[Compartment syndrome in the left lower leg following semiradical hysterectomy under general anesthesia combined with epidural anesthesia]

Abstract

A 72-year-old woman, ASA physical status II, weighing 47 kg, with uterine cancer was scheduled for semiradical hysterectomy. She had uncontrolled diabetes mellitus with FBS 123 mg x dl(-1) and HbA1c 7.0%. After an epidural catheter had been placed at the L1-2 level, general anesthesia was induced with propofol 100 mg, fentanyl 50 microg and vecuronium 5 mg. The trachea was intubated, and ventilation was controlled. Anesthesia was maintained with 1.5% sevoflurane in 30% oxygen and epidural anesthesia. Systolic blood pressure was maintained between 80-120 mmHg throughout the operation and the total blood loss was 1260 g. Continuous epidural anesthesia was started 1 hour before the end of operation using 0.2% ropivacaine and 3.7 microg x ml(-1) fentanyl at 5 ml x hr(-1). She awoke in the operating room and her trachea was extubated. After awaking from anesthesia, she complained of weakness and numbness in the both lower extremities. We considered these as an influence of epidurally administered 5 ml of 0.5% ropivacaine 30 min before the end of surgery. However, 2 hours later, she complained of right lower leg pain. We removed the epidural catheter, considering the possibility of the epidural catheter tip stimulating nerve root. However, next morning, the frontal part of her right lower leg turned reddish and swollen, and the pain appeared with the pulse of dorsalis pedis artery hardly palpable. Taken together these symptoms and the elevation of creatine kinase to 20000 IU x l(-1), we diagnosed as a compartment syndrome. In the evening of the postoperative one day, emergent fasciotomy was performed under local anesthesia. She was discharged with full recovery of her right leg function, and a well healed fasciotomy scar. Magnetic resonance angiography (MRA) on the 10th postoperative day demonstrated the obstruction of the right superficial femoral artery and anterior tibial artery. Emergent fasciotomy is the recommended treatment for severe compartment syndrome. Early recognition, diagnosis, and surgical intervention averted potential neural and functional impairment in this patient.