compartment syndromes associated with hemorrhagic hypotension

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Hyperbaric oxygen reduces edema and necrosis of skeletal muscle in
compartment syndromes associated with hemorrhagic hypotension
MJ Skyhar, AR Hargens, MB Strauss, DH Gershuni, GB Hart and WH Akeson
J Bone Joint Surg Am. 1986;68:1218-1224.
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Copyright
Hyperbaric
Oxygen
Muscle
BY
M.
J.
From
SKYHAR,
M.D.t,
the
and
This
to hyperbaric
edema
and
G.
necrosis
R.
B.
ol Bone
and
study
oxygen
HARGENS,
and Necrosis
Veterans
Memorial
SAN
DIEGO,
BEACH,
M.
AND
Administration
Hospital
of exof the
associated
with
phate
groups
that
with
hyperbaric
potension
gen)
tical
and were compared
with six dogs that
compartment
syndrome
and hypotensive
but were not exposed
hours
later,
edema
weights
of the muscles
atmospheres
to hyperbaric
was quantified
(the pressurized
of pure
had
oxy-
an idencondition
oxygen
Forty-eight
by measuring
the
muscle
compared
with the contralateral
muscle),
and necrosis
of muscle
was evaluated
by measuring
the uptake
of technetium99m stannous
pyrophosphate.
The ratio for edema
was
significantly
(p = 0.01) greater
in dogs that had not been
exposed
to hyperbaric
oxygen
(1 . 15 ± 0.01) than in the
dogs that had been treated
with hyperbaric
oxygen
(1.01
±
0.03),
and the ratio for necrosis
of muscle
was also
significantly
(p = 0.04) greater
in dogs
hyperbaric
oxygen
(1 .96 ± 041)
than
been
treated
with
hyperbaric
oxygen
Comparisons
were also made
with
normal
control
dogs and separately
six
normotensive
‘ment
syndrome
treated
absolute
*
dogs
and
that
normal
had
with hyperbaric
oxygen.
uptake
of technetium-99m
No benefits
in any
form
have
been
the muscles
of four
with the muscles
of
an
blood
that had not had
in those that had
(1.05
±
0.11).
identical
pressure
The
received
water
stannous
or will
compartand
were
not
content
and
pyrophos-
be received
1218
Centers,
H.
San
Diego.
muscles
different,
of the four
indicating
oxygen
that
are
combined
primarily
associated
with
with
hemorrhagic
The results
of this study sugmay be helpful
in treating
oxygen
who have
borderline
compartment
syndrome
to fifty millimeters
of mercury
and no neurodeficit)
that is associated
with hemorrhagic
hybut
efficacy
that
such
treatment
adjunct
to the
and fasciotomy.
and
treatment
mans.
indications
should
be considered
standard
treatment
of fluid
We are now evaluating
the
for
of borderline
hyperbaric
compartment
oxygen
in
syndrome
the
in hu-
Compartment
syndrome
of skeletal
muscle
develops
the intracompartmental
pressure
is elevated
suffito reduce
capillary
perfusion
to the extent
that the
intracompartmental
and
tional,
thirty
tissues
necrotic9.
millimeters
We
of mercury
decompression
of
tensive
patient’6.
for development
mental
pressure
hours produces
intracompartmental
meters
of
mercury
Trauma
orrhagic
employ
ischemic
, non-func-
a threshold
as one
pressure
of
indication
coagulopathy,
and systemic
canine
hind-limb
compartment
hypotension,
an intracompart-
of twenty
millimeters
of mercury
for six
a degree
of necrosis
as great as that produced
by an
compartment
frequently
become
for surgical
a compartment
syndrome
in the normoFactors
that lower the threshold
pressure
of compartment
syndromes
include
local
injury
to blood
vessels,
hypotension23.
For a model
syndrome
with hemorrhagic
from
a commercial
party related
directly
or indirectly
to the subject
of this article.
Funds
were received
in total or partial
support
of the research
or clinical
study presented
in this article.
The funding
sources
were Veterans
Administration
and National
Institutes
of Health
Grants
GM-24901
. AM-26344,
and RCDA
AM 00602
to Dr. Hargens.
1 Division
of Orthopaedics
and Rehabilitation
(V- I S 1 ). Veterans
Administration
and University
of California
Medical
Centers,
San Diego.
California
92161.
Baromedical
Department.
