a 74-year - old woman ( body weight : 60 kg , height : 149 cm , asa physical status : 2 ) was scheduled for posterior lumbar decompressive fusion surgery at l4 - 5 under the diagnosis of spondylolisthesis . the patient 's previous medical history entailed ten years of diabetes , which was well - controlled with oral hypoglycemic agents . two weeks prior to the operation , she had undergone cervical intervertebral anterior fusion at c7-t1 and she had also been taking methylprednisolone 750 - 1,000 mg daily for 11 days . the patient was placed under general anesthesia via a preexisting 18-gauge iv catheter on the right forearm with 0.9% normal saline . a noninvasive blood pressure ( nibp ) cuff and an additional 18-gauge iv catheter with 0.9% normal saline were applied through the cephalic vein at the level of the left forearm . after performing allen 's test , a radial artery cannulator was inserted at the right side and then the nibp on the left arm was checked every 30 minutes . general anesthesia was induced with thiopental sodium , midazolam and fentanyl and it was maintained with sevoflurane - n2o in oxygen after tracheal intubation . the patient 's position was changed to prone using a wilson 's table with her arms extended at the shoulders and the elbows naturally flexed . she was covered with a warming blanket ( bair hugger , augustine medical inc , eden prairie , mn , usa ) over both arms and the upper body . normal saline 550 ml was infused thorough the left iv catheter by gravity for the first 3 hours of the operation . as the blood loss increased , an infusion of blood under pressure was applied . approximately 20 minutes after the pressurized infusion on left forearm , the anesthetist found problems of dripping of the left iv fluid . to confirm the iv site , the warm blanket was uncovered , and several 2 - 3 cm - sized bullae , a big bruise and tensely pale swelling from the palm to the upper part of the forearm were discovered on the confirmed left iv site ( fig . , a total of 550 ml of normal saline that was infused by gravity and 50 ml of packed red blood cells and 150 ml of normal saline via a pressure bag inflated to 200 mmhg had been injected through a cephalic vein of the left forearm . the process of refilling the digital capillaries took over 4 seconds , and arterial pulsation was weakly palpable . the nibp cuff and the left forearm iv catheter were removed under the presumptive diagnosis of impending compartment syndrome . a plastic surgeon was quickly consulted and we injected hyaluronidase 1,500 u ( h - lase , l&h pharm , korea ) subcutaneously on the patient 's forearm and hand to decompress the increased pressure of the compartments by absorbing the extravasated blood and fluid ( fig . the patient 's arms were elevated above the heart level while the operation was continued . after 4 hours of operation , the patient was extubated in the operating room and then moved to the recovery room . in the postanesthesia recovery unit , a physical examination revealed no signs of motor weakness , sensory abnormality or color change on the left forearm and hand . the radial arterial pulsation and capillary filling had recovered and the edema was slightly decreased . as the patient did not complain of pain on passive movement , she was transferred to the general ward . the edema on the left forearm and hand subsided in three days and the patient was discharged without any complications about her left forearm two weeks later . compartment syndrome defined as a condition in which the circulation and function of the tissue within a closed space are compromised by increased pressure inside that space . the common causes of compartment syndrome are muscle avulsion , bone fracture of the tibia or forearm , and external compression . iatrogenic causes by extravasation related to anesthesia have been reported with drugs like diazepam and antibiotics , hyperosmolar solution such as mannitol , hypertonic saline , a pressurized iv infiltration , bier block   and arterial cannulation . the pathophysiology of compartment syndrome is caused by increased intracompartmental pressure that is strong enough to impede microcirculatory perfusion , and this results in ischemic injury to muscle , nerves and other compressed structures . intravenous infiltrations have been classified into 4 stages and the first is local pain without swelling or redness , the second is pain , redness and minimal swelling , the third is moderate swelling and blanching , and the forth is capillary refilling of more than 4 seconds and skin breakdown . matsen   found that neural abnormality began after 30 minutes of ischemia and this became irreversible after 12 hours , the permeability of the capillary endothelium increased after about 3 hours of ischemia , and muscle changes began after about 2 hours and this became irreversible after 4 hours of ischemia . the importance of making an early diagnosis and treatment involving hyaluronidase and fasciotomy can not be overemphasized . a failure to diagnose impending compartment syndrome by the time of emergence from anesthesia may result in permanent injury . the diagnosis of compartment syndrome is based on intra - compartmental pressure measurement by a wick catheter , simple needle manometry , an infusion technique and using a slit catheter . the threshold of the compartment pressure that requires treatment is controversial , but the indications for fasciotomy includes the clinical signs , symptoms and an intracompartmental pressure of 15 - 25 mmhg , or in the absence of clinical sign andsymptoms , an intracompartmental pressure of more than 25 mmhg . however tobias et al .   