Use of a tourniquet with and without adrenaline reduces blood loss during liposuction for lymphoedema of the arm.

Sixty-two patients with lymphoedema of the arm after mastectomy and with hypertrophy of the adipose tissue were consecutively treated by liposuction in three different ways. The first group was operated on without the use of a tourniquet. In the second group, liposuction extended up to the distal edge of the tourniquet, and then into the proximal upper arm previously covered by the tourniquet using the 'dry' technique. Treatment of the third group was identical to that of the second one, but the area covered by the tourniquet was treated by the tumescent technique. Eighteen patients who did not have lymphoedema either treated or not treated with adrenaline served as a reference group to see how blood transfusions varied with various volumes of aspirate. Using a tourniquet significantly reduced blood loss and the number of transfusions, which was further reduced by tumescence. In the historical reference group, the number of blood transfusions increased as the volume of aspirate increased, and further if no adrenaline was added.     

Abdominoplasty with Total Abdominal Liposuction for Patients with Massive Weight Loss

Background Massive weight loss after bariatric surgery is associated with significant skin excess, laxity, and ptosis over the abdomen. Good results have been achieved with abdominoplasty and circumferential lipectomy. However, blood transfusions are sometimes needed, and patients may require long hospital stays. Furthermore, morbidity rates are high. Total abdominal liposuction performed with abdominoplasty allows for the preservation of lymphatic vessels below Scarpa’s fascia and eliminates the need for upper flap undermining. This study aimed to evaluate this technique in patients with anterior abdominal redundancy attributable to massive weight loss after bariatric surgery. Methods The charts of 60 patients treated between December 2001 and October 2004 were retrospectively reviewed. All the patients had undergone previous bariatric surgery as well as subsequent total abdominal liposuction and abdominoplasty. Results The average amount of wetting solution used was 3.1 l, and the average total aspirate was 2.5 l. The mean pannus weight was 3,649 g, and the average dimension was 48 × 25 × 6 cm. No patient required a blood transfusion. The median in-hospital stay was 1 day, with 42% of the patients treated as outpatients. The median follow-up period was 3 months. Morbidity was 22%. Factors associated with the development of complications were weight of the pannus, transverse dimension of the pannus, and body mass index. All the patients were satisfied with the results. Conclusions Total abdominal liposuction followed by abdominoplasty is adequate treatment for anterior abdominal redundancy for patients with massive weight loss.     

不同止血带使用方法对TKA围手术期失血量影响的临床研究

目的研究人工全膝关节置换术（TKA）中两种不同止血带使用方法对围手术失血总量的影响。方法选取2009年1月至2010年6月60例60～75岁单侧TKA患者进行研究,随机分成A组（30例,术中采用截骨完成后使用止血带至手术结束）和B组（30例,术中采用全程在止血带下完成手术）,所有手术均由同一组医师完成,比较A、B两组患者围手术期总失血量、显性出血量、隐性失血量、输血比例、输血量及手术时间的差异。结果 A组在显性失血量、手术时间较B组明显增加,差异有统计学意义（P〈0.05）;而在围手术期总失血量、隐性失血量、输血比例、输血量A组较B组明显减少,差异有统计学意义（P〈0.05）。结论在TKA手术当中截骨完成后开始使用止血带的方法,是一种能够明显减少围手术期总失血量、降低输血比例及输血量的新手术方式,同时减少了手术后并发症的发生率。     

Liposuction in the treatment of lymphoedema; a preliminary report

Liposuction was used in the treatment of primary and secondary lymphoedema in 19 patients. Seven patients had no previous surgical treatment and 12 had previously been treated with microlymphaticovenous anastomoses and/or surgical reduction. There was subjective improvement in 11 of the 13 patients available for follow-up. There was objective improvement in 10 of the 11 patients with unilateral lymphoedema, with an average reduction of 23% of the excess volume. Seven of the 13 patients were on conservative treatment prior to liposuction. The average reduction in this group was 20.5%. The average follow-up time was 9.5 months. From this preliminary report it can be concluded that liposuction, either as a primary procedure or as an adjunct, can be a useful procedure in the treatment of both primary and secondary lymphoedema.     

