Atraumatic Compartment Syndrome in Patients on Extracorporeal Membrane Oxygenation: A Case Series

Extracorporeal membrane oxygenation (ECMO) is a lifesaving procedure used to treat cardiopulmonary failure. Atraumatic extremity compartment syndrome is a known complication of limb ischemia related to thrombi from ECMO cannulation, prolonged hypotension, and pressor use. The purpose of this study is to describe a series of patients at a single institution who developed atraumatic compartment syndrome on ECMO.

A retrospective review was done at a single academic center between January 1, 2005, and October 30, 2023. The inclusion criteria were clinical diagnosis of compartment syndrome not attributable to trauma (ie, crush injury, fracture, traumatic vascular injury) while on ECMO, which was treated with fasciotomy. Data were collected on patient demographics, clinical course, and limb outcomes.

A total of 41 patients met the inclusion criteria. Average time to diagnosis of compartment syndrome after cannulation was 2 ± 2 days. All patients received VA-ECMO. The majority (36 patients, 88%) underwent peripheral cannulation through the femoral artery (35 patients) or axillary artery (1 patient). All patients were diagnosed clinically, although 17 patients (41%) had confirmatory compartment pressures taken intraoperatively. Fasciotomies were conducted in every case. Postoperatively, 19 patients (46%) developed an acute kidney injury, and 15 (37%) required dialysis. Twenty-two patients (54%) died before discharge. Of the surviving 19 patients, 3 (16%) underwent amputation of the affected extremity, and 14 (74%) had some form of persistent neurological deficits (loss of sensation, muscle weakness, or persistent foot drop).

Patients on ECMO who develop compartment syndrome have a high rate of in-hospital mortality, limb loss, and long-term limb deficits. Prompt clinical diagnosis and treatment is critical. There should be a high index of suspicion for patients undergoing VA-ECMO, especially with femoral artery cannulation.