Memorial
Hospital
Medical
Center
of
Long Beach,
Long Beach,
California
90801.
CALIFORNIA
hyperbaric
RELEVANCE:
hyperbaric
D.
DIEGO,
Beach
necrosis
syndromes
only as an
replacement
when
ciently
Medical
Long
with
and
BEACH,
SAN
contralateral
control
were not significantly
CLINICAL
patients
(twenty
logical
(two
Beach,
the edema
that
LONG
MD.I’,
of Cal(ftirnia
ofLong
treatment
reduced
anesthetized
dogs while the mean arterial
blood pressure
was maintained
at sixty-five
millimeters
of mercury
after
30 per cent loss of blood volume.
These dogs were treated
M.D4,
AKESON,
University
the
gest
oxygen
STRAUSS,
H.
in the
ofdogs
duced
lateral
in the anterolimb
of seven
B.
Center
compartment
hypotension.
of autologous
plasma
of the left hind
Associated
W.
and
Medical
compartment
syndromes
that are complicated
by hemorrhagic
hypotension
. A compartment
syndrome
(twenty
millimeters
of mercury
for six hours)
was inby infusion
compartment
of Skeletal
Hypotension*
LONG
Department.
are
Incorporated
Syndromes
Rehabilitation.
that
Surgery.
Edema
PH.D.t,
M.D4,
examined
the effect
on the development
of muscle
and Jou:t
Hemorrhagic
HART,
the Baromedical
ABSTRACT:
posures
A.
DIEGO,
of Orthopaedics
Division
Journal
in Compartment
M.D.t,
SAN
by The
Reduces
with
GERSHUNI,
966
pressure
for
to skeletal
of forty
to fifty
milli-
eight hours in a normotensive
dog23.
muscle
sometimes
leads to an acute
syndrome’6,
and severe
blood loss
in patients
who have multiple
injuries.
also occurs
The hem-
shock
causes
peripheral
vascular
insufficiency’3,
blood pressure,
and reduced
blood flow to skeletal
Metabolic
and respiratory
alterations
also accom-
decreased
muscle78.
pany
hemorrhagic
tance
to
insulin
shock.
and
These
abnormalities
THE JOURNAL
alterations
of
OF BONE
produce
the
AND
resis-
metabolism
JOINT
SURGERY
of
HYPERBARIC
amino
volving
acid and
injection
OXYGEN
glucose
in skeletal
of xenon1 33 and
REDUCES
EDEMA
muscle2’9.
A study iniodine- 13 1 into skeletal
AND
NECROSIS
weight)
OF SKELETAL
was
thetic
administered
agent,
intramuscularly
followed
(twenty
in
to a Harvard
respirator.
Bicillin
(1.2
units)
administered
presence
of
changes
lower
of compartment
Once
is usually
required
the threshold
syndrome23.
a compartment
improved,
but
to restore
cause
hemorrhagic
edema
hypotension’4.
pressure
function
skeletal
muscle
partment
of edema
in the
methods
needed.
and
presence
of hypotension.
for the treatment
of comthat intermittent
the edema
and
in experimentally
in normotensive
necrosis
was
of muscle
and of the
phate in experimental
viable tissues
bedo not always resolve
of the tissue
significantly
syndromes
development
decompressed,
perfusion
may not be all that is
to marginally
and ischemia
Strauss
et al. determined
hyperbaric
oxygen
reduced
with
for the
were
reflected
treatment
necrosis
of
induced
com-
(cefazolin
blood
arterial
ducer
and
ard).
In
the
administration
of hyperbaric
oxygen
induced
compartment
syndromes
that
hemorrhagic
hypotension.
had
Materials
Preparation
and
experimentally
limbs
using
of dogs
Methods
mongrel
to thirty
(Table
normal
I). Group
1 consisted
blood
pressure
and
drome
was
also had
anterolateral
mercury
kilograms
were
not produced.
Group
normal
blood
compartment
for
six
divided
of four
in which
weighing
into
four
normal
dogs
a compartment
2 consisted
sev-
groups
that
had
syn-
of six dogs
that
pressure,
but in each of them
syndrome
(twenty
millimeters
hours)
was
produced.
3 consisted
Group
of
that had a compartment
syndrome
that
to the one produced
in the dogs in Group
2.
six hypotensive
dogs
identical
Group
4 consisted
same compartment
3, and these
of seven
syndrome
dogs
were
hypotensive
dogs
as that produced
treated
with
that had the
in Groups
2
hyperbaric
oxygen.