Application of liposuction and its clinical significance]

300 liposuction patients involving 444 anatomical areas are reported in this paper. The clinical significance of the applied anatomy and the comparison between groups are analyzed. 1. The distribution of the liposuction areas. 2. The distribution of blood vessels in the abdominal wall, buttocks and thighs and its relation to the volume of fat removed as well as blood loss. The blood vessels are so abundant in the abdominal wall that the blood loss is larger than that in the buttocks and thighs in the operation. According to the anatomical characteristics of distribution of the blood vessels, the authors pointed out a few "relatively forbidden areas". In group 2 we intentionally avoided doing liposuction in these areas. The results showed that the blood loss was less than that in group 1 and that the volume of fat removed could obviously be increased. 3. The characteristics of liposuction in severe obesity or in patients over 90kg body weight: The aspirate volume is big; the blood versus fat ratio is low. So it is possible to increase the aspirate volume. The elasticity of skin of the abdominal wall is very high. It is not necessary to remove skin in very obese patients with abdominal dermatochalasis.     

Safe Total Corporal Contouring with Large-Volume Liposuction for the Obese Patient

The advent of the tumescent technique in 1987 allowed for safe total corporal contouring as an ambulatory, single-session megaliposuction with the patient under regional anesthesia supplemented by local anesthetic only in selected areas. Safety and aesthetic issues define large-volume liposuction as having a 5,000-ml aspirate, mega-volume liposuction as having an 8,000-ml aspirate, and giganto-volume liposuction as having an aspirate of 12,000 ml or more. Clinically, a total volume comprising 5,000 ml of fat and wetting solution aspirated during the procedure qualifies for megaliposuction/large-volume liposuction. Between September 2000 and August 2005, 470 cases of liposuction were managed. In 296 (63%) of the 470 cases, the total volume of aspirate exceeded 5 l (range, 5,000–22,000 ml). Concurrent limited or total-block lipectomy was performed in 70 of 296 cases (23.6%). Regional anesthesia with conscious sedation was preferred, except where liposuction targeted areas above the subcostal region (the upper trunk, lateral chest, gynecomastia, breast, arms, and face), or when the patient so desired. Tumescent infiltration was achieved with hypotonic lactated Ringer’s solution, adrenalin, triamcinalone, and hyalase in all cases during the last one year of the series. This approach has clinically shown less tissue edema in the postoperative period than with conventional physiologic saline used in place of the Ringer’s lactate solution. The amount injected varied from 1,000 to 8,000 ml depending on the size, site, and area. Local anesthetic was included only for the terminal portion of the tumescent mixture, wherever the subcostal regions were infiltrated. The aspirate was restricted to the unstained white/yellow fat, and the amount of fat aspirated did not have any bearing on the amount of solution infiltrated. There were no major complications, and no blood transfusions were administered. The hospital stay ranged from 8 to 24 h for both liposuction and liposuction with a lipectomy. Serous discharge from access sites and serosanguinous fluid accumulation requiring drainage were necessitated in 32 of 296 cases (10.8%). Minor recontouring touch-ups were requested in 17 of 296 cases (5.7%). Early ambulation was encouraged for mobilization of third-space fluid shifts to expedite recovery and to prevent deep vein thrombosis. Follow-up evaluation ranged from 6 to 52 months, with 38 (12.8%) of 296 patients requesting further sessions for other new areas. Average weight reduction observed was 7 to 11.6 kg (approx. 4 to 10% of pre-operative body weight). Meticulous perioperative monitoring of systemic functions ensures safety in tumescent megaliposuction for the obese, and rewarding results are achieved in a single sitting.     

