A new tourniquet system that determines pressures in synchrony with systolic blood pressure in total knee arthroplasty

This study reports the comparison of the clinical use of a new tourniquet system for total knee arthroplasty that can determine its pressure in synchrony with systolic blood pressure (SBP) with the conventional that keeps the initial setting pressure. We prospectively applied the additional pressure of 100 mm Hg based on the SBP recorded before skin incision to consecutive 72 procedures (conventional, initial 36; new, following 36). Six knees with the conventional and none of 5 with the new showed oozing blood in surgical field after sharp rise in SBP. Based on no statistically significant differences of the perioperative blood loss without any tourniquet-related postoperative complications in both groups, the new system seemed to be a practical device especially for controlling a bloodless surgical field.     

The association between admission systolic blood pressure and mortality in significant traumatic brain injury: A multi-centre cohort study

Introduction

Low systolic blood pressure (SBP) is an important secondary insult following traumatic brain injury (TBI), but its exact relationship with outcome is not well characterised. Although a SBP of <90 mmHg represents the threshold for hypotension in consensus TBI treatment guidelines, recent studies suggest redefining hypotension at higher levels. This study therefore aimed to fully characterise the association between admission SBP and mortality to further inform resuscitation endpoints.

Methods

We conducted a multicentre cohort study using data from the largest European trauma registry. Consecutive adult patients with AIS head scores >2 admitted directly to specialist neuroscience centres between 2005 and July 2012 were studied. Multilevel logistic regression models were developed to examine the association between admission SBP and 30 day inpatient mortality. Models were adjusted for confounders including age, severity of injury, and to account for differential quality of hospital care.

Results

5057 patients were included in complete case analyses. Admission SBP demonstrated a smooth u-shaped association with outcome in a bivariate analysis, with increasing mortality at both lower and higher values, and no evidence of any threshold effect. Adjusting for confounding slightly attenuated the association between mortality and SBP at levels <120 mmHg, and abolished the relationship for higher SBP values. Case-mix adjusted odds of death were 1.5 times greater at <120 mmHg, doubled at <100 mmHg, tripled at <90 mmHg, and six times greater at SBP < 70 mmHg, p < 0.01.

Conclusions

These findings indicate that TBI studies should model SBP as a continuous variable and may suggest that current TBI treatment guidelines, using a cut-off for hypotension at SBP < 90 mmHg, should be reconsidered.     

Metabolic effects of a low-pressure tourniquet system compared with a high-pressure tourniquet system in arthroscopic anterior crucial ligament reconstruction

Background : Bloodless field is an integral part of orthopedic surgery. Use of tourniquet is associated with a risk of skeletal muscle ischemia and reperfusion injury. The purpose of this prospective, open-randomized study was to determine if the use of a tourniquet system using low pressure, with a wide, curved cuff connected to a microprocessor pump is safer than a standard tourniquet system with a narrow, straight cuff using higher inflation pressures.
Methods : Test parameters used as markers of muscular injury and anaerobic metabolism were femoral vein blood lactate, pH, pCO₂, pO₂, potassium, aspartate aminotransferase activity, myoglobin, creatine kinase and creatine kinase-MM activity levels after release of tourniquet. Twenty-six ASA I-II patients were studied.
Results : Tourniquet times varied between 30 and 144 min. Deflation of the tourniquet caused a significant release of lactate, myoglobin and potassium detected in the femoral vein blood. pCO₂ increased, but pH and pO₂ decreased after tourniquet deflation. There were no differences between the study groups. The tourniquet time showed a significant correlation with femoral vein lactate.
Conclusion : The main finding of this study was that the metabolic changes were more pronounced with the longer tourniquet time. The results of the study did not show any difference on metabolic markers of muscular injury during the first hour afterelease of tourniquet between the two tourniquet systems.     

Mortality rates increase dramatically below a systolic blood pressure of 105-mm Hg in septic surgical patients

Background

This study used a prospective surgical database, to investigate the level of systolic blood pressure (SBP) at which the mortality rates begin to increase in septic surgical patients.