One week before
production
of the compartment
drome
in Groups
2, 3, and 4, 250 milliliters
of blood
withdrawn
an
of
from
thejugular
vein.
The
blood
synwas
was centrifuged
food
but
Xylazine
hydrochloride
(one
VOL.
NO.
1986
68-A,
8. OCTOBER
water
intake
milligram
was
not restricted.
per kilogram
of body
with
period.
dorsutures
lamp.
Both
given intravenously
supplements
of 500
The
at 38 degrees
dog’s
core
Celsius
the temperature
at 34 degrees
temperatures
tem-
by a heating
were
and a thermistor
model
B-2).
of the
Celsius
monitored
thermometer
Shock
was
induced
by a slow
hemorrhage
minutes.
The
mean
arterial
and the hemorrhage
was
until an arterial
pressure
of sixty-five
was obtained.
The average
volume
in the dogs
drawn
was
fifty-six
The arterial
pressure
ervoir
to an appropriate
So
that
the open
blood
pressure
was
continued,
if necessary,
millimeters
of mercury
of blood that was with-
monitored
milliliters
per kilogram
of body weight.
was maintained
by adjusting
the resheight
above the level of the heart
catheter
and
tubing
produced
a hydrostatic
column
of blood that maintained
the animal’s
arterial
pressure constant
at sixty-five
millimeters
of mercury.
Further
adjustments
hours
Model
denied
hypotensive
with
probes
Electro-Medical,
of twenty
chloride
solution
and
day before
production
were
incision
anchored
in Groups
3 and 4 (Table
I); approximately
30 per cent of
the calculated
blood volume
was allowed
to flow from the
cannulated
left carotid
artery
into a reservoir
over a period
Celsius
dogs
to an exit
was
was
The
access
to the central
venous
system.
central
venous
line was maintained
by
maintained
an infrared
pressure
One
the
and then
beneath
the animal,
and
muscle
was maintained
continuously
(Rochester
and the plasma
was decanted.
The red blood
cells were
diluted
with an appropriate
volume
of 0.9 per cent sodium
then were returned
to the animal.
of the compartment
syndrome,
the
was
Hemorrhagic
dogs
neck
pressure-trans(Hewlett-Packhemorrhagic
to undergo
Heparmn (5,000 units) was
of cannulation,
with hourly
during
Shock
conditioned
enteen
and
to treat
in the hind
units
pad placed
gastrocnemius
intermittent
liter
intermittent
flushing
with heparinized
saline.
The left carotid
artery
was cannulated
with silicone-treated
PE-240
tubing
(Clay Adams)
and was ligated
distally
for the initiation
of
of the Animals
Twenty-three
was
using
one
4), the left jugular
vein
and was ligated
distally.
subcutaneously
to serve as permanent
The patency
of this
achieved
and
into
recorder
were
tunneled
was
on the dog’s
perature
be
that
tubing
drome
could
dogs
of the weight
not treated
with hyperbaric
oxygen2’.
of this study was to determine
if similar
injected
a strain-gauge
strip-chart
(Groups
3 and
with K-SO tubing
by ratios
used in
of ne-
G benzathine)
intramuscularly
gram),
using
hypotension
cannulated
hemorrhage.
at the time
effects
pressure,
four-channel
sally
were also
evidence
(one
(penicillin
of lactated
Ringer
solution,
was infused
through
the right
brachial
vein at a rate of two milliliters
per minute
during
the compartment
syndrome.
The right brachial
artery
was
cannulated
for continuous
monitoring
of the mean
central
crosis
of muscle
was reduced
in the experimental
limbs of
the dogs that received
hyperbaric
oxygen
as compared
with
those
of the dogs
that had an identical
compartment
syn-
beneficial
sodium)
The reduction
and untreated
dogs.
Histological
criteria
grading
necrosis
of muscle.