The importance of preoperative hemoglobin evaluation in large volume liposuction: lessons learned from our 15-year experience

Liposuction of >5 L of total aspirate at one setting is defined as large volume liposuction (LVL). A retrospective chart review was performed on all patients who underwent LVL from January 1990 to June 2005. Sixty-two patients underwent LVL. The mean volume of total aspirate was 8 L (5.0-11.7 L). There were a total of 6 patients who had complications. These included symptomatic postoperative anemia requiring blood transfusions on postoperative day 1 (n = 5), and an expanding hematoma requiring operative evacuation without transfusion (n = 1). Two of the patients who had blood transfusions had a history of gastric bypass and all of the patients were preoperatively anemic (<11.5 mg/dL). The mean follow up was 38 months. LVL is safe when performed in healthy patients under strict guidelines. Hemoglobin levels of all potential LVL patients should be checked preoperatively, and surgery should be withheld for levels <12 g/dL.     

The effect of tourniquet use in total knee arthroplasty

We conducted a prospective, randomised study on primary total knee replacements to evaluate the effects of tourniquet use on total calculated blood loss using Gross formula, post-operative measured blood loss, operating time, need for blood transfusion, post-operative pain, analgesia requirement and knee flexion. Forty patients were operated on with the use of an arterial tourniquet with pressure of 350 mmHg (group A), and 40 patients without the use of a tourniquet (group B). Total calculated blood loss was significantly increased ( P=0.0165) without the use of a tourniquet. There was no significant difference in measured blood loss or operating time. The median units of blood given were similar in both groups. In spite of autologous transfusions 14% of patients received additional homologous transfusions. At 6 h post-operatively pain was significantly less ( P=0.0458) in group B but was similar at 24 and 48 h. There was no significant difference in analgesia requirement. The mean change in total flexion in group B was significantly better ( P<0.001) at 5 days than in group A, but knee flexion was similar at 10 days and 3 months. Knee arthroplasty operations without the use of a tourniquet cause a greater blood loss but have only small benefits in the early post-operative period.     

Influence of tourniquet ischemia on perioperative blood loss after total knee arthroplasty

The purpose of this study was to evaluate the effect of tourniquet use with constant pressure until wound closure on perioperative blood loss in total knee arthroplasty (TKA). Sufficient patients were included in the study to produce statistically relevant conclusions. In this retrospective case control study 547?patients who were treated with TKA because of osteoarthritis of the knee joint were included and of these 262?patients were operated with the use of a tourniquet (300?mmHg) and 285 without. The perioperative blood loss was calculated using patient height, body weight and preoperative and postoperative hematocrit values. The patient collectives were comparable in mean age, gender distribution and ASA classification. In the group with an operation using a tourniquet, 24?patients (9.2%) received erythrocyte transfusions compared to 36?patients (12.6%) in the group without tourniquet use (not significant). The average perioperative blood loss without tourniquet use was 1.5±0.6?l (range ?0.2 to 4.3?l). In contrast patients treated with the use of a tourniquet lost on average only 1.2±0.5?l (range ?0.2 to 3.4?l) (p<0.001). The use of a tourniquet reduces the perioperative blood loss in TKA if it is kept tight during the operation.     

Use of Tourniquet During Knee Arthroplasty in Patients With Radiographic Arterial Calcifications

BackgroundUse of tourniquet during total knee arthroplasty (TKA) in patients with radiographic arterial calcifications is controversial. Intimal arterial calcifications are feared to be associated with ischemic complications such as delayed wound healing and arterial thrombosis, whereas medial calcifications stiffen the arterial wall, possibly leading to tourniquet failure and increased blood loss.MethodsWe conducted a prospective cohort study to determine the incidence of tourniquet failure (inflated up to 300 mm Hg), blood transfusions, wound healing, and ischemic complications in thighs with and without arterial calcifications on preoperative radiographs, in 2548 consecutive primary TKAs conducted in our unit over a 5-year period. Eighty-six thighs showed vascular calcifications: 58 medial and 28 intimal.ResultsThighs with vascular calcifications had higher risk of tourniquet failure as compared to those without calcifications (P < .001), but with no significant increase in incidence of blood transfusions. All cases of tourniquet failure in the calcification group occurred in thighs with medial calcifications, whereas all cases of tourniquet failure in the control group occurred in obese patients. There was no difference in wound healing and ischemic complications in limbs with and without arterial calcifications.ConclusionThe presence of arterial calcifications on preoperative radiographs increases the risk of tourniquet failure at 300 mm Hg in patients undergoing TKA, with no significant increase in rate of blood transfusions, wound healing or ischemic complications.     

