A dual-sensor ultrasound based method for detecting elevated muscle compartment pressures: A prospective clinical pilot study.

BACKGROUND: Acute compartment syndrome (ACS) is a limb-threatening condition associated with elevated muscle compartment pressures (MCPs). The only existing treatment of ACS is to reduce MCP by fasciotomy; however, a reliable clinical method for detecting elevated MCPs is lacking. A dual-sensor (ultrasound and pressure) technology to detect elevated MCPs was previously tested on cadavers. Our goal was to examine the use of this technology in the clinical setting. METHODS: Patients with tibia fractures were prospectively enrolled. Observers used a dual-sensor probe to measure the amount of pressure required to flatten the anterior compartment fascia (CFFP). Direct-MCP measurements and 4-compartment fasciotomy were done for suspected ACS. RESULTS: Fifty-two patients were enrolled into the study. Nine patients underwent fasciotomy for a clinical diagnosis of ACS. Both CFFP (p-value = 8.395e-08) and delta-CFFP (p-value = 4.114e-05) were significantly larger in the fasciotomy group compared to the non-fasciotomy group. CFFP measurements showed very strong correlations to the direct MCP measurements (p-value = 0.006746, rho = 0.9285714), and delta-CFFP showed strong correlation (p-value = 0.06627, rho = 0.75). CFFP measurements had good inter-observer variability, with an interclass correlation (ICC) of 0.814 (95%-Confidence Interval: 0.631-0.907) and excellent intra-observer variability with an ICC of 0.942 (95%-Confidence Interval: 0.921-0.958). CONCLUSION: The results of this pilot study suggest that the proposed ultrasound-based method is useful in detecting elevated MCPs and may be helpful in the diagnosing ACS or ruling out the need for urgent fasciotomy. Large-scale clinical trials are needed to validate these claims.

Implementing a Pressure Injury Prevention Bundle to Decrease Hospital-Acquired Pressure Injuries in an Adult Critical Care Unit: An Evidence-Based, Pilot Initiative.

Patients in critical care units (CCUs) are at risk of the development of hospital-acquired pressure injuries (HAPIs). Research supports the use of a pressure injury prevention (PIP) bundle to standardize PIP strategies and reduce the incidence of HAPIs. PURPOSE: This evidence-based practice initiative was undertaken to implement a PIP bundle to decrease HAPIs in an adult patient CCU. METHODS: A literature review was conducted during the first month of the implementation of the initiative to identify best PIP and bundle implementation practices. Wound, ostomy, and continence nurses conducted educational sessions and mentored registered nurses who became PIP bundle resource nurses. Adoption of the bundle was validated using an audit tool and PIP rounds. The pre- and post-implementation HAPI indices, pressure injuries / patient care days × 1000, were compared. RESULTS: Implementation of the PIP bundle resulted in a notable decrease in HAPIs on the unit. During the pre-intervention period, January 2017 to January 2018, there were 9 HAPIs (HAPI index 3.4). During the 10-month post-intervention period, 1 HAPI developed (HAPI index 0.48). CONCLUSION: An evidence-based PIP bundle initiative was implemented in an adult patient CCU to standardize the process for HAPI prevention and reduce the number of HAPIs. Staff involvement and leadership support were vital to the success of the initiative. Integration of the bundle into practice resulted in a notable decrease in HAPIs.

Management of Lower Extremity Fractures in the Elderly: A Focus on Post-Operative Rehabilitation.

Fractures in the elderly population are increasing in incidence and represent a rising burden of disease. It is difficult for the elderly population to adhere to restricted weight bearing, and immobility poses significant risks and increased morbidity. Therefore, a primary goal of fracture management in the elderly population is early post-operative weight bearing. This review examines published literature regarding lower extremity fracture management in the elderly, with a focus on post-operative rehabilitation. While extensive literature supports early weight bearing after hip fractures in the elderly, further research is warranted to provide guidelines for management of other lower extremity fractures in this population.

A Novel Non-invasive Method for the Detection of Elevated Intra-compartmental Pressures of the Leg.

Acute Compartment Syndrome is a devastating consequence of musculoskeletal trauma. Currently the diagnosis is based on clinical signs and symptoms, and while adjuncts such as invasive intra-compartmental pressure measurements are often used to corroborate the physical exam findings, there remains no reliable objective test to aid in the decision to perform a decompressive fasciotomy. In a cadaver model of compartment syndrome, an ultrasound (US) based method has been shown to be a reliable measurement of increased intra-compartmental pressure. An absolute pressure of >100 mbar or a difference of 50 mbar in the CFFP between the legs can be considered pathologic. Using an ultrasound transducer, coupled with a pressure sensor, the pressure needed to flatten the superficial fascia of the anterior compartment of lower legs (Compartment Fascia Flattening Pressure [CFFP]) can be measured. The CFFP of the injured leg is compared to the CFFP of the uninjured leg. This US measured index can then serve as an adjunct to the physical exam in evaluating injured lower extremities and assessing the need for decompressive fasciotomy. The advantages of this protocol include: being a non-invasive method and an easily reproducible technique.

