Forearm compartment syndrome from intravenous mannitol extravasation during general anesthesia.

A 49-yr-old woman, ASA physical status IV, weighing 80 kg, with a severe headache from a posterior communicating aneurysm rupture was scheduled for aneurysm clipping. Her neurologic examination was normal. In the operating room, the usual monitors were placed, anesthesia was induced with thiopental 400 mg, lidocaine 100 mg, fentanyl 250 g, and rocuronium 50 mg via a preexisting right antecubital 18gauge IV catheter. The trachea was intubated, and ventilation was controlled. General anesthesia was maintained with isoflurane and remifentanil 0.125 g · kg 1 · min 1 via a 20-gauge IV catheter in the left hand. A 20-gauge right radial arterial cannula was inserted. The right arm was laterally tucked and pressure points were padded. Sixty minutes after scalp incision, mannitol was given through the right antecubital IV at approximately 5 g/min. The surgeon noted that the brain bulk had decreased. Fortyfive minutes after the initial administration of mannitol, the arterial pulse-pressure waveform and the ipsilateral pulse oximeter tracing dampened. After undraping, the forearm was discovered to be tensely swollen and cyanotic, with delayed capillary refill. There was a free flow of blood from the arterial cannula and a pulse was palpable. A hand surgeon performed a fasciotomy extending from the wrist to the forearm, after clipping of the aneurysm. The patient awoke in the operating room and was tracheally extubated. In the postanesthesia recovery unit, physical examination revealed weakness in the left lower extremity, palpable radial arterial pulses, normal capillary filling, and a normal upper-extremity neurologic examination. In the intensive care unit, forearm edema gradually decreased, over several days. She was discharged with full function of her right arm, and a well healed fasciotomy scar.