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 In the historical reference group, the number of blood transfusions increased as the volume of aspirate increased, and further if no adrenaline was added.     

The effects of infiltration with adrenaline on blood loss during reduction mammaplasty.

Between March and November 1990 a prospective study of the effect of an infiltration of diluted adrenaline on bleeding during and after reduction mammaplasty was carried out in 12 consecutive patients. There was a significant reduction in blood loss to less than 50% of that from the non-infiltrated breasts. There was no signs of increased postoperative bleeding or reduced flap viability as a result of infiltration of adrenaline.     

Association between tourniquet use and intraoperative blood loss during below-knee amputation

BACKGROUNDDespite over 150000 amputations of lower limbs annually, there remains a wide variation in tourniquet practice patterns and no consensus on their necessity, especially among orthopedic patient populations. The purpose of this study was to determine whether tourniquet use in orthopedic patients undergoing below knee amputation (BKA) was associated with a difference in calculated blood loss relative to no tourniquet use.AIMTo determine if tourniquet use in orthopedic patients undergoing BKA was associated with a difference in calculated blood loss relative to no tourniquet use.METHODSWe performed a retrospective review of consecutive patients undergoing BKA by orthopedic surgeons at a tertiary care hospital from 2008 through 2018. Blood loss was calculated using a combination of the Nadler equation for preoperative blood volume and a novel formula utilizing preoperative and postoperative hemoglobin levels and transfusions. Univariate and forwards step-wise multivariate linear regressions were performed to determine the association between tourniquet use and blood loss. A Wilcoxon was used to determine the univariate relationship between tourniquet use and blood loss for in the restricted subgroups of patients who underwent BKA for trauma, tumor, and infection.RESULTSOf 97 eligible patients identified, 67 underwent surgery with a tourniquet and 30 did not. In multivariate regression, tourniquet use was associated with a 488 mL decrease in calculated blood loss (CI 119-857, P = 0.01). In subgroup analysis, no individual group showed a statistically significant decrease in blood loss with tourniquet use. There was no significant association between tourniquet use and either postoperative transfusions or reoperation at one year.CONCLUSIONWe found that tourniquet use during BKA is associated with decreased calculated intraoperative blood loss. We recommend that surgeons performing this procedure use a tourniquet to minimize blood loss.     

The use of lidocaine with adrenaline reduces blood loss and operating time in free TRAM breast reconstruction

Free transverse abdominis myocutaneous flap (TRAM) reconstruction is regarded as a major operation involving significant blood loss and a long operating time. Infiltration of a local anaesthetic with adrenaline has been used to reduce blood loss in reduction mammoplasty with good results. In this study, 80-100 ml 0.5% lidocaine with adrenaline (1:100,000) was infiltrated preoperatively in 13 TRAM reconstruction patients (study group). Infiltration was subcutaneous to the lower abdomen, the mastectomy scar and the other breast (if operated on). In the control group (15 patients), there was no such infiltration. The groups were similar to each other in patient and oncological characteristics. Perioperative blood loss was significantly lower in the study group (382 ml) than in the control group (987 ml). The operating time was also significantly shorter in the study group (142 min) than in the control group (188 min). There were no systemic side effects of lidocaine or adrenaline, nor where there were any flap losses, skin necroses or wound infections calling for revision in either group.     

Hypotensive epidural anesthesia in total knee replacement without tourniquet: reduced blood loss and transfusion