Avoiding and Managing Complications After Hip Fracture Fixation.

There is an enormous burden of disease associated with the management of a failed hip fracture fixation. The goal of surgical management is to facilitate an early return to mobilization with the retention of as much independence as possible. Despite numerous studies that are focused on the care of patients with proximal femur fractures, complication rates remain high. Surgeons should review current strategies to avoid and manage complications after hip fracture fixation. This will have important implications given the detrimental consequences of failed management of hip fractures, including permanent disability, life-threatening medical complications, and an increased risk of death.

Compartment syndrome-induced muscle injury is diminished by the neutralization of pro-inflammatory cytokines.

OBJECTIVES: Compartment syndrome (CS) is one of the most devastating consequences of musculoskeletal trauma. The pathophysiology of CS includes elevation of intracompartmental pressure (ICP), causing damage to the microcirculation, decreased oxygen delivery, tissue anoxia, and cell death. CS is a combined ischemic and inflammatory condition that induces the systemic inflammatory cascade. In complete ischemia, within the first hour of reperfusion, a peak in the pro-inflammatory cytokine, tumor necrosis factor alpha (TNF-α) has been previously reported. The purpose of this study was to examine the suspected systemic inflammatory cytokine/chemokine release in response to CS, and to evaluate the microvascular dysfunction, tissue injury, and inflammatory response following the neutralization of pro-inflammatory cytokines TNF-α and/or interleukin-1 beta (IL-1ß). METHODS: Twenty-eight male Wistar rats were randomly assigned into 5 groups: Sham (no CS), CS (with isotype control), CS+TNF-α neutralizing antibody (NA), CS+IL-1ß NA, CS+Combo (both TNF-α and IL-1ß NA). CS was induced by elevation of ICP above 30 mm Hg through an infusion of isotonic saline into the anterior compartment of the hind limb for 2 hours; NA were administered just prior to fasciotomy. Microvascular perfusion, cellular tissue injury, and inflammatory response within the extensor digitorum longus muscle were assessed using intravital video microscopy for 45 minutes after fasciotomy. Systemic levels of 24 different cytokines/chemokines were also measured, using the xMAP Luminex technology. RESULTS: Of the 24 cytokines/chemokines sampled, 6 were significantly elevated from their baseline levels, and included the pro-inflammatory cytokines TNF-α, IL-1ß, growth-related oncogene/keratinocyte chemoattractant (GRO/KC), monocyte chemoattractant protein 1 (MCP-1), macrophage inflammatory protein 1 alpha (MIP-1α), and the anti-inflammatory cytokine IL-10. CS resulted in a significant decrease in microvascular perfusion, from 75 ±â€Š2% continuously perfused capillaries in the sham to 31 ±â€Š4% in CS (P < .001), a significant increase in tissue injury (0.33 ±â€Š0.4 versus 0.04 ±â€Š0.01 in sham) and leukocyte activation (14 ±â€Š2 adherent leukocytes/1000 µm2 versus 2 ±â€Š1 adherent leukocytes/100 µm2 in sham, P < .001). CS-associated tissue injury was significantly decreased with TNF-α neutralization (P < .05), both when administered alone or in combination with IL-1ß (P < .05). Additionally, TNF-α neutralization blocked CS-associated leukocyte activation (P < .05); IL-1ß neutralization also diminished leukocyte adhesion (P < .05). Perfusion remained virtually unchanged in CS animals treated with NA (36 ±â€Š4%, 32 ±â€Š3% and 30 ±â€Š2% in CS+TNF-α, CS+IL-1ß and CS+Combo groups, respectively). CONCLUSION: The results of this study indicate that CS induces a systemic inflammation, as evidenced by upregulation of inflammatory cytokines/chemokines in circulation. Neutralization of TNF-α led to a significant reduction in tissue injury; however, it had no effect on the CS-induced microvascular dysfunction. This suggests a distinct role of TNF-α in the pathophysiology of muscle injury in CS.

Inflammation, Bone Healing, and Anti-Inflammatory Drugs: An Update.

Fracture healing is a unique multifaceted process requiring the presence of cells, molecular mediators, and angiogenic factors. The state of inflammation dominates the initial phase, but the ideal magnitude and duration of the process for an optimal outcome remains obscure. Biological response modifiers, such as platelet-rich plasma (PRP) preparations, have been used to reconstitute the desirable early inflammatory state, but the results obtained remain inconclusive. Ongoing research to characterize and quantify the inflammatory response after bone fracture is essential in order to better understand the molecular insights of this localized reaction and to expand our armamentarium in the management of patients with an impaired fracture healing response. Non-steroidal anti-inflammatory drugs frequently administered for analgesia after trauma procedures continue to be a cause of concern for a successful bone repair response.