Use of a Pneumatic Tourniquet Improves Outcome Following Trans-tibial Amputation

BACKGROUND: It is traditionally taught that a pneumatic tourniquet is contraindicated for trans-tibial amputations in patients with peripheral arterial disease. However, tourniquets are used successfully during total knee arthroplasty in elderly patients. Vascular patients undergoing a trans-tibial amputation have a high perioperative mortality and morbidity-notably the need for wound revision or a higher amputation level. We hypothesised that a tourniquet, used during amputation, would reduce blood loss and subsequent complications without compromising healing. METHODS: This was a prospective non-randomized study of 89 adult patients who underwent a trans-tibial amputation between January 2001 and December 2003. The endpoints were: haemoglobin levels, the need for blood transfusion, perioperative morbidity, revision rate and mortality. Patients were divided into two groups: a group with a pneumatic tourniquet (n=42) and a group without (n=47). RESULTS: The haemoglobin fall was 14.8% in the non-tourniquet group and 5.6% in the tourniquet group, with a higher need for transfusion in the non-tourniquet group. The revision rate was 14.3% in the tourniquet group and significantly higher in the non-tourniquet group (38.3%). Mortality was similar in both groups: 7.1% for the tourniquet and 6.4% for the non-tourniquet group. CONCLUSION: The use of a pneumatic tourniquet is safe and significantly reduces both blood loss and transfusion requirements during trans-tibial amputation. A pneumatic tourniquet reduces revision rates by over 50%, with subsequent cost savings.     

Pathology study of rabbit calf muscles after repeated compression

To elucidate the pathogenesis of chronic compartment syndrome, we examined pathological changes in the soleus (red) and extensor digitorum longus (EDL; white) muscles in Japanese white rabbits after repeated compression with a pneumatic tourniquet. Repeated tourniquet compression via cuff inflation was carried out on the rabbits, calves daily, for 2 h, then stopped for 30 min, and then applied for another 2 h. The contralateral hindlimb, which was not compressed, served as a control. Animals were allocated to 15 groups, with pressures of 40, 80, and 120 mmHg for periods of 1 day, 3 days, 1 week, 2 weeks, and 4 weeks. Skeletal muscle specimens in each group were studied by histopathological and histochemical (ATPase) methods. After compression for 1 day, regardless of pressure, and compression for 3 days in the 40-mmHg pressure group, edematous changes in regions with mild inflammation and increases in fiber diameter were observed in the muscles. After compression for 3 days in the 80- and 120-mmHg pressure groups, and after 1, 2, or 4 weeks in the 40-mmHg pressure group, a few necrotic fibers and scattered fibers with some mononuclear cell infiltrates indicative of early-stage necrosis were detected. In the groups with 80 or 120 mmHg pressure for 1, 2, or 4 weeks, muscle fibers exhibited marked degenerative changes, which were more pronounced in the 120-mmHg group than in the 80-mmHg group. The pathological changes were more pronounced in the soleus than in the EDL muscles, indicating that these two muscles differed in sensitivity to repeated compression. Additionally, average muscle wet weight and average fiber diameter for both types of muscle were increased in the 1-day and 3-day compression groups and decreased in the 1-week, 2-week, and 4-week compression groups. These findings clearly differ from those of previously reported single-compression experiments. Our findings indicate that repeated compression may cause serious muscle degeneration, particularly in red muscles. Received for publication on Oct. 22, 1997; accepted on Feb. 26, 1998     

Induction of nerve growth factor mRNA in a rat dorsal root ganglion after application of a tourniquet