Histological
but were
The purpose
was
animals.
uptake
of technetium-99m
pyrophosand control
limbs,
comparing
treated
sodium
Once they
connected
per
anesthetized,
million
a pre-anes-
pentobarbital
kilogram
ofbody
weight).
the dogs were intubated
and
milligrams
Ancef
has been
fasciotomy
immediately,
particularly
Better
and more effective
partment
syndromes
are
These
as
by intravenous
muscle
showed
that the transport
of nutritive
substances
and
metabolic
products
through
the interstitial
space is impaired
the
1219
MUSCLE
in height
of compartment
conditions,
and
returned
Compartment
usually
were
syndrome
the
blood
not necessary.
under
was
hypotensive
warmed
After six
blood-
to 38 degrees
to the animal.
Syndrome
Autologous
plasma
was warmed
to 37 degrees
Celsius,
filtered,
and infused
intramuscularly
into the anterolateral
muscle
compartment
of the left hind limb through
a 19-
1220
M.
J. SKYHAR
ET
TABLE
AMPLITUDE
AND
D URATION
Group
Groupl:
normal
AL.
I
OF INTR ACOMPARTMENTAL
PRESSURE
No. of
Dogs
Mean
Arterial
Blood
Pressure
during
Compartment
Syndrome
(mm Hg)
4
95±5
IN TH E EXPERIMENTAL
Duration
(Hrs.)
0
compartment
(no
6
LIMBS
Amplitude
(mm Hg)
controls
Group2:
HIND
98±6
0
syndrome)
20
6
hyperbaric
oxygen,
normal
blood pressure
no
Group
3:
no hyperbaric
oxygen.
reduced
blood
pressure
6
65
20
6
Group
4:
hyperbaric
oxygen,
reduced
blood
pressure
7
65
20
6
gauge
needle.
The rate and volume
to nine milliliters)
of plasma
that was
(approximately
injected
was
seven
sufficient
to a recovery
cage,
where
they
hours after onset of the compartment
to elevate
intracompartmental
pressure
to twenty
millimeters
of mercury
in Groups
2, 3, and 4 (Table
I). This pressure
of necrosis
was
and
maintained
reservoir
of autologous
In the
the
for six hours
dogs
left
by adjusting
the height of the
above
the site of the infusion.
plasma
in Group
1 , an infusion
anterolateral
compartment
fused. Intramuscular
pressures
by strain-gauge
transducers
the
left
anterolateral
needle
but
was
placed
in
no plasma
was
in-
were monitored
at proximal
and
compartment
of each
continuously
distal sites
dog
using
in
slit
and the pressures
were recorded
on a strip-chart
recorder.
In each animal,
the left anterolateral
compartment
was pressurized
and the contralateral
compartment
served
catheters”,
as the
placed
control.
in an
An infusion
needle
identical
fashion
into
malize
their effects
of technetium-99m
and slit catheters
were
the control
leg to nor-
on the formation
of edema
and
stannous
pyrophosphate
in each
of muscle
3 exactly
uptake
leg.
as will
4.
Within
partmental
fifteen
catheters,
monoplace
hyperbaric
oxygen
oxygen
system,
at two
for
Animals
in Groups
3 and
mercury
for six hours),
by transfusion
saline
line
tially
with
solution
blood
was
pressure.
from
normal
blood
autologous
also
restored
blood.
If necessary,
to restore
the normal
basewas allowed
to recover
par-
dog
the anesthesia
of
of
whole
infused
Each
was
so that
intubation
(Vickers
of the intracom4 was put in a
clinical
a one-hour
of absolute
1 , 2,
hyperbaric
exposure
pressure
to pure
while
the
breathed
spontaneously.
Access
from outside
the chamber
was
to the jugular-vein
established
by con-
necting
the tubing
port
to an intravenous-line
in the bulkhead
of the chamber.
The line was occasionally
heparinized
normal
saline solution.
The dog
sedated
cage.
pressure
for
for Group
in Groups
after removal
dog in Group
chamber
CHS/3)
atmospheres
determined
for the dogs
minutes
each
Forty-eight
the amounts
with
intravenous
pentobarbital
flushed
with
was kept lightly
sodium
(ten
grams
per kilogram
of body
weight)
as necessary
treatment
with hyperbaric
oxygen.
After the first
4
For dogs in Groups
3 and 4 (Table
I), at the completion
of six hours
of hemorrhagic
shock
with pressurization
the left anterolateral
compartment
(twenty
millimeters
were
,
animal
catheter
exposure
Protocols
and edema
be described
usually
slept.
syndrome
to hyperbaric
Four
hours
oxygen,
later,
the dog
a second
was
one-hour
milli-
during
one-hour
returned
to its
treatment
with
hyperbaric
oxygen
was administered,
and after four more
hours
a third treatment
was given,
so that each dog had
three
one-hour
exposures
to hyperbaric
oxygen
over
an
eleven-hour
period.