Large-Volume Liposuction in 181 Patients

Liposuction is a commonly performed cosmetic surgery procedure that is associated with complications, including fatalities. Many of these have been associated with large-volume liposuction. During 1998 the American Society of Plastic Surgery Task Force on Lipoplasty and the Plastic/Cosmetic Surgery Committee of the Medical Board of California have both arbitrarily defined large-volume liposuction as greater than 5000 cc and asked that surgeons not remove any more than this volume except in specific circumstances such as a hospital-type setting [1]. This study includes 181 patients who have had greater than this amount of total aspirate removed in a single procedure. From January 1, 1996, to February 11, 1997, we used tumescent liposuction only (31 patients). From February 12, 1997, to June 30, 1998, we used a combination of ultrasonic liposuction using the Lysonix 2000 Ultrasonic Liposuction Unit and tumescent liposuction (150 patients). During the last part of the latter series we calculated the blood loss of 45 patients derived from preop and 5-day postop hematocrits. The results show that (1) there is no correlation between the aspirate volume and the calculated blood loss; (2) the majority of the calculated blood loss is not in the cannister; and (3) no deaths occurred, but one patient suffered a deep venous thrombosis and two patients suffered pulmonary emboli. As others have pointed out [2–6] large-volume liposuction can be performed relatively safely if this procedure is treated with the respect it deserves and the practitioner exercises sound surgical judgment, uses appropriate technique, and does not try to cut corners to save money for the patient by performing this surgery in minimal settings.     

Nonanemic Patients Do Not Benefit from Autologous Blood Donation Before Total Knee Replacement

A retrospective analysis of 221 patients undergoing unilateral total knee arthroplasty between January 2007 and April 2008 was performed to look at rates of total transfusions, allogenic transfusions, and autogenic transfusions. Two senior surgeons performed all the surgeries. During that period, patients in group A (129 patients) all donated one unit of autologous blood and patients in group B (92 patients) did not donate. Within both groups, patients were further divided by preoperative hemoglobin level as either anemic or non-anemic. A hemoglobin of 12.5 g/dL was used as the cutoff. Ninety-eight patients in group A (76%) required autologous blood. Patients in group A received a higher total number of transfusions (0.93 per patient) than those in group B (0.33 per patient; p < 0.001). The rate of allogenic transfusion was lower for group A (14%) than for group B (25%; p < 0.033). The reduction of allogenic transfusions associated with preoperative autologous blood donation was confined to anemic patients (29% in group A vs 72% in group B; p = 0.0006). There was no difference in allogenic blood transfusions in non-anemic patients between group A (8%) and group B (9%; p = 0.91). Limiting autologous blood donation to anemic patients decreased cost compared to routine autologous blood donation (US 256.63/patient versus US256.63/patient versus US 511.44/patient) without exposing patients to increased allogenic blood transfusions. Targeted blood management in total knee replacement surgery decreases transfusion rates and reduces cost.     

Prospective randomized evaluation of a collagen/thrombin and autologous platelet hemostatic agent during total knee arthroplasty

The purpose of this study was to evaluate the effectiveness of a collagen/thrombin and autologous platelet hemostatic agent in preventing blood loss during primary total knee arthroplasty. This prospective, double-blinded, randomized study was designed to enroll a total of 100 patients. Patients were randomized 1:1 to either the treatment arm (standard hemostasis plus study product) or the control arm (standard hemostasis alone). Transfusion requirements, as determined by a blinded investigator using standardized criteria, were significantly lower in the treatment group (no blood transfusions) compared with the control group (5 transfusions; P = .007). These data support the addition of the study product to prevent blood transfusions after primary total knee arthroplasty.     