BACKGOUND AND OBJECTIVES: For decades, hypotensive anesthesia has been used in an attempt to reduce intraoperative blood loss. Hypotensive epidural anesthesia (HEA) is a relatively new technique in hypotensive anesthesia. Use of a tourniquet has been shown to be associated with a higher risk of cardiovascular and thromboembolic complications. The effect of HEA on blood loss and need for transfusion in total knee replacement (TKR) is not known. METHODS: Thirty consecutive patients scheduled for TKR were randomized to HEA without tourniquet or spinal anesthesia with the use of a tourniquet (SPI). HEA was performed as an epidurally induced sympathetic block and there was an infusion of low-dose epinephrine to stabilize the circulation. RESULTS: Intraoperative mean arterial blood pressure was 48 mm Hg (HEA) versus 83 mm Hg (SPI) (P <.001). Intraoperative blood loss was 146 mL (HEA) versus 13 mL (SPI) (P <.001). Postoperative blood loss at any time was significantly reduced in the HEA group, and total loss of blood was 1,056 mL (HEA) versus 1,826 mL (SPI) (P <.001). Half of the bleeding took place during the first 3 postoperative hours and 80% during the first 24 hours. In the HEA group, 57% of the patients went through surgery and the hospital stay without receiving blood transfusion versus 19% in the SPI group (P <.05). There was a significantly reduced amount of blood transfusion in the HEA group (193 mL) versus 775 mL in the SPI group (P <.005). No cardiopulmonary, cerebral, or renal complications were registered. CONCLUSIONS: We conclude that HEA is a safe technique that allows TKR without a tourniquet. Compared with spinal anesthesia, the use of HEA for TKR significantly reduces blood loss and the need for blood transfusion.     

The effects of a pneumatic tourniquet on blood loss in total knee arthroplasty.

OBJECTIVE: In lower-extremity surgery there are significant risks associated with the use of tourniquets. This prospective study was done to assess to what extent these risks may be offset by the potential advantages of tourniquets, namely reductions in blood loss, length of hospital stay and complication rates. DESIGN: A prospective case study. SETTING: A major urban hospital. PATIENTS: Sixty-three consecutive patients scheduled for primary cemented total knee arthroplasty (TKA) were blindly randomized into tourniqet (n = 33) and non-tourniquet (n = 30) groups. INTERVENTION: TKA during which a pneumatic tourniquet was applied or not applied to control blood loss. MAIN OUTCOME MEASURES: Perioperative blood loss, operating time, complication rates, hospital stay and transfusion needs. RESULTS: Differences in the total measured blood loss, intraoperative blood loss and the Hemovac drainage blood loss between the 2 groups were not significantly different (p > 0.25). The calculated total blood loss was actually lower in the non-tourniquet group (p = 0.02). Between the groups there were no statistical differences in surgical time, length of hospital stay, transfusion requirements or rate of complications (although there was a trend to more complications in the tourniquet group (p = 0.06)). CONCLUSION: The effectiveness of a pneumatic tourniquet to control blood loss in TKA is questionable.     

Varicose vein surgery using a pneumatic tourniquet: reduced blood loss and improved cosmesis.

A prospective controlled randomised study has been performed of 100 consecutive patients undergoing varicose vein surgery. One group underwent saphenofemoral flush ligation and multiple lower leg avulsions with the leg exsanguinated with a Rhys-Davies cuff, and ischaemia maintained with a pneumatic tourniquet. The other group underwent identical surgery but with a 30 degree head down tilt only. Blood loss was significantly less (13.5 +/- 12 ml vs 133 +/- 78 ml; P less than 0.01) and postoperative cosmesis was significantly improved in patients in the tourniquet group. Operating time was similar (27 +/- 11 min vs 30 +/- 13 min) in the two groups.     

Dilute adrenaline infiltration and reduced blood loss in reduction mammaplasty.

The aim of this review was to assess the use of dilute adrenaline infiltration in reduction mammaplasty and to determine whether it had any associated complications. The closed technique for adrenaline infiltration was used with no reported infection. One hundred breast reductions in 50 patients were compared by dividing them into two groups of 25 patients each. Group A had 1:500,000 adrenaline in normal saline infiltration; group B did not. Both groups were matched equally for age and general health. Results showed that blood loss was less for group A when measured by the fall in postoperative hemoglobin (2.5 g per deciliter vs. 3.5 g per deciliter). This was statistically significant (p < 0.05). There was no significant difference in postoperative drainage (group A, 158 ml; group B, 182 ml). Group A required fewer blood transfusions (two vs. eight), without the risk of increased complications. Blood transfusions were given in the earlier part of the study, but currently are rarely needed. Adrenaline infiltration at this dilution is virtually free from any side effects. It decreases intraoperative blood loss and facilitates the operation without the need for blood transfusion.     

