irrigation fluid during the procedure. A pressure-controlled arthroscopic pump (Dyonics IntelliJet Arthoscopic Fluid Management System V1.H; Smith & Nephew, Andover, MA, USA) with pressure set at 30 mm Hg was used. The ossification in the bursa was prepared and resected with a bur.

Fig. 1

a, b Reconstruction of the preoperative computed tomography scan of the left hip, anterior-posterior and lateral view. Calcifications of the bursa iliopectinea marked by arrows. c Excerpt of the hemodynamic parameters of the electronic anesthesia protocol. T0 to T60 surgery (in min). Arrow 1 supine position and transesophageal echocardiography, arrow 2 left tilt, arrow 3 abdominal sonography and paracentesis. BD blood pressure, MAP mean arterial pressure, SpO2 percutaneous oxygen saturation, HF heart rate, VES ventricular extrasystole, Art. BD invasive arterial blood pressure

Despite deep muscle relaxation a continuous increase in the peak airway pressure was observed. Accordingly, the plateau pressure of the ventilator increased from a baseline value of 18 mbar up to 32 mbar 45 min after start of the operation (T45). At T30 progressive hemodynamic instability developed with reduction of arterial pressure from 126/78 mm Hg to 85/60 mm Hg and a sharp decrease in pulse pressure amplitude (Fig. 1c). A pulsus paradoxus-like pattern was observed. Hemodynamics could temporarily be stabilized by additional intravenous volume bolus of 2 × 500 ml warmed Ringerfundine and intermittent application of vasopressors (ephedrine and norepinephrine). At T60 the hemodynamic situation deteriorated further and dramatically despite continuous vasopressor (norepinephrine) and fluid therapy. Therefore, the surgeon was informed to finish the procedure as soon as possible. Beside the respiratory and hemodynamic alterations, a rapid drop of the esophageal temperature (starting at T30) from 36 °C to 34.6 °C was observed. Prompt diagnostic work-up of the impending circulatory collapse was started. A transesophageal echocardiography immediately performed by a senior staff anesthesiologist revealed an empty left ventricle with a normal pump function and a collapsed right atrium. A pericardial tamponade was excluded. The patient was turned to the supine position. Using sonography a pneumothorax was also excluded and correct position of the endotracheal tube was confirmed by auscultation and bronchoscopy. After removing the drapes, a hard ballooned abdomen was found. The table was tilted to the left and the hemodynamic situation showed some improvement, probably because of partial relief of the inferior vena cava compression by the presumed high pressure in the abdomen. An abdominal sonography found a substantial amount of free fluid in the abdomen. A decision to perform a paracentesis was made and immediately more than 3l of clear fluid were collected. A definitive drainage was installed and the patient was transferred to the intensive care unit. After drainage of more than 8l of additional clear fluid collected with the paracentesis over a few hours the patient was rewarmed and finally extubated. He was discharged home 2 days later in good conditions. A follow-up telephone call after 3 weeks documented an uneventful recovery.

Discussion

A properly performed hip arthroscopy is considered a low-risk procedure [3, 7, 8] and overall, complications of hip arthroscopy seem to be rare [3, 4]. The most common complications are neurapraxia [6], portal wound bleeding, portal hematoma [2], trochanteric bursitis, septic arthritis and instrument breakage. In two systematic reviews, the cited complication rates varied between 0.41% and 0.45% for major complications and from 4.1% to 7.9% for minor ones. The most observed minor complications were osteochondral or temporary neural damage [5, 10]. Extra-articular fluid extravasation was the most frequent major complication. Retroabdominal and intra-abdominal fluid transfer during hip arthroscopy have been previously described [1] and seems to be more frequent in female patients and after long operating times [4]. It is a rare complication in the presence of an intact joint capsule [7]; however, it can be a devastating complication if the barrier to the retroperitoneal space is interrupted [1]. In our case the hip arthroscopy was extracapsular beneath the psoas muscle. The procedure therefore was prone for retroperitoneal fluid transfer. The transfer of the irrigating fluid along the psoas compartment and to the retroperitoneum was possible although the pressure of irrigating fluid was carefully regulated and a lower pressure level was chosen than usual. The rapid accumulation of intra-abdominal fluid compromised venous return and caused severe obstructive shock. The deterioration of the hemodynamic situation could have been interpreted as tension pneumothorax (most common cause of obstructive shock) or pericardial tamponade. Only the understanding of the procedure, its potential complications and good communication with the surgeon revealed the pathophysiological cause of a severely compromised venous return, almost unresponsive to fluid boluses and vasopressors. The surgeon’s agreement to abort the procedure immediately was fundamental to save the patient’s life. The drop of the patient’s core temperature is also a noteworthy sign that should raise the suspicion of unwanted heat extraction by the irrigation fluid transferred into the retroperitoneum and the abdomen or even the thorax [9].

Conclusion

A hemodynamically relevant compression of the vena cava inferior due to fluid transfer should be taken into account during a hip arthroscopic procedure, especially when the capsule system of the hip is not intact or an extracapsular procedure is performed. Surgeons and anesthetists should communicate openly whenever unexpected findings occur especially in cases of instable vital signs. Thereby appropriate measures have to be taken to avoid a fatal outcome and the procedure should be aborted as quickly as possible.