Transplant Unit, Churchill Hospital, Oxford, UK
Correspondence and offprint requests to: Mr Toby Richards, Transplant Unit, Churchill Hospital, Oxford, UK. Email: toby.richards{at}virgin.net
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Introduction |
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Case |
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At operation, general anaesthesia included epidural access, right internal jugular central line and right radial arterial line. Tissue mismatch was A2-B2-DR2. Immunosuppression included anti-thymocyte globulin at induction with tacrolimus, mycophenolate motif and prednisolone continued post-operatively. The operation was uneventful, lasting 5 h. Fluid management included blood (2 units), colloid (3 l) and crystalloid (4 l). He was extubated 2 h post-operatively on the intensive therapy unit.
In the immediate post-operative period, he had primary renal and pancreatic graft function. Pain was well controlled and there was spontaneous breathing with saturations maintained above 95% on 4 l of oxygen. After several hours, he complained of increasing pain, not controlled despite epidural and supplementary morphine. Pain was severe in both hands. Sensory and motor loss was noted in both hands, except the fifth fingers, in the distribution of the median nerve. Central and radial cannulae were removed. He had generalized swelling compatible with a systemic inflammatory response syndrome (SIRS) following the operation, but there was no evidence of an upper limb compartment syndrome. There was no evidence of upper limb ischaemia, and arterial Doppler examination at the wrist was normal. Emergency bilateral carpal tunnel release was performed. Thickening of the carpal ligaments and compression of the median nerves were noted at operation. There was immediate relief of pain following operation.
The patient made a steady recovery, and was discharged on the 12th post-operative day. Neurophysiological conduction studies immediately following discharge revealed severe abnormalities of median nerve conductions across both carpal tunnels, consistent with carpal tunnel entrapment. Repeat studies 2 months later showed marked improvement in comparison with the previous results.
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Discussion |
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Although acute exacerbations of CTS occur, they are rare. It may be seen in pregnancy, following forearm and proximal wrist bone fractures or haemorrhage secondary to excessive anticoagulation or coagulation defects. Management is initially conservative. Emergency decompression may be required. Relevant to this case, acute CTS has been reported following radial artery cannulation [3]; following removal of the radial arterial line, there was no local bleeding and subsequent arterial Doppler examination was normal.
Other conditions may present in a similar way to acute CTS. Acute oedema secondary to seronegative symmetrical synovitis with pitting oedema (RS3PE) has a rapid onset of polysynovitis associated with bilateral pitting oedema of the dorsum of both hands [4].
Increased incidence of chronic CTS was reported following KPT in two case series. In 19 cases, all but one resolved without surgical intervention [5]. In a further five cases, immediately post-operatively, none required surgical intervention [6]. Suggested pathophysiological mechanisms included rapid normalization of Na-K-ATPase activity leading to an acute accumulation of sodium in interstitial tissue, swelling of the median nerve and a resultant entrapment neuropathy.
In this case, acute CTS developed immediately following KPT operation, and emergency decompression resulted in instant resolution of symptoms. The mechanism of median nerve entrapment may have been related to both patient and operative factors. The patient was a long-term diabetic with increased risk of CTS and, although asymptomatic, had signs of CTS at decompression suggesting occult disease. There was, however, no pre-operative indication for neurophysiological studies.
The nature of KPT operation, prolonged procedure, large volume of fluid transfused and ischaemic reperfusion response trigger significant SIRS. Consequent fluid shift from already increased intravascular fluid volume to the interstitial space results in tissue swelling. Local interstitial tissue swelling may have precipitated acute median nerve compression in this case with occult CTS.
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Conclusion |
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Conflict of interest statement. None declared.
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References |
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