Methods

All acute, septic general surgical patients older than 15 years of age admitted between January 2012 and January 2015 were included in these analyses.

Results

Of a total of 6,020 adult surgical patients on the database, 3,053 elective patients, 1,664 nonseptic, 52 duplicates, and 11 patients with missing SBP were excluded to leave a cohort of 1,232 acute, septic surgical patients. The median age (intraquartile range [IQR]): 48 (32 to 62) and roughly 50:50 sex ratio (620 female: 609 male). Most of the patients were African: 988 (80.2%) followed by Asians (128 or 10.4%). More than two-thirds (852 or 69.2%) of the patient cohort underwent some form of surgery, and 152 or 12.3% required intensive care unit (ICU) admission. The median length of ICU stay (IQR) was 2 (1 to 4.5) days. The median length of total hospital stay (IQR) was 4 (2 to 9) days. The median SBP (IQR) on admission was 122 (107 to 138). A total of 167 patients died (13.6%). Those that died did have a significantly lower mean SBP compared with the survivors (116 vs 125, P <. 001). Six of 10 patients (60%) with a SBP less than 70 died. The receiver operating characteristic analysis suggests an optimal SBP cut-off of 111 when predicting mortality (area under the receiver operating characteristic curve: .6 [.551, .65]). This cut-off yields a moderate sensitivity (70%), high positive predictive value (90%) but low specificity, and negative predictive value when predicting mortality. Based on this optimal cut-off, 388 or 31.5% of the patients would be classified as shocked. The inflection curve below with fitted nonlinear curve (95% confidence intervals) clearly shows the upward change in observed mortality frequency at lower systolic and base excess (ie base deficit) values. Shocked patients had a significantly higher frequency of mortality (20% vs 11%, P < .001), a significantly higher median lactate (1.9 vs 1.5, P < .001), and mean base deficit (−2.8 vs −1.0, P = .001). No significant difference in mean age, ICU admission, duration of ICU admission, and total length of hospital stay was observed by shocked status.

Conclusions

Our data suggest that patients who die have a significantly lower SBP and clinically significant hypotension in sepsis with regard to increased mortality risk begins at a level of ∼111-mm Hg. This finding needs to be incorporated into bundles of care for surgical sepsis.     

Gender influences outcomes in trauma patients with elevated systolic blood pressure

Background

This analysis explored the association between gender and systolic blood pressure (SBP) in trauma patients and then established how gender influenced outcomes in those with elevated SBP.

Methods

Demographics and outcomes were compared using the Los Angeles County Trauma System Database and multivariable modeling determined predictors for SBP, pneumonia, and mortality.

Results

Age and male sex were significant predictors for increased SBP, whereas the Injury Severity Score (ISS) ≥16 was a significant predictor for decreased SBP. In both male and female TBI patients, SBP ≥160 mmHg was associated with increased pneumonia (Adjusted odds ratio [AOR] = 1.74, P = .002 and AOR = 2.37, P = .046, respectively), whereas SBP ≥160 mmHg was a predictor for mortality only among male TBI patients (AOR = 1.48, P = .03). In non-TBI patients, SBP ≥160 mmHg was not a predictor for pneumonia or mortality in either sex.

Conclusions

In this retrospective review of trauma registry data, men presented with higher SBP. In patients with TBI, regardless of gender, increased SBP was associated with increased pneumonia, and in men with TBI increased SBP was associated with increased mortality. The cause and relevance of these epidemiological findings require further investigation.     