We investigated the mRNA levels of neurotrophins and neurotrophin receptors in a rat dorsal root ganglion (DRG), after tourniquet application to a hind limb, to identify the nerve-protective molecules that are induced immediately after peripheral nerve crush and play a part in the process leading to secondary events. No significant expression of nerve growth factor (NGF) mRNA or protein was observed in the control or contralateral DRG. NGF mRNA expression started within 2 h and NGF protein expression was observed in Schwann cells at 4 h after application of the tourniquet, due to termination of the neurotrophin supply from peripheral nerves. The levels of neurotrophin 3 mRNA were significantly increased in the DRGs on both sides at 1 and 2 h after tourniquet application, but no significant changes in brain-derived neurotrophic factor and neurotrophin 4/5 expression levels were observed in either the contralateral or ipsilateral DRG. The expression levels of neurotrophin receptors in the DRGs on both the contralateral and ipsilateral sides had decreased at 1 to 2 h after application of the tourniquet and had returned to the control levels at 4 h after tourniquet application.     

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 μ 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.     

在充盈不佳血管中止血带对套管针穿刺的影响

对７６ 例接受套管针输液、外周静脉充盈不佳的患者进行了止血带影响套管针穿刺一针见血率与送管成功率的研究。观察组３５ 例采用分次扎止血带穿刺和送管后松止血带,与对照组４１ 例传统方法一次扎止血带穿刺和送管前松止血带进行了对照比较,结果表明：２ 组扎止血带法穿刺一针见血率相差显著（ Ｐ＜０ ．０５） ;２ 组松止血带法送管成功率有显著性差异（ Ｐ＜０ ．０１）。说明利用套管针在静脉充盈不佳血管穿刺时,行分次扎止血带和送管后松止血带可以提高穿刺成功率。     

黄金万红膏预防气压止血带受压部位皮肤损伤75例临床观察

目的:观察涂擦中药制剂黄金万红膏预防气压止血带受压部位皮肤损伤的效果。方法:将150例四肢手术患者随机分为实验组和对照组,两组各75例,观察组患者涂擦黄金万红膏加石膏棉纸衬垫后上气压止血带,实验组患者未加其他任何干预措施,最后比较两组患者发生皮肤损伤情况。结果:实验组和对照组术后10分钟皮肤评分有统计学差异(P0.01),实验组和对照组术后1小时皮肤评分有统计学差异(P0.01)。结论:涂黄金万红膏后上气压止血带,可减少患者皮肤损伤的发生,减轻病人的痛苦,有利于术后的康复。     

Carpal Tunnel Release With Wide Awake Local Anesthesia and No Tourniquet: With Versus Without Epinephrine

Background: Wide awake local anesthesia and no tourniquet (WALANT) relies on epinephrine to create a relatively bloodless field. This study evaluated the effect of epinephrine on carpal tunnel release (CTR) surgical time and bleeding, including the need for use of a tourniquet or electrocautery. The hypothesis was that wide awake anesthesia without epinephrine is a viable option for CTR but increases operative time. Methods: Records of all patients who underwent CTR under wide awake anesthesia between October 2017 and September 2018 were reviewed. The injection consisted of either 10 cc of 1% lidocaine with 1:100,000 epinephrine mixed with 1 cc of sodium bicarbonate (8.4%) (WALANT group) or 10 cc of 1% lidocaine (wide awake local anesthesia, no tourniquet and no epinephrine [WALANE] group). The time between skin incision and skin closure was calculated. Tourniquet and electrocautery use as well as operative complications were documented. Results: Thirty-two patients underwent 43 CTRs; 22 CTRs were done under WALANT, and 21 CTRs were done under WALANE. The skin-skin time was 12.8 minute (6-25 minute; standard deviation [SD] = 4.7) for WALANT and 17.4 minute (9-30 minute; SD = 5.8) for WALANE. There was a significant statistical difference (36%) in skin-skin time between the 2 groups. None of the patients required electrocautery or a tourniquet. There were no operative complications. Conclusion: Operative time increased by 36% when epinephrine was not used. Epinephrine is not an absolute necessity to perform wide awake anesthesia but, at the same time, has the added value of decreasing surgical time. Level of evidence: IV     