treated compartment syndrome conservatively without fasciotomy in spite that the interstitial pressure of the biceps brachii and triceps brachii muscle was over 30 mmhg . it is difficult to diagnose compartment syndrome early in the case of an anesthetized or obtunded patient who is incapable of expressing pain . therefore , frequent examination of the extremities is crucial to make a timely diagnosis and minimize the risk of permanent injury . monitoring includes inspection , pulse oximetry and assessing the intraarterial pressure wave of the upper arm . once the injury occurs , the methods of management can be either operative or non - operative . non - operative management involves daily cleansing and topical application of antiseptic cream , enzymatic debridement , hyaluronidase application , subcutaneous saline flush - outs and liposuction . laurie et al .   used topical hyaluronidase in an extravasation injury of a rabbit model . heclker   applied hyaluronidase less than an hour after extravasation , and none of the patients suffered full - thickness skin defects or weakness of the motion of any joint . a definite surgical treatment for severe compartment syndrome is fasciotomy . fasciotomy decompresses the pressure of a compartment and prevents permanent injury of nerves and vessels . tiwari et al .   reported that their patients recovered from compartment syndrome without complication by performing fasciotomy . the wait - and - see approach is strongly contraindicated for treatment , and this approach can quickly result in permanent sequelae . the effectiveness and significance of prevention can not be emphasized enough . khan and holmes   established the protocol and kit to prevent extravasation , which consists of large central vein catheterization , avoidance of multiple perforations on same the vein , avoidance of perfusion under pressure , close monitoring of the venous puncture site , avoidance of sites on hands and near joints and avoidance of limbs with impaired circulation . in our case , at first the skin lesion such as bullae could be considered to be caused by the heat of the warming blanket . but the warming blanket covering the upper body and both arms did not contact directly with in skin and it did not increase the temperature enough to cause the bullae . with the abrupt onset and no allergy history , the signs also excluded the possibility of necrotizing fasciitis or cellulitis . in this case , we considered impending compartment syndrome that was due to the extravasation from a pressurized infusion of normal saline and packed red blood cells , although we did not measure the intracompartmental pressure . there were several factors that adversely affected the local tissue blood flow and perfusion to produce compartment syndrome on the forearm . the patient 's skin and vessels were thin and they lacked elasticity due to her diabetes and the preoperative steroid medication . moreover , we performed a pressurized intravenous infusion and put the blood pressure cuff on the same side and we repeatedly examined the blood pressure every 30 minutes . extravasation of the fluids may have increased the pressure within a limited space and worsened the circulation below the blood pressure cuff . as the thin walls of the venules were pressured and might be ruptured , the administrated fluid and blood were extravasated and this increased the capillary perfusion pressure and caused compartment pressure and high hydrostatic pressure , which all ultimately resulted in edema and bullae . there have been a few cases of compartment syndrome from pressurized infusion like our report . another adverse factor may be the patient 's age , which increases the vulnerability of skin and also vein fragility . in this reported case , subcutaneously or intramuscularly injected hyaluronidase absorbs body fluid or blood components in connective tissue , it lowers the compartmental pressure and it prevents the injury of nerves and vessels . in conclusion , compartment syndrome is a rare complication of extravasation injury due to pressurized infusion . it can increase the possibility of permanent injury in nerves and vessels if it is not treated in a timely manner . anesthesiologists have to be even more attentive to closely monitor all intravenous sites , and particularly because a patient is unable to complain of their pain when under general anesthesia , or a patient has more vulnerable veins due to use of steroid or the difficulty of venous access .
a 74-year - old woman underwent posterior lumbar decompressive fusion at l4 - 5 for treating spondylolisthesis , with the patient under general anesthesia and she was in the prone position . following attempts to transfuse blood using a pressurized bag , the intravenous infusion site of the left hand along with the noninvasive blood pressure cuff was changed . swelling and several bullae on the left forearm and hand were visible . 
 removal of intravenous catheter , hyaluronidase injection , wet dressing were subsequently performed . in postanesthesia recovery unit , 
 the patient did not complain of pain , and the radial pulse and oxygen saturation of the left appeared normal . 
 three days after the incident , the edema on the patient 's forearm and hand subsided , and the patient was discharged without any complications two weeks afterwards . 
 impending compartment syndrome should be given close attention , and particularly when performing pressurized infusion in patients who are unable to express pain because they are under general anesthesia .