The
amounts
of swelling
and
of the experimental
and control
anterolateral
were observed
and compared
before
and after
to hyperbaric
tenseness
compartments
each exposure
oxygen.
and the Harvard
respirator
were no longer
necessary
The intracompartmental catheters,
carotid
and brachial
artery catheters,
and temperature
probes
were removed,
but the jugular-vein
infusion
Quantification
of Necrosis
of Muscle
and
Edema
.
site
taken
itored
two
was
maintained
with
a heparin
lock.
The
dogs
were
to the vivarian
recovery
room,
where they were monuntil they were fully awake.
They were given one to
milligrams
per
kilogram
intramuscularly
for
analgesia.
During
compartment
the twelve
syndrome,
of body
weight
of meperidine
hours after the six-hour
episode
of
the dogs in Group
3 were confined
Intracompartmental
quantified
by uptake
phosphate,
hours after
of
skeletal
necrosis
technetium-99m
as described
by Hargens
the onset of pressurization
of muscle
stannous
was
pyro-
et
‘‘
Forty-eight
of the compartment,
.
each animal
was sedated
by an intramuscular
injection
of
xylazine
(fifty milligrams).
A bolus
of five millicuries
of
technetium-99m
pyrophosphate
was then injected
intravenously
into the brachial
vein.
The dog remained
and was held upright
by a cloth sling under
the
THE JOURNAL
OF BONE
AND
JOINT
sedated
abdomen
SURGERY
HYPERBARIC
OXYGEN
REDUCES
EDEMA
the
to equalize
circulation
of the blood
in the two hind limbs.
Three hours after injection
of the isotope,
the dog was killed
with an overdose
of intravenous
pentobarbital
sodium.
The
three major
ialis cranialis,
muscles
of the anterolateral
extensor
digitorum
longus,
compartment
and fibularis
AND
NECROSIS
data
were
the segments
side
to
muscle
that on the control
groups
from each
one-centimeter-thick
Each
segment
model
for studies
that was obtained
and its uptake
was determined
times
99m
segments
1 185).
side.
animal
Experimental
were cut into
cluded
from
the contralateral
Two other groups
to rule out the
rhagic
hypotension
absolute
of radioactivity.
or
uptake
contralateral
of
control
muscles.
of technetium-99m
stannous
pyrophosphate
in a gamma
well-counter
(Chicago
Nuclear,
were
were
then compared
with
treated
in an identical
samples,
uptake
and to permit
Each
segment
was
each
diluted
iO
the different
radioactivity,
GROUP
were
to hyperbaric
solution
of technetiumto determine
the absolute
comparison
between
counted
for gamma
treated
oxygen
technetium-99m
done
dogs.
and
in each
in the
of each
without
hyperbaric
poses
of comparison
hyperbaric
oxygen
ratios
hyperbaric
3).
of uptake
in
on
the
for
the
(Group
4)
for the six dogs that
but were not exposed
The
results
from
our
oxygen23,
were
with animals
in the present
that
study.
GROUP
both,
or
oxygen
the ratios
manner
(Group
2) were inof hemor-
pyrophosphate
The
with
1 and
effects
oxygen,
pyrophosphate
3
120
percentage
muscles
(Groups
systemic
hyperbaric
that
standard
samples
The
pyrophosphate
of the uptake
technetium-99m
dogs
from
the original
injection
pyrophosphate,
were used
standard
control
of dogs
possible
was weighed,
Triplicate
in this fashion
and
of radioactivity.
dog.
.
control
of muscle
for decay
experimental
limb to that in the control
limb were determined using the sum of the uptake of isotope
in the segments
from the pressurized
muscles
and the sum of the uptake
in
each side were weighed
individually
for the evaluation
of
edema,
as previously
described2’
An index for edema
was
calculated
as the ratio of the weight
of muscle
on the exand
all segments
corrected
1221
MUSCLE
of the total dose of technetium-99m
sample
was then calculated.
Ratios
(tiblon-
gus) were removed
from both limbs simultaneously
by two
operating
teams.