上肢手术气囊止血带个体充气压力的研究

目的探讨上肢手术时气囊止血带适宜的个体充气压力。方法对30例健康成年志愿者,按右上臂周径大小分为S组(≤25cm)、M组(26～30cm)和L组(＞30cm),用彩色多普勒超声血流显像仪分别测定肱动脉血流100%和50%阻断时气囊止血带充气压力值。以周径和测定值为依据确定充气压力：周径≤25cm者,充气压力为25 kPa(IkPa=7．5mm Hg),＞25cm者。以肢体周径(cm)作为个体充气压力(kPa)值,最大值≤40kPa。用上述方法应用于上肢手术150例,并观察术中创面止血效果和术后止血带副损伤发生情况。结果30例右侧肱动脉血流100%和50%阻断时气囊止血带充气压力参考值分别为：S组[(19．17±1．95)kPa,(?)±s,下同]和(11．50±1．98)kPa,M组(21．18±2．09)kPa和(13．45±1．86)kPa,L组(27．00±4．12)kPa和(16．43±1．13)kPa,各组阻断压力差异有统计学意义(P＜0．01)。手术应用150例中,上臂周径平均为(28．13±3．53)cm,气囊止血带充气压力平均为(28．19±3．03)kPa。手术应用个体充气压力,止血效果优147例,良3例,术后均无止血带副损伤。结论以上肢缚扎止血带处肢体周径(cm)作为充气压力的参考值(kPa),是上肢手术适宜的个体充气压力。     

Increased systolic daily ambulatory blood pressure in adult women born preterm

We have studied 24-h ambulatory blood pressure and kidney function in three groups of adult women: (1) born full term but with birth weights below the 3rd percentile for gestational age (n =18), (2) born preterm before gestational week 33 (median birth weight 1,250 g, range 950–2,040 g) (ex-preterm, n =14), and (3) those born full term with normal birth weights (comparison group n =17). We have previously published the results from the study. We recalculated the daily ambulatory blood pressure and redefined the time interval from 6:00–24:00 to 8:00–20:00, since this better corresponds to daily active life. We found significantly increased mean daily systolic ambulatory blood pressure in the ex-preterm group. The result supports the suggestion that disturbance and/or disruption of the normal prenatal milieu seem to affect arterial blood pressure in adult life.     

正常高值血压男性人群勃起功能调查

目的:了解正常高值血压的男性人群勃起功能障碍(ED)的患病情况。方法:2010年6～9月,本市行政、事业单位在职人员在我院进行年度健康体检中,对未发现明显器质性疾病的已婚男性,根据血压分为正常血压组、正常高值血压组两组。按参加体检的先后顺序,在两组人群中分别抽取120例男性,用勃起功能国际问卷-5调查表进行问卷调查。结果:正常高值血压的男性人群ED的患病率为25.8%。在控制了年龄、民族、职业、文化程度、经济收入、吸烟、饮酒、体育锻炼、肥胖、脂肪肝、血脂、血糖和血尿酸一系列因素后,正常高值血压组ED的患病率比正常血压组高,差异有统计学意义(25.8%vs 14.2%,P<0.05)。结论:正常高值血压的男性人群ED患病率较正常血压人群高。     

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。     

止血带的使用方式对膝关节置换术失血量和手术时间的影响

目的探讨不同止血带使用方式对全膝关节置换术中、术后失血量的影响及意义.方法 2006年5月至2009年4月行单侧全膝关节置换术的膝关节骨关节炎患者88例,排除凝血机制异常者,患者根据止血带使用方式不同分为手术开始时开始使用组和安装假体时开始使用组,手术开始时开始使用组46例,安装假体时开始使用组42例,其他操作两组相同,记录手术时间、止血带使用时间,记录术中失血量、术后引流量,计算总失血量和隐形失血量.用两独立样本t检验比较两组间的差异.结果 手术开始时开始使用组：手术时间75～140 min,平均95.9 min;止血带使用时间54～105 min,平均65.2 min.安装假体时开始使用组：手术时间85～150 min,平均98.2 min;止血带使用时间18～30 min,平均24.1 min.术中失血量：手术开始时开始使用组132～640 ml,平均251.8 ml;安装假体时开始使用组320～965 ml,平均570.5 ml,术中失血量有统计学意义（P＜0.01）.术后引流血量：手术开始时开始使用组560～1310 ml,平均630.3 ml;安装假体时开始使用组470～1 190 ml,平均576.9 ml,两组间比较有统计学意义（P＜0.05）.总失血量：手术开始时开始使用组平均1 371.7 ml,安装假体时开始使用组平均1 419.3 ml,两组比较总失血量无统计学意义（P＞0.05）.隐形失血量：手术开始时开始使用组574.7 ml,安装假体时开始使用组437.3 ml,隐形失血量比较有统计学意义（P＜0.05）.手术开始时开始使用组发生肌肉疼痛4例,神经麻痹1例,对照组未发生使用止血带发生的并发症.结论 手术开始时开始使用组可减少术中失血,提供良好的手术视野利于手术操作,但术后失血较多,尤其是隐形失血量较多,对总失血量无明显影响.止血带使用时机对手术时间无影响.     

