What should I anticipate and how can I assist when surgeons perform an emergency fasciotomy for compartment syndrome at the bedside in the Intensive Care Unit (ICU)?

Preparing for Bedside Fasciotomy in ICU Compartment Syndrome

As an ICU nurse, you should immediately prepare for emergency fasciotomy by gathering equipment, monitoring vital signs, and administering medications to optimize patient outcomes and prevent limb loss. 1

Understanding Compartment Syndrome and Fasciotomy

Compartment syndrome is a surgical emergency that occurs when increased pressure within a muscle compartment compromises circulation and tissue viability. In the ICU setting, this may result from:

• Reperfusion injury following revascularization
• Prolonged ischemia
• Crush injuries
• Severe trauma to the extremity

The diagnosis is based on clinical findings including:

• Pain (often disproportionate to injury)
• Pain with passive stretch
• Paresthesia
• Paresis (weakness)
• Tense, swollen compartment
• In late stages: pallor and pulselessness 1

Immediate Nursing Preparations

Equipment to Gather

• Fasciotomy tray/surgical instruments
• Multiple sterile drapes and gowns
• Sterile gloves in various sizes
• Suction equipment
• Irrigation solutions
• Gauze and dressings (large quantities)
• Blood pressure cuff for tourniquet if needed
• Negative pressure wound therapy (NPWT) devices 1

Medication Preparation

• Analgesia (IV opioids)
• Sedation medications
• Local anesthetics
• Antibiotics (prophylactic)
• Tetanus prophylaxis if indicated
• Heparin or other anticoagulants (unfractionated heparin is recommended for patients with acute limb ischemia) 1

Laboratory and Monitoring

• Obtain baseline labs if not already done:
  • Complete blood count
  • Coagulation studies
  • Creatine kinase (CK) levels
  • Serum electrolytes (particularly potassium)
  • Renal function tests
  • Arterial blood gases
• Set up continuous vital sign monitoring
• Prepare for compartment pressure measurement if not already done 1

During the Procedure

Nursing Role

• Assist with patient positioning
• Monitor vital signs continuously
• Document findings and interventions
• Assist with medication administration
• Prepare for significant blood loss
• Maintain sterile field
• Anticipate the need for:
  • Multiple fascial incisions
  • Debridement of necrotic tissue
  • Irrigation of the wound 1

Critical Monitoring

• Watch for signs of:
  • Hemodynamic instability
  • Reperfusion syndrome
  • Electrolyte abnormalities (especially hyperkalemia)
  • Metabolic acidosis
  • Myoglobinuria 1

Post-Procedure Care

Immediate Post-Procedure

• Maintain wound care with sterile dressings
• Continue monitoring for:
  • Signs of ongoing compartment syndrome
  • Bleeding
  • Infection
  • Renal dysfunction from myoglobinuria
• Ensure adequate urine output (>2 mL/kg/hr) to prevent acute kidney injury 1

Wound Management

• Prepare for delayed primary closure or skin grafting
• Set up negative pressure wound therapy if ordered
• Anticipate regular dressing changes
• Monitor for signs of infection 1

Systemic Management

• Maintain fluid resuscitation
• Monitor for acute kidney injury
• Continue pain management
• Position extremity without elevation (to avoid compromising blood flow)
• Monitor for development of compartment syndrome in other limbs 1

Special Considerations

Prevention of Complications

• Acute kidney injury: Maintain adequate hydration and urine output
• Infection: Administer prophylactic antibiotics as ordered
• Coagulopathy: Monitor for disseminated intravascular coagulation
• Recurrent compartment syndrome: Continue monitoring compartment pressures in at-risk patients 1

Documentation

• Document baseline neurovascular status
• Record compartment pressures if measured
• Document appearance of the limb before and after fasciotomy
• Record all medications administered
• Document wound appearance and dressing changes 1

Pitfalls to Avoid

• Delaying fasciotomy when compartment syndrome is suspected (can lead to irreversible tissue damage)
• Inadequate pain control (pain is a key symptom and requires aggressive management)
• Failing to monitor for systemic complications (rhabdomyolysis, acute kidney injury)
• Inadequate wound care leading to infection
• Missing compartment syndrome in other limbs 1, 2

Remember that timely fasciotomy is critical for limb salvage, and your role in preparation, assistance during the procedure, and post-procedure care directly impacts patient outcomes. Early fasciotomy is associated with lower rates of limb amputation and shorter hospitalization for patients with compartment syndrome 1.