What is the immediate definitive management for an upper‑extremity compartment syndrome caused by a large infiltrated intravenous (IV) line during surgery under general anesthesia (GA)?

Management of Upper Extremity Compartment Syndrome from Large Infiltrated IV During Surgery

Immediate emergency fasciotomy of all involved compartments is the definitive treatment and must be performed without delay once upper extremity compartment syndrome from IV infiltration is diagnosed. 1, 2, 3

Immediate Recognition and Initial Actions

Remove All Constricting Elements

• Immediately discontinue the IV infusion and remove the catheter to stop further fluid extravasation 3
• Remove all dressings, bandages, or any constricting materials from the affected extremity 3
• Position the limb at heart level—not elevated—as elevation further decreases arterial perfusion pressure and worsens tissue ischemia 1, 2, 3

Clinical Diagnosis

• Pain out of proportion to the clinical situation is the earliest and most reliable warning sign, even in a patient emerging from general anesthesia 1, 2, 3
• Pain on passive stretch of the affected muscle compartment (wrist/finger extension for volar forearm, wrist/finger flexion for dorsal forearm) is the most sensitive early clinical finding 1, 2
• Increasing firmness and tension of the compartment indicates rising intracompartmental pressure 1, 2
• Paresthesias (sensory changes) result from nerve ischemia and serve as an early warning 1, 2

Critical pitfall: Do not wait for late signs (pulselessness, pallor, paralysis, or motor weakness) before intervening—these indicate irreversible tissue damage has already occurred 1, 2, 3

Diagnostic Confirmation

When to Measure Compartment Pressures

• Measure compartment pressures only if the diagnosis remains uncertain after clinical assessment 1, 2, 3
• In patients still under general anesthesia or heavily sedated who cannot report pain, direct pressure measurement is indicated 1, 2
• Use traditional needle manometry, multiparameter monitors, or dedicated transducer-tipped intracompartmental pressure monitors 1

Pressure Thresholds for Fasciotomy

• Fasciotomy is indicated when compartment pressure ≥30 mmHg 1, 2
• Fasciotomy is indicated when differential pressure (diastolic blood pressure minus compartment pressure) ≤30 mmHg—this is the most widely recognized cut-off in current practice 1, 2
• The differential pressure threshold accounts for individual perfusion status and is preferred over absolute pressure alone 1

Critical pitfall: Do not delay fasciotomy to obtain imaging studies—imaging has no role in acute compartment syndrome management and delays definitive treatment 1

Definitive Surgical Management

Emergent Fasciotomy

• Arrange urgent surgical consultation immediately and proceed to the operating room without delay 1, 2, 3
• Perform fasciotomy of all involved compartments in the upper extremity (typically volar and dorsal forearm compartments, and potentially hand compartments if involved) 1, 2, 3
• Irreversible ischemic damage typically occurs within 6–8 hours of symptom onset; fasciotomy should not be postponed beyond this window 1
• In this specific scenario of IV infiltration during surgery, the time window may be even shorter given the acute nature of fluid extravasation under pressure 4

Intraoperative Findings

• Expect heavily swollen muscle compartments with greatest tension in the area of infiltration 5, 4
• Clear any hematoma or fluid collections encountered 5
• Assess for muscle viability and document extent of injury 5

Post-Fasciotomy Management

Prevent Rhabdomyolysis Complications

• Monitor for myoglobinuria by checking urine color and laboratory testing 1, 2, 3, 6
• Maintain urine output >2 mL/kg/h with aggressive crystalloid resuscitation to prevent acute kidney injury from myoglobin precipitation 1, 2, 3
• Administer sodium bicarbonate to alkalinize urine (target urine pH >6.5), as myoglobin is less likely to precipitate in alkaline urine 1, 2
• Monitor serum creatine kinase (CK), myoglobin, and renal function serially 6, 4

Wound Management

• Use negative pressure wound therapy to reduce discomfort and facilitate closure in the initial post-fasciotomy period 1, 2
• Consider early delayed primary closure (typically 3–10 days) if minimal tissue bulge is noted or resolves with systemic diuresis and limb positioning 1, 2, 5
• Provide diligent wound care to mitigate infection risk 1, 2

Rehabilitation

• Initiate hand therapy early postoperatively, possibly before wound closure 7
• Implement edema management strategies and appropriate splinting 7
• Serial physical examinations are essential to monitor for recovery and complications 7

Key Clinical Pearls

Why IV Infiltration Causes Compartment Syndrome

• Pressurized infusion of crystalloid into a closed fascial space rapidly elevates intracompartmental pressure above capillary perfusion pressure 4
• The upper arm and forearm compartments are particularly vulnerable when large volumes infiltrate under pressure 6, 4
• General anesthesia may mask early warning signs, delaying recognition 6

Monitoring in the Immediate Postoperative Period

• For high-risk scenarios like this, repeat clinical assessment (pain, neurovascular status, compartment tension) every 30–60 minutes for the first 24 hours 1
• Hemorrhagic injuries or reperfusion of previously ischemic tissue mandate this intensive monitoring interval 1

Critical pitfall: Relying solely on palpation for diagnosis is unreliable (sensitivity only 54%, specificity 76%)—clinical suspicion based on pain characteristics should drive decision-making 1, 2, 3