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This study used an experimental model (canine hind limb) of compartment syndrome, monitored with phosphorus 31 nuclear magnetic resonance spectroscopy, to determine the pressure threshold for metabolic deterioration in skeletal muscle previously subjected to ischemia. Our results show that muscle subjected to 6 h of antecedent ischemia has a lower tolerance to increased tissue pressure than otherwise normal muscle. The threshold was found to occur at a delta P (difference between mean blood pressure and limb compartment pressure) of 40 mm Hg, compared with a delta P of 30 mm Hg in muscle that was not subjected to antecedent ischemia. In addition, once the critical pressure threshold of postischemic muscle was crossed, there was a more rapid rate of high-energy phosphate depletion than that seen in normal muscle pressurized to the same degree beyond its delta P threshold. For compartment syndromes that appear after relatively atraumatic ischemia (i.e., drug overdose-induced limb compression, proximal arterial trauma causing distal limb ischemia, etc.), of < or = 6 h, fasciotomy should be performed at a delta P < or = 40 mm Hg. Compartment pressure elevation after local blunt muscle trauma and ischemia may well require earlier or even prophylactic fasciotomy. Fasciotomy in ongoing postischemic compartment syndromes should be considered particularly urgent owing to the rapid rate of metabolic deterioration that is observed once the critical delta P threshold is crossed. The type of compartment syndrome should always be considered when interpreting tissue pressure measurements as indications for fasciotomy.

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Background The Oncology Institute of Ljubljana (OIL) is the main cancer care institution in Slovenia. Extravasation is a serious complication of intravenous chemotherapy. Clinical outcomes vary from minor symptoms to severe tissue damage. The aim of the guidelines is to provide appropriate, professional and clear instructions on how to treat the patients in whom extravasations occur. Purpose To develop guidelines for treating anticancer drug extravasation, which contain the management algorithm of antidotes and treatments that should be performed, as well as risk factors and strategies to prevent extravasation. Furthermore, to statistically review all documented cases of anticancer drug extravasations from January 2010 to September 2013. Materials and methods 47 different intravenous anticancer drugs are available in chemotherapy protocols in OIL. Our extravasation guidelines were based on a literature review, through research and analysis of guidelines and articles obtained. Results Anticancer drugs are classified according to their damage-causing potential as vesicant, non vesicant and irritant; this determines the treatment regimens recommended. From the literature reviewed it was obvious that some anticancer drugs differ in classification according to their injury-inflicting potential and treatment regimens. In our guidelines we did not consider that distinction between vesicant and non-vesicant drugs to be absolute. The measures to be taken when chemotherapy extravasation occurs are based on the classification of their potential, ATC classification and knowledge of the actions of the drug and its antidote. Our guidelines include three specific antidotes: dimethyl sulfoxide, hyaluronidase and dexrazoxane, found in the literature review. A total of 47 anticancer drugs available in our guidelines were divided into 10 vesicants, 10 irritants and 16 non-vesicant drugs. 8 drugs were classified as both vesicant and irritant and 3 drugs as both irritant and non vesicant. Topical application of cold packs is recommended for 20 anticancer drugs, warm packs for 4 drugs, for 5 drugs we can use either of them and 18 drugs require none of the above. Specific management of some anticancer drugs (packs, antidotes) is changed when a large volume and high concentration is extravasated. In the events reported, the extravasated drugs were classified as vesicant in 59% of cases, irritant in 17% and non-vesicant in 24% of cases. In 60 cases specific antidotes and in 77 cases cold packs were administered but in 32 cases further action was required. Antidotes were administered in 11% of cases studied: mainly dimethyl sulfoxide (48%) and hyaluronidase (41%) but also dexrazoxane. Conclusions The guidelines are a valuable tool for our institute as well as for other medical centres throughout Slovenia. In addition each case of extravasation is documented through an anticancer drug extravasation documentation form. No conflict of interest.