偶测血压与动态血压在肾性高血压诊治中的临床价值

目的 探讨偶测血压与动态血压评价肾性高血压的临床价值.方法 选择97例肾性高血压患者,服用盐酸贝拉普利联合缬沙坦治疗4个月,观察治疗前、后采用偶测血压和24 h动态血压监测,并检测24 h尿蛋白、血清肌酐及肝功能进行分析.结果 9r7例患者用偶测血压与24 h动态血压监测诊断肾性高血压的符合率为73.2%;因低血压(26例)与高血钾(3例)等不同原因提前退出试验34例.余63例患者经治疗后与治疗前偶测血压和24 h动态血压监测值比较均降低;治疗前、后24 h平均收缩压、24 h平均舒张压值与动态血压值比较差异有统计学意义(P<0.01);治疗后24 h动态血压的总有效率与偶测血压比较差异也有统计学意义(P<0.05);昼夜节律比与治疗前比较明显恢复(P<0.01).结论 24 h动态血压监测与偶测血压比较更能敏感的、客观的、全面的评价肾性高血压的诊疗价值与安全性.     

A pilot randomised controlled trial of the management of systolic blood pressure during endovascular thrombectomy for acute ischaemic stroke

It is unknown whether systolic blood pressure augmentation during endovascular thrombectomy improves clinical outcomes. This pilot randomised controlled trial aimed to assess the feasibility of differential systolic blood pressure targeting during endovascular thrombectomy procedures for anterior circulation ischaemic stroke. Fifty-one eligible patients fulfilling the national criteria for endovascular thrombectomy were randomly assigned to receive either standard or augmented systolic blood pressure management from the start of anaesthesia to recanalisation of the target vessel. Systolic blood pressure targets for the standard and augmented groups were 130–150 mmHg and 160–180 mmHg, respectively. The study achieved all feasibility targets, including a recruitment rate of 3.5 participants per week and median (IQR [range]) of mean systolic blood pressure separation between groups of 139 (135–143 [115–154]) vs. 167 (150–175 [113–188]) mmHg, p < 0.001. Data completeness was 99%. Independent functional recovery at 90 days (modified Rankin Scale 0, 1 or 2) was achieved in 30 (59%) patients, which is consistent with previously published data. There were no safety concerns with trial procedures. In conclusion, a large randomised controlled efficacy trial of standard vs. augmented systolic blood pressure management during endovascular thrombectomy is feasible.     

The use of the wide-awake local anesthesia no tourniquet technique in foot and ankle injuries