Use of patient-specific cutting blocks reduces blood loss after total knee arthroplasty

Total knee arthroplasty (TKA) is associated with substantial blood loss. Sources of bleeding are the femoral and tibial intramedullary canals, which are violated during implantation using standard instrumentation. Patient-specific instrumentation (PSI) and computer-assisted surgery (CAS) do not require violation of the intramedullary canals. Therefore, we sought to assess the impact of these methods on blood loss and transfusion requirement. A retrospective cohort study was conducted in a series of 107 consecutive primary TKAs. The first group (n = 32) was operated with standard instrumentation, the second group (n = 35) with CAS and the third group (n = 40) with PSI. A tourniquet was used in all cases. Mean (standard deviation) calculated total blood loss was 442 (160), 750 (271) and 700 (401) ml for the PSI, CAS and standard instrumentation groups, respectively (p < 0.001), with no significant differences between CAS and standard instrumentation (p = 0.799). Significant differences were found in terms of transfusion requirements, with 12.5, 42.9 and 21.8% of the patients requiring transfusion (p = 0.010). Post hoc analysis revealed that only the difference between PSI and CAS were statistically significant (p = 0.003). In conclusion, PSI reduces blood loss when compared to both CAS and standard instrumentation TKA performed with the use of a tourniquet.     

Limb blood flow in the presence of a tourniquet.

There is little accurate data on the blood flow to a limb distal to the site of application of a tourniquet. This has been studied in Rhesus monkeys with 50 mu diameter microspheres labelled with 51Cr and by the washout of 22Na injected into the tissues. One limb was exsanguinated and the circulation occluded with a pneumatic tourniquet and the opposite limb used as a control. The results show that blood flow to the occluded limb is less than 1 per cent of the flow to the control limb. It is unlikely that this relieves the ischaemia in any way as has been suggested.     

Use of a tourniquet in patients with sickle-cell disease

Fifteen patients, 13 male and two female, known to be carrying the sickle-cell gene (12 HbSS and 3 HbAS), who were undergoing operations requiring a bloodless field, were included in the study. Of the 12 with HbSS, seven had haemoglobin A, component of between 11 and 27%, three had fetal haemoglobin ranging from 5.7 to 29% and the remaining two had increased haemoglobin A₂ concentrations suggesting a beta non-thalassaemia combination. All had a tourniquet applied to the appropriate limb and were given general anaesthesia with moderate hyperventilation throughout the procedure. The tourniquet inflation time was 61.7 ± 27.5 min. The mean PaO₂ remained above 200 mmHg, mean PaCO₂ was less than 37 mmHg, and pH ranged between 7.40 and 7.45. There were no clinically important changes in BP or ECG. All patients made uneventful recoveries and none developed sickle-cell crises. It is suggested that it is safe to use tourniquet in patients with sickle-cell disease provided optimum acid-base status and oxygenation are maintained throughout the procedure.     

Prostaglandin E1 reduces blood loss during and after resection of lumbar herniated disc

Controlled hypotension was employed during resection of lumbar herniated disc on 10 patients. Prostaglandin E₁ (PG) was used as a hypotensive agent. The systolic blood pressure was lowered less than 100mmHg in the hypotensive group. The average blood loss during surgery was 95 ± 41ml for the hypotensive group compared with 154 ± 81ml for the normotensive group (P 0.05). The blood loss after surgery was also significantly less in the hypotensive group than in the normotensive group (P 0.05). We conclude that PG is an effective hypotensive agent on blood loss during and after surgery.(Kashimoto S, Nakamura T, Yamaguchi T: Prostaglandin E₁ reduces blood loss during and after resection of lumbar herniated disc. J Anesth 6: 294–296, 1992)     

Blockade of protein C activation reduces microvascular surgical blood loss.