负压抽吸法治疗四肢淋巴水肿

目的　介绍应用负压抽吸法治疗四肢淋巴水肿。方法　应用抽吸法治疗四肢淋巴水肿35例,在肢体的肿胀部位作多个小切口,插入吸引管,在负0.8～0.9个大气压下将淤积的淋巴液和增生的脂肪组织吸出,术后配合压迫疗法。结果　随访3～6个月,肢体明显缩小,质地变软,取得显著近期效果。结论　负压吸引法治疗四肢淋巴水肿,切口小,创伤轻,对非严重纤维化的患者是一种安全有效地治疗方法,其近期效果明显,远期效果有待进一步观察。     

影响血液流变学检测的护理相关因素分析及对策

目的探讨影响血液流变学检测检验误差的护理相关因素。方法将60例骨科患者随机分为三组各20例,第1组分别采集3管血标本,于1h内检测;第2组分别采集4管血标本,15℃下放置1、4、8、24h后检测;第3组用成人血压袖带束缚左右两臂,分别空气加压至40、110mmHg后采集血标本,于1h内检测。结果全血切变率、血浆黏度检测结果比较,第1组第3管显著高于第1管;第2组放置8、24h显著高于1h;第3组110mmHg束臂压力显著高于40mmHg(P<0.05,P<0.01)。结论血液流变检测结果受采样顺序、时间,束臂压力因素影响;建议采集多管标本时首先采集血液流变学,于4h内检测,止血带压力不宜过大。     

Effect of tourniquet use on blood loss in total knee arthroplasty

AIM: To reduce blood loss in total knee arthroplasty various physical measures including the use of a tourniquet are recommended. The question of an early tourniquet release is still unsettled. PATIENTS AND METHOD: To confirm our theory that blood loss and need of blood transfusions might be reduced while removing the tourniquet for meticulous hemostasis before wound closure we analysed 70 (41 male, 29 female) consecutive patients with total knee arthroplasty for osteoarthritis performed by a single surgeon in a prospective-randomized study between 1/1996 to 6/1998. In group I the tourniquet was released before, in group II after wound closure. RESULTS: We couldn't find any significant differences in the estimated blood loss, the decrease of hemoglobin and hematocrit level, and the transfusion need. In Group II we observed two cases of deep vein thrombosis. This difference was not significant. CONCLUSION: We conclude that tourniquet release for hemostasis is not an effective tool in reducing blood loss or transfusion need in total knee arthroplasty.     

Wrist tourniquet: the most patient-friendly way of bloodless hand surgery

BACKGROUND: The literature is scarce on wrist tourniquets. In this study, three well-established locations of tourniquet setting including upper arm, proximal forearm, and wrist were compared on the same limb using both clinical as well as biochemical variables in paramedical volunteers. METHODS: Twenty unmedicated, healthy, paramedical, right-hand dominant volunteers participated in the study. The left upper arms were used for monitoring. Blood pressures and heart rates were monitored and recorded before (baseline) and immediately after the application of the tourniquet, every 5 minutes, and at the time the patient requested deflation. An intravenous cannula (22 G) was placed on the right hand to obtain samples, which were taken at baseline and immediately after deflation of the tourniquet to evaluate the levels of pO2, pCO2, O2 saturation, pH, bicarbonate, blood sugar, lactate, hematocrit, and electrolytes. The tourniquets were applied to the right upper arm, forearm, and wrist of each subject with 5-day intervals between each trial. Subjective discomfort and tourniquet pain levels were recorded. For each trial, tourniquet tolerance and details of discomfort were recorded. Statistical analysis was performed as appropriate. RESULTS: Twenty volunteers aged 20 to 44 years were included. For each trial, in the first 10 minutes after inflation of the tourniquet, the heart rate and systolic blood pressure were increased compared with baseline values. Diastolic blood pressure was elevated immediately after inflation and remained so until deflation in each trial. Diastolic blood pressure values were higher in the upper-arm tourniquet group compared with wrist. Then pH, pO2, and O2 saturation values were decreased and pCO2 and lactate levels were increased compared with baseline values in each trial. Blood sugar was decreased significantly in the arm group. The decrease in pH, pO2, O2 saturation, and blood sugar in the upper arm group was significantly higher compared with wrist and forearm groups. The lactate value was higher in the upper arm group compared with wrist. Visual analog scale and numerical rating scores were lower in the wrist group compared with others at all times. The longest tourniquet tolerance was in the wrist group. In the wrist group, curling was observed in all subjects but the fingers could easily be extended. CONCLUSION: The wrist tourniquet is the most comfortable technique of bloodless surgery for procedures limited to the hand region.     