PurposeAlthough the wide-awake anesthesia no tourniquet (WALANT) technique has demonstrated high efficacy, safety, patient satisfaction, and cost-effectiveness in hand surgery, there are limited data on its use in foot and ankle surgery. This study aimed to evaluate the efficacy of the WALANT technique in selected foot and ankle injuries in terms of intra- and post-operative characteristics.Material and methodsPatients with foot and ankle injuries who underwent surgery with the WALANT technique were evaluated in this retrospective study. A total of 31 patients (22 male/9 female) with a mean age of 40 ± 16 years were evaluated for the type of injury, underlying comorbidities, American Society of Anesthesiologists Classification (ASA) score, intraoperative visual analog pain (VAS) and anxiety (VAS-A) scores, duration of operation, complications, need for intensive care and duration of hospitalization.ResultsThere were 15 patients with medial malleolus fracture, 5 with lateral malleolus fracture, 5 with Achilles tendon ruptures, 2 with proximal phalangeal fracture, and 1 with Lisfranc injury, medial malleolus + syndesmotic injury, deltoid ligament + syndesmotic injury and fifth metatarsal fracture. ASA I–II score was determined in 27 patients and ASA III score in 4. The mean operation time was 36.6 ± 7 min, and the mean length of hospital stay was 8.3 ± 6.1 h. The median VAS pain score was 1 (range, 0–4), the median VAS-A score was 1 (range, 0–3) and no patient needed further anesthetics during the operation. No patient needed intensive care unit stay and no complications were observed in any patient.ConclusionThe WALANT technique was seen to provide satisfactory anxiety and pain scores, acceptable complications, and a short length of hospital stay in patients with foot and ankle injuries. Simple foot and ankle injuries can be managed successfully with this technique through adequate hemostasis without a tourniquet.Level of evidence: Level III.     

偶测血压与动态血压在肾性高血压诊治中的临床价值

目的 探讨偶测血压与动态血压评价肾性高血压的临床价值.方法 选择97例肾性高血压患者,服用盐酸贝拉普利联合缬沙坦治疗4个月,观察治疗前、后采用偶测血压和24 h动态血压监测,并检测24 h尿蛋白、血清肌酐及肝功能进行分析.结果 9r7例患者用偶测血压与24 h动态血压监测诊断肾性高血压的符合率为73.2%;因低血压(26例)与高血钾(3例)等不同原因提前退出试验34例.余63例患者经治疗后与治疗前偶测血压和24 h动态血压监测值比较均降低;治疗前、后24 h平均收缩压、24 h平均舒张压值与动态血压值比较差异有统计学意义(P<0.01);治疗后24 h动态血压的总有效率与偶测血压比较差异也有统计学意义(P<0.05);昼夜节律比与治疗前比较明显恢复(P<0.01).结论 24 h动态血压监测与偶测血压比较更能敏感的、客观的、全面的评价肾性高血压的诊疗价值与安全性.     

Blood pressure assessment in haemodialysis patients: Comparison between pre-dialysis blood pressure and ambulatory blood pressure measurement

Aim: Hypertension is common in haemodialysis (HD) patients. Determining the most appropriate method of blood pressure (BP) measurement, representative of target organ damage, is still an issue. BP variations between pre‐ and post‐HD treatment, or between on‐dialysis day and off‐dialysis day, are common. The aim of this study was to examine the possible differences between pre‐HD office BP (OBP) levels, inter‐HD (iHD) or HD day 24 h ambulatory BP measurement (ABPM) with 48 h ABPM, where the latter was considered the gold standard. Methods: 163 HD patients were studied. BP was monitored consecutively for 48 h with a Takeda TM2421 device, then sub‐analysed into two periods of 24 h: HD and iHD day. An average of 12 sessions pre‐HD OBP measurements was determined. Results: OBP significantly overestimates systolic (SBP) and diastolic BP (DBP) when compared with 48 h ABPM. SBP and DBP are significantly higher on iHD day than on HD day: 141.2 ± 20.8 versus 137.9 ± 20.9, and 77.1 ± 11.1 versus 76.1 ± 10.9 (P < 0.01). No differences of SBP night/day ratio were reported between 48 h ABPM and iHD 24 h ABPM or HD 24 h ABPM. The highest correlations were reported between 48 h SBP/DBP with iHD or HD 24 h ABPM (r² = 0.95, P < 0.001), while the lowest between 48 h SBP/DBP and OBP (r² = 0.40, P < 0.01, r² = 0.12, P < 0.01). The narrowest limits of agreement using the Bland and Altman test were reported between 48 h SBP or DBP and 24 h iHD or HD day ABPM. Considering 48 h ABPM, 80.5% of patients had BP higher than the norm, compared with 61.7% of patients in the case of OBP (χ² = 13.28, P < 0.001). The sensibility for detecting hypertension for iHD day 24 h ABPM was 98.4%, with specificity of 90%. The sensibility of 24 h HD day ABPM was 90.3%, with specificity 96.6%. In the case of OBP, sensibility and specificity were considerably lower, that is, 72.6% and 83.3% respectively. Conclusion: Significant differences are shown between OBP and 48 h ABPM in the recognition of a hypertensive state. OBP measurement has a lower sensibility and specificity than 24 h ABPM, which remains a valid alternative approach to 48 h ABPM in HD patients. Errors of OBP estimation should be taken into account, with possible negative impact on treatment strategies and epidemiology studies.     