The three muscles
comprising
the muscle
groups
from
perimental
for
OF SKELETAL
for uptake
previous
included
of
study,
for pur-
were treated
Using
paired
with
and
4
I
I
I
I
100
80
60
:t:
E
E
(I)
100
(I)
w
ci
w
I-
w
U-
0
60
uJ
\
80
-1
0
1
2
3
TIME
(hrs)
4
5
0
1
2
3
4
5
6
TIME (hrs)
FIG.
1
Condensed
plots of the maximum
range
of mean arterial
pressure
(indicated
by bars above
and below
the median)
for four representative
dogs in
Group
3 and four representative
dogs in Group
4. The mean
arterial
pressures
are presented
for the hour preceding
hemorrhage
and for each hour
during
the period
of hemorrhagic
hypotension.
During
the hypotensive
period.
the arterial
pressures
of some
dogs changed
abruptly
from
sixty-five
millimeters
of mercury,
but immediate
adjustments
were made to restabilize
the pressure
at sixty-five
millimeters
of mercury.
The data points
that are
marked
with an asterisk
indicate
essentially
no variation
of mean arterial
pressure
for the given hour.
VOL.
68-A,
NO.
8.
OCTOBER
1986
1222
M.
J. SKYHAR
El
AL.
1.50
0
I-
::
1
0
w
I-
I-
C.)
w
-I
1.00
ILi
0
()
LU
.
><
Lii
-J
C-)
(I)
:D
I4A
GROUP
I
GROUP
2
GROUP
3
GROUP
4
FIG. 2
Comparison
of weights
of the muscles
of the anterolateral
compartment
of the normal
dogs and of the three
groups
of dogs with compartment
syndrome.
Group
1 consisted
of normal
controls;
Group
2, dogs that had compartment
syndrome,
normal
blood
pressure,
and no treatment
with
hyperbaric
oxygen;
Group
3, dogs that had compartment
syndrome,
hypotension,
and no treatment
with hyperbaric
oxygen;
and Group
4, dogs that
had compartment
syndrome,
hypotension,
and treatment
with hyperbaric
oxygen.
The results
(mean
and standard
error) are expressed
as ratios of the
weight
of the experimental
anterolateral
compartment
to that of the contralateral
anterolateral
compartment.
The Group-4
dogs had significantly
less
edema
than did the Group-3
dogs (p = 0.01).
Two days after pressurization,
the Group-2
dogs did not have significant
edema
as compared
with the
Group- I dogs.
The water content
of the contralateral
compartment
was not different
in the four groups
of animals.
0
-J
I-
0
LJ
0
0
:i:
0
0
:i:
0
0
>-
0
GROUP
I
GROUP
2 GROUP
3 GROUP
4
FIG. 3
Comparison
of ratios
of uptake
of technetium-99m
stannous
pyrophosphate
of the muscles
of the anterolateral
compartment
of the normal
dogs and
of the three groups
of dogs that had compartment
syndrome.
Group
1 consisted
of normal
controls;
Group
2, dogs that had compartment
syndrome,
normal
blood
pressure,
and no treatment
with hyperbaric
oxygen;
Group 3, dogs that had compartment
syndrome,
hypotension,
and no treatment
with
hyperbaric
oxygen;
and Group 4, dogs that had compartment
syndrome,
hypotension,
and treatment
with hyperbaric
oxygen.
The results
(mean
and
standard
error)
are expressed
as ratios of the uptake
in the experimental
anterolateral
compartment
to that in the contralateral
anterolateral
compartment.
Group-4
dogs had significantly
less necrosis
of muscle
(uptake
of pyrophosphate
in the experimental
leg) than did Group-3
dogs (p = 0.04).
For
purposes
of comparison,
results
for uptake
from a previous
study of hypotensive
dogs that had an identical
compartment
syndrome
and were not treated
with hyperbaric
oxygen23
are included
in this figure only. The Group-2
dogs did not have significant
necrosis
as compared
with the Group-i
dogs. The
uptake
of pyrophosphate
in the contralateral
compartment
was not different
in the four groups
of animals.
unpaired
Student
at p < 0.05.
t tests,
the statistical
significance
was
Results
Plots
of the mean
and range
of arterial
blood
pressures
set
in four representative
animals
from Groups
3 and 4 during
the experimental
period demonstrated
that the blood
pressures of these hypotensive
dogs were maintained
at essentially
the same
levels
during
the six-hour
compartment
syndrome
(Fig.