Protein C is a natural anticoagulant glycoprotein which prevents intravascular clot formation. Protein C functions as an anticoagulant when converted to an active serine protease (activated protein C). Activated protein C is formed at the site of the endothelial injury in response to blood clotting and helps limit the size of blood clots. We tested the hypothesis that by temporarily blocking the activation of intrinsic protein C, we could reduce subsequent surgical blood loss from a microvascular surgical wound. The formation of activated protein C was blocked systemically by intravenous administration of a monoclonal antibody (HPC4) which binds to circulating protein C and prevents its conversion to activated protein C. Domestic pigs were blindly pretreated with intravenous HPC4 or saline then underwent partial-thickness skin graft harvesting to create a reproducible microvascular wound. Blood loss was measured from each wound and the hemostatic effect of protein C blockade was compared to intravenous saline alone as well as to topical thrombin or thromboplastin. We found that blocking the activation of protein C significantly (P = 0.005) reduces surgical blood loss in this model by 27% compared to saline control animals. Intravenous HPC4 performed equally as well as topical thrombin or tissue thromboplastin. In addition, topical thrombin acted synergistically with HPC4 to reduce blood loss an additional 44% (P = 0.01) as compared to intravenous HPC4 or topical thromboplastin alone. Autopsies performed 1 week after HPC4 treatment showed no evidence of systemic thrombosis resulting from the protein C blockade.(ABSTRACT TRUNCATED AT 250 WORDS)     

Methods to decrease the blood loss during operations under hypothermia without perfusion]

The work analyzes causes of high blood loss in operations under conditions of nonperfusion deep hypothermia. It was found to be related with the division of massive adhesions in the preocclusive period and with the presence of prolonged heparinemia after occlusion. A combination of a minimal trauma of adhesions, reliable surgical hemostasis, early suturing the wound of the chest and early neutralization of activity of heparin allowed the operation blood loss to be 2.4 times less and the postoperative blood loss--2.7 times less.     

Oedema of the hand after fasciectomy with or without tourniquet

Two groups of patients with Dupuytren's disease were treated by limited fasciectomy. A tourniquet was used for one group, and an elevated hand table without tourniquet for the other. Taking into account other factors controlling oedema it was discovered over a post-operative period of twenty-eight days that “Tourniquet” hands remained significantly increased in volume compared to “Non-Tourniquet” hands. Other facts of clinical interest also emerge from the trial and are discussed. It is concluded that the use of the elevated hand table without tourniquet, not only allows an unlimited and uninterrupted period for hand surgery, but also reduces the subsequent oedema.     

Amino acid infusion induces thermogenesis and reduces blood loss during hip arthroplasty under spinal anesthesia

The thermic effect of amino acids is augmented under general anesthesia and counteracts hypothermia. Mild hypothermia may increase surgical bleeding. We studied whether amino acids also induce thermogenesis under spinal anesthesia and whether this endogenous heat production reduces bleeding during hip arthroplasty. Rectal temperature, oxygen uptake, and perioperative bleeding were measured in 22 patients receiving an IV amino acid mixture (Vamin 18), 240 kJ/h) for 1 h before and then during spinal anesthesia and in 24 control patients receiving acetated Ringer's solution. Blood loss was calculated after surgery by weighing the swabs and the content of the suction tubes after subtraction of the saline used. After surgery, the closed drains were weighed after 24 h. In the amino acid group, the preanesthesia temperature increased by 0.4 degrees C +/- 0.2 degrees C (P < 0.01) and was unchanged in controls. At end of surgery, core temperature had decreased by 0.9 degrees C +/- 0.4 degrees C in controls and by 0.4 degrees C +/- 0.3 degrees C in the amino acid patients (P < 0.01). Oxygen uptake increased by 26 +/- 7 mL/min, or 16% +/- 5% (P < 0.05), from baseline in the amino acid patients, whereas it was unchanged in the controls. Blood loss during surgery was significantly larger in the control patients (702 +/- 344 mL) than in the amino acid patients (516 +/- 272 mL) (P < 0.05). After surgery, there were no significant differences in shed blood volume. In conclusion, amino acid infusion also induced a thermogenic response under spinal anesthesia. In addition, the prevention of temperature decrease during spinal anesthesia seemed to have a positive effect on intraoperative blood loss. IMPLICATIONS: Infusion of a balanced mixture of amino acids during spinal anesthesia prevented core body temperature decrease. Bleeding was also less pronounced.