Relationship between blood pressure during haemodialysis and ambulatory blood pressure in between dialyses

BACKGROUND.: Ambulatory blood pressure measurements in haemodialysis patientsare relevant in view of the high cardiovascular morbidity andmortality in chronic haemodialysis patients. METHODS.: Twelve normotensive patients were studied from the beginningof one dialysis until the end of the next (mean 64 h, SD 19h) using a Spacelabs oscillometric blood-pressure recorder. RESULTS.: A circadian blood pressure rhythm was present in six of the12 patients. In seven patients the lowest pressure recorded(including the dialysis sessions) occurred 5–6 h afterdialysis (late post-dialysis dip). Blood pressure did not increasesharply in the hours before dialysis although it increased slightlyin the interdialytic interval as a whole, at a mean rate of5.6 mmHg per 24 h (SD 4.1, P<0.001). We could not find ablood pressure measurement during dialysis (or combination ofmeasurements) which reliably reflects interdialytic blood pressure:the 95% confidence intervals were 25 mmHg or higher. CONCLUSION.: Ambulatory blood pressure measurements are needed for adequatemonitoring of the control of blood pressure in haemodialysispatients.     

收缩压变异率监测患者血容量变化的准确性

目的 评价收缩压变异率(SPV)监测患者血容量变化的准确性.方法 择期行体外循环下冠状动脉旁路移植术患者22例,男性17例,女性5例,年龄49 ～ 79岁,身高153 ～ 173 cm,体重55～ 89 kg,体表指数1.53 ～ 2.00 m2,ASA分级Ⅱ或Ⅲ级,采用经外周动脉压力波形分析技术监测每搏量变异率(SVV)和有创动脉波形监测更改标名后计算SPV.关胸后立即进行容量负荷试验,颈内静脉输注6％羟乙基淀粉130/0.4 50～ 80 ml/min,直至心指数(CI)增加10％时停止输注.分别于切皮前平卧位(T1)、切皮前头低30°(T1')、平卧位开胸前(T2)、开胸后(T2’)、关胸后平卧位容量负荷试验前(T3)、容量负荷试验后(T3')、缝皮后平卧位(T4)、缝皮后头低30°(T4 ')时记录HR、MAP、SPV、CI、SVV、每搏指数(SVI)、体循环血管阻力指数(SVRI)、CVP和肺毛细血管楔压(PCWP).计算T1'与T1、T2’与T2、T3'与T3 及T4'与T4时SVV的差值(△SW)和SPV的差值(△SPV),绘制△SVV和△SPV判断血容量变化的受试者工作特性曲线.结果 与T1时比较,T1'时MAP、CVP、PCWP、CI和SVRI升高,SVV和SPV降低(P＜0.05);与T2 时比较,T2' 时HR升高,CVP降低(P＜0.05);与T3时比较,T3'时MAP、CVP、PCWP和CI升高,SVV和SPV降低(P＜0.05);与T4时比较,T4'时MAP、CVP和PCWP升高,SVV和SPV降低(P＜0.05).△SVV和△SPV判断血容量变化的受试者工作特性曲线下面积分别为0.603和0.616,差异无统计学意义(P＞0.05).结论 SPV可准确地监测患者血容量变化.