1). After
ThE
this period,
JOURNAL
the intracompartmental
OF BONE
AND
JOINT
SURGERY
HYPERBARIC
catheters
mals
were
was
with
treated
removed
restored
OXYGEN
and
the blood
to normal.
Group-4
hyperbaric
oxygen
and
REDUCES
pressure
ani-
that were
then
dogs
were
mechanisms
animals
OF SKELETAL
treated
that
with
were
hyperbaric
not
1223
MUSCLE
treated
oxygen
with
compared
hyperbaric
with
the
oxygen.
The
by which
hyperbaric
oxygen
reduces
necrosis
skeletal
muscle
in compartment
syndromes
associated
with hemorrhagic
hypotension
are probably
similar
to those
of
Qualitatively,
there
was
reduction
swelling
in the experimental
were exposed
to intermittent
of
compartments
hyperbaric
tenseness
episode
drome
of compartment
syndrome
for Group
1).
The effect
of hyperbaric
(sham
oxygen
is reflected
by the muscle-weight
and contralateral
control
limbs
ratio
of 1 . 15 for the dogs
(Group
uptake
3).
reduced
Group-3
(p
dogs
0.04)
=
(Fig.
the hypoafter the
compartment
on edema
hyperbaric
less (p
that were
Necrosis
of technetium-99m
elucidated
namely,
=
not exposed
of
muscle,
to hyperbaric
as quantified
pyrophosphate,
in Group-4
3). Accumulation
(Group
than the
was
by
cells’
exposed
to
creased
‘
The
.
hyperbaric
uptake
ifying
mean
oxygen
for the dogs
was
1 .05,
that
reflecting
the experimental
were
dogs
1 .96,
were
indicating
treated
and
However,
with
less
normal
control
of technetium-99m
4 (compartment
treatment
with
ment syndrome
oxygen)
p = 0.66,
(Group
with
creased
Also,
the
water
thus
uptake
of technetium-99m
pyrophosphate
were not different
in the contralateral
four
groups
of dogs
in this
study
by direct
is
inhaled
atmospheres
in dissolved
action
gen-
oxygen.
This
for basal
hemoglobin-borne
of the increased
of the tissues,
and decreased
capillary
is
oxy-
partial
pres-
blood
reduced
transudation
capillary
blood
and diapedesis3’5.
pressure
causes
a shift
De-
in the trans-
flow
‘.
different
results
in-
shock
alters
and
that
protein-rich
occur
p
interstitial
damage
in intracel-
edema.
Failure
to occur.
The shock
that
injury
(as in our model)
the
When
concomitantly
crease
in blood
microcirculatory
0.68).
massive
resulting
of
is asrarely
precipitates
organ-failure
syndromes
and is primarily
associated
with the shift of fluid from
interstitial
to intracellular
spaces2#{176}.The pathophysiology
of acute
compartment syndrome
includes
intracellular
or interstitial
edema,
or both, depending
on the etiology,
resulting
in compromise
drome
per gram
control
mus-
with
permeability,
organs
is likely
with soft-tissue
of the microcirculation9.
and
is associated
vascular
diffuse
multiple
sociated
and
(minimum
The
to tissue
lular
for dogs
content
at three
increase
of
of fluid to promote
greater
resorption
of
fluid and decreased
interstitial-fluid
pressure,
improving
local microcirculation
There are two general
forms of shock associated
with
in
and Group
2 (compartpressure
and no treatment
absolute
oxygen
pressure
extravascular
muscles
of the dogs in Groups
normal,
with uptake
of techabout equal to that in the con-
,
partial
high to meet the requirements
of tissue
in the absence
of
capillary
I ), ra-
hypotension
the
pure
of oxygenation
in-
oxygen
were
not significantly
respectively).
These
dicate
that the experimental
1 2, and 4 were essentially
netium-99m
pyrophosphate
muscles.
dogs
state:
oxygen5.
Hyperoxygenation
also helps
to drive
oxygen
across
partial
barriers’7
such as the intracellular
and interstitial edema that is associated
with compartment
syndrome.