Risk factors for acute nerve injury after total knee arthroplasty

Introduction: In this we study identified potential risk factors for post?total knee arthroplasty (TKA) nerve injury, a catastrophic complication with a reported incidence of 0.3%?1.3%. Methods: Patients who developed post‐TKA nerve injury from 1998 to 2013 were identified, and each was matched with 2 controls. A multivariable logistic regression model was built to calculate odds ratios (ORs). Results: Sixty‐five nerve injury cases were identified in 39,990 TKAs (0.16%). Females (OR 3.28, P = 0.003) and patients with history of lumbar pathology (OR 6.12, P = 0.026) were associated with increased risk of nerve injury. Tourniquet pressure < 300 mm Hg and longer duration of anesthesia may also be risk factors. Discussion: Surgical planning for females and patients with lumbar pathology should be modified to mitigate their higher risk of neurologic complications after TKA. Our finding that lower tourniquet pressure was associated with higher risk of nerve injury was unexpected and requires further investigation. Muscle Nerve 57 : 946–950, 2018     

Hair tourniquet syndrome of toes and fingers in infants

ObjectiveHair tourniquet syndrome is an uncommon condition characterized by strangulation appendages by a hair or thread. The aim of this study was to evaluate the results of hair removal and antibiotic therapy in our patients with hair tourniquet syndrome.MethodsBetween January 2012 and August 2018, 16 patients (8 boys, 8 girls; mean age: 118.5 [range: 20 to 380] days) were treated surgically for hair tourniquet syndrome. All patients were treated surgically under local or general anesthesia in the pediatric emergency department or in the operating theater using magnifying loupes. The age, gender, affected fingers or toes and the affected sides of the patients and the duration of symptoms until presentation were recorded.ResultsA total of 24 toes and fingers were treated for hair tourniquet syndrome. The right side was affected in 12 patients, the left side was affected in three, and both sides in one. The second toe was affected in three patients, the third toe in eleven, the fourth in six, and the fifth in two patients. Both the thumb and the second finger were affected in one patient. The average duration of the symptoms (excessive crying, swelling, redness) was 1.5 (range: 1 to 2) days. All patients healed without any complications.ConclusionHair tourniquet syndrome should be kept in mind as an etiology in infants with toe and finger strangulation. These patients should be examined undressed. Immediate removal of hair is an effective treatment method to save appendage.Level of evidenceLevel IV, Therapeutic Study     

Preventing the Collapse of a Peripheral Vein During Cannulation: An Evaluation of Various Tourniquet Techniques on Vein Compressibility

Background

Venous access can occasionally be difficult to obtain secondary to near-complete compressibility of peripheral veins in some patients.

Objective

This study utilizes ultrasound to assess vein compressibility with different tourniquet techniques commonly available in the emergency department.

Methods

After approval by the Institutional Review Board, a prospective single-center study was conducted assessing the compressibility of basilic veins with ultrasound. Compressibility was assessed at baseline, use of one proximal tourniquet, two tourniquets (one distal and one proximal), and a proximal blood pressure cuff inflated to 150 mm Hg. Vein compressibility was rated as complete, moderate, or mild after light pressure was applied with the ultrasound probe.

Results

One hundred healthy patients were recruited into the study. Ninety-eight subjects had completely compressible basilic veins at baseline. When one tourniquet and two tourniquets were applied, 62 and 31 participants, respectively, demonstrated completely compressible veins. Fisher's exact test comparing one vs. two tourniquets revealed no difference between these two techniques (p = 0.4614). Only two participants continued to have a completely compressible vein after application of the blood pressure cuff with statistical significance by Fisher's exact test compared to both tourniquet groups (p < 0.0001).

Conclusions

Both tourniquets and blood pressure cuffs can decrease the compressibility of peripheral veins. Although no difference was identified between one and two tourniquets, utilization of blood pressure cuffs significantly decreased compressibility. The findings of this study can be utilized in the emergency department when attempting to obtain peripheral venous access, specifically supporting the use of blood pressure cuffs to decrease compressibility.