Impact of Large-Volume Liposuction on Serum Lipids in Orientals: A Pilot Study

Recent advances in liposuction techniques now make it possible to remove considerable amounts of subcutaneous adipose tissue. However, the metabolic consequences of this procedure are not well documented. The aim of this study was to identify the effects from the surgical removal of subcutaneous fat on the body weights and serum lipids of patients who have undergone large-volume liposuction. In this study, eleven consecutive patients with a minimum aspirate volume of 5,000 ml were evaluated, and their serum lipids were measured at a postoperative 2-month follow-up assessment. Tumescent fluid was infiltrated using the superwet technique. The liposuction device used was a Liposlim power-assisted liposuction system. The amount of solution infiltrated and the volume of aspirate were measured. Pre- and postoperative serum lipids, body weights, and body mass indices were compared. Statistical analysis was performed on lipid profile changes and aspirate volumes using Spearman's correlations. The average volumes of infiltrate and aspirate were 7,241 and 6,790 ml, respectively. Mean body weight decreased from 64.5 +/- 18.8 to 59.9 s +/- 17.8 kg (p < 0.01). The change in body weight per 1 l of aspirate volume was 0.67 +/- 0.10 kg/l. The mean body mass index dropped from 23.8 +/- 4.4 to 22.0 +/- 4.2 kg/m(2) (p < 0.01), and the mean total serum cholesterol levels from 168.2 +/- 23.6 to 162.9 +/- 26.5 mg/dl, an average of 3.2%. The mean low-density lipoprotein (LDL) decreased from 94.3 +/- 20.5 to 89.5 +/- 19.0 mg/dl, a 5.1% drop, and the mean high-density lipoprotein (HDL) decreased from 55.8 +/- 9.5 to 53.7 +/- 10.7 mg/dl, a 3,8% drop. The mean HDL/LDL proportion increased from 62.6 +/- 20.9% to 63.5 +/- 22.4%, averaging 1.4%. However, no significant correlation was found between the aspirated volume of fat and lipid profile change. In conclusion, over a 2-month period, large-volume liposuction reduced weight and total cholesterol level and increased the HDL/LDL ratio. The authors hope to discover whether the therapeutic impact of liposuction is long-lasting, and to determine whether it reduces the morbidity and mortality associated with obesity.     

Wound drainage following radical mastectomy: the effect of restriction of shoulder movement.

A randomized prospective clinical trial has been performed to determine the effect of temporary immobilization of the shoulder on wound drainage following radical mastectomy. In 64 patients admitted to the trial the mean volume of drainage was reduced by 40 per cent in those who had shoulder movement restricted for the first 7 days after operation when compared with the group in whom early arm exercises were encouraged. The mean drainage time was reduced by 29 per cent. Shoulder immobilization did not result in increased shoulder stiffness, although there was an increased incidence of mild lymphoedema of the arm.     

Use of a pneumatic tourniquet induces changes in central temperature

Twenty-six patients requiring orthopaedic surgery were anaesthetized and oesophageal and rectal temperature were monitored continuously. Twenty patients requiring a pneumatic tourniquet were allocated prospectively to one of two groups: passive group (Pg) with reflective insulation on all available skin surface (n = 10) and forced group (Fg), with active warming by a forced air system (n = 10). Six patients without a tourniquet were used as a reference group (Rg). The pneumatic tourniquet time was similar in the tourniquet groups. During tourniquet inflation, oesophageal temperature increased with time. The difference was significant compared with the reference group at approximately 20 min. At about 30 min, oesophageal temperature in group Fg was significantly higher than that in group Pg. After tourniquet deflation, temperature decreased transiently. Changes in rectal temperature were similar but delayed significantly. A mechanism to explain the increase in core temperature during pneumatic tourniquet use remains unclear. A redistribution mechanism by cooling of the blood in a cold and vasodilated limb could explain the decrease of temperature after tourniquet deflation.