The administration
of hyperbaric
oxygen
causes
va-
nance
ver-
to muscle
pyrophosphate
syndrome
hyperbaric
oxygen)
with normal
blood
with hyperbaric
(p = 1 .00 and
sufficiently
genation
trauma.
with
Breathing
.
pressure,
the mean
hyperbaric
damage
to
a fifteenfold
not
limb.
of uptake
of the
that
pyrophosphate
limb.
significantly
As compared
absolute
of tissue
the
was
in the experimental
ratio
tralateral
for
of technetium-99m
necrosis
in Group
ratio
al. for the normotensive
and vasoconstriction.
sure of oxygen
on the blood
vessels,
reducing
blood
flow
by approximately
20 per cent3. This vasoconstrictive
effect
may seem undesirable;
however,
the net effect
is mainte-
dogs as compared
with
ofthis
radionucleotide
indicates
irreversible
ischemic
injury,
since pyrophosphate
is absorbed
by the calcium
deposits
of necrotic
and severely
injured
proportional
soconstriction
significantly
et
Hyperoxygenation
increases
the amount
of physically
dissolved
oxygen
in the fluids of plasma
and tissue
and
erates
of muscle
oxygen
0.01)
by Strauss
hyperoxygenation
directly
oxygen’
syn-
ratios of the experimental
(Fig. 2). The mean ratio for
the dogs that were treated
with
4) was unity and was significantly
oxygen
and
of the dogs that
oxygen.
All dogs
in Groups
3 and 4 recovered
uneventfully
from
tensive
period.
All dogs
were killed
two days
des
NECROSIS
were
not.
tios
AND
of the
animals
Group-3
EDEMA
pressure
perfusion
intracompartmental
shock
and compartment
in the clinical
and shifts
in fluid
in the compartment
pressure.
These
syn-
setting,
the
de-
decrease
the
and increase
factors
combine
to
This is important
because
our comparisons
of
ratios for the experimental
and control
sides for weight
and
uptake of pyrophosphate
assumed
that the contralateral
(control) muscle
remains
normal
in terms of water content
and
lower the threshold
of intracompartmental
pressure
for the
development
of ischemia
and necrosis.
For this reason,
improper
application
or prolonged
use of military
anti-shock
uptake
of pyrophosphate
hemorrhagic
hypotension
a compartment
syndrome
in the lower
absence
of injury to the extremity622.
=
despite
exposure
of the animal
to
or hyperbaric
oxygen,
or both.
trousers
for the treatment
Clinical
Discussion
sive
As has been previously
state2’
in the hypotensive
,
significantly
reduces
induced
compartment
ductions
in the
VOL.
NO.
68-A,
8.
edema
OCTOBER
demonstrated
in the normotenstate hyperbaric
oxygen
also
edema
and
syndrome.
and
1986
necrosis
This
necrosis
of muscle
is reflected
of muscle
after
by
in the
an
redogs
experience
of acute
has
hypovolemia
extremity
indicated
main
untoward
effects
of treatment
oxygen’2.
They are, in order of importance,
toxicity,
barotrauma
to the middle
ear,
confinement
eliminated
old
for
within
the chamber.
by the use of oxygen
seizures,
appropriate
that
there
may
cause
even
in the
are
three
with
hyperbaric
cerebral
oxygen
and anxiety
due to
These effects
are virtually
pressures
below the threshpre-treatment
evaluation,
and
1224
M.
judicious
use ofproper
of hyperbaric
oxygen
animals.
The
efficacy
medications’2.
Untoward
side effects
were not a problem
in this study in
and indications
oxygen
in the treatment
derline
compartment
of mercury
without
der investigation
.
This
who
a neurological
at the University
.
randomized
.
have
(twenty
includes
have trauma
concomitant
so-called
available,
to fifty
.
study
AL.
resuscitation
couraging.
bor-
millimeters
deficit)
are presently
of California
at
.
clinical
ET
of hyperbaric
for the use
of patients
syndrome
.
Diego.
J. SKYHAR
ment
unSan
.
patients
who
to a single
hypovolemic
extremity,
shock,
both without
and with
followed
by appropriate
with fluid. The results
to date
However,
hyperbaric
chambers
and
syndrome
their
use
must
still be considered
in treating
NOTE: The authors
thank B. R. Thompson.
Johansson
for their expert
technical
assistance.
w#{252}tie preparation
of the manuscript.
C.
have been enare not widely
patients
K. Freestone,
They also
with
compart-
adjunctive
in nature.
R. C. OHara.
thank J. Robison
A. Crenshaw,
and
for her assistance
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THE
JOURNAL
OF BONE
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JOINT
SURGERY