From the Guidelines
Fluid resuscitation for compartment syndrome should be approached cautiously, prioritizing urgent surgical fasciotomy as the primary management, and when fluids are needed, administering isotonic crystalloids judiciously at maintenance rates. The management of compartment syndrome is primarily focused on relieving the pressure within the affected compartment to prevent further tissue damage and necrosis. According to the guidelines for the acute care of severe limb trauma patients 1, the treatment of established compartment syndrome involves early fasciotomy.
Key Considerations
- The volume to be administered during fluid resuscitation remains debated, but most retrospective studies report that patients who eventually developed acute kidney injury had a longer time to initiate volume resuscitation compared to those who did not 1.
- Isotonic crystalloids like normal saline or lactated Ringer's solution should be administered at maintenance rates unless the patient has concurrent hypovolemic shock, with typical maintenance rates being 1-2 mL/kg/hr in adults, adjusted based on hemodynamic parameters and urine output.
- Aggressive fluid boluses should be avoided as they may increase edema within the affected compartment, potentially raising compartmental pressures further.
- Careful monitoring of compartment pressures (normal <20-30 mmHg), distal pulses, pain levels, and neurovascular status is essential during fluid administration, as indicated by the study on disaster nephrology: crush injury and beyond 1.
- Hypotonic solutions should be avoided as they may worsen tissue edema.
- If the patient requires volume resuscitation for shock, this should be balanced against the risk of worsening compartment syndrome, with early surgical consultation for definitive management through fasciotomy. Some studies suggest that volumes greater than 6L may be required in patients with severe rhabdomyolysis to prevent acute kidney injury and the need for renal replacement therapy 1. However, the primary focus should remain on urgent surgical intervention to relieve compartment pressure, with fluid management playing a supportive role.
From the Research
Fluid Resuscitation for Compartment Syndrome
- The use of hypertonic lactated saline (HLS) resuscitation has been shown to reduce the risk of abdominal compartment syndrome in severely burned patients 2.
- Aggressive intravenous fluid resuscitation (IVFR) has been conditionally recommended to improve outcomes of acute renal failure and lessen the need for dialysis in patients with rhabdomyolysis 3.
- Early and excessive crystalloid administration has been identified as a predictor of secondary abdominal compartment syndrome in patients with severe extremity injuries 4.
- Excessive fluid resuscitation with crystalloids can lead to intra-abdominal hypertension and abdominal compartment syndrome, emphasizing the need for careful consideration of fluid balance in acutely ill patients 5.
- The choice of fluid for resuscitation, such as Plasma-Lyte versus Lactated Ringer's, may impact patient outcomes, with Plasma-Lyte associated with prolonged hospital and SICU length of stay in trauma patients 6.
Key Considerations
- The amount and type of fluid used for resuscitation can impact the risk of compartment syndrome and other complications.
- Aggressive fluid resuscitation strategies may be necessary to improve outcomes in certain patient populations, such as those with rhabdomyolysis.
- Careful monitoring of fluid balance and patient response to resuscitation is crucial to minimize the risk of complications.
- The use of balanced crystalloids, such as Plasma-Lyte, may be associated with different outcomes compared to traditional fluids like Lactated Ringer's.