Comparison of efficacy and safety of different tourniquet applications in total knee arthroplasty: a network meta-analysis of randomized controlled trials

ObjectiveTotal knee replacement (TKA) is an effective way to treat teratogenic and disabling knee diseases such as advanced osteoarthritis. Tourniquets are often used in TKA to reduce bleeding and to get a better visualization of the surgical field, while it is related to safety concerns. We did this network meta-analysis to comprehensively compare the efficacy and safety of various tourniquet application strategies.MethodPubMed, Embase, Cochrane Library, CNKI, and WanFang Database were systematically searched from January 1990 to May 2020. A network meta-analysis with a frequentist framework was done to assess the relative efficacy and safety by comparing seven clinical important endpoints.Results38 eligible studies that assessed 3007 participants who underwent TKA were included in this network meta-analysis. Tourniquet inflation before osteotomy then deflation after wound closure effectively reduce perioperative bleeding (WMD compared with control group −234.66, 95% CI [–409.19 to −60.13]), while shortening the operation time (WMD −8.98, 95%CI [–14.07 to −3.88]) and reducing postoperative complications, including DVT (OR −0.58, 95%CI [–1.19 to 0.03]) and minor wound complications (OR −1.38, 95%CI [–3.00 to 0.25]). No difference was found in the late postoperative knee pain and function outcomes.ConclusionsUsing tourniquets during the entire operation can effectively reduce blood loss, but it also can cause many safety problems, including DVTs, wound oozing, delayed healing, and serious wound complications. Tourniquet inflation before osteotomy then deflation after wound closure effectively can reduce perioperative bleeding while shortening the operation time and reducing postoperative complications, so it could be the ideal tourniquet application strategy in TKA.

Key messages

• This is the first study that comprehensively compared different tourniquet application strategies to evaluate their impact on postoperative recovery following TKA, and five clinically important endpoints were assessed in this study: perioperative blood loss, operation time, postoperative pain and function, and complications.
• We conclude that tourniquet inflation before osteotomy then deflation after wound closure could be the ideal tourniquet application strategy in TKA.

     

血管内皮活性因子在止血带诱发肺换气功能损伤中的作用及参麦注射液的干预效果

目的:观察血管内皮活性因子一氧化氮(N0)和内皮素-1( ET-1)在止血带诱发肺换气功能损伤中的作用及参麦注射液对其的干预效果.方法:选择单侧下肢手术患者(需要上止血带)26例,按单盲法随机分为对照组(C组,n=14)和参麦注射液组(SM组,n=12).于L2,3间隙行脊椎-硬膜外联合阻滞.SM组于上止血带15 min前将参麦注射液0.6 mL·kg-1加入100 mL生理盐水静脉滴注完毕,C组在相同时间内滴注等量的生理盐水.动态观察2组患者上止血带前(T0)、松止血带后30 min(T1),2 h(T2),6 h(T3),24 h(T4)5个时点血气指标及血NO和ET-1的浓度变化.结果:与T0时比较,C组T3时动脉血氧分压、血NO浓度降低,肺泡-动脉血氧分压差和血ET-1浓度升高(P＜O.05,P＜0.01);SM组T3时血NO浓度降低(P＜0.05),各时点血气指标和血ET-1浓度比较差异无统计学意义.与C组比较,SM组松止血带后的动脉血氧分压和血NO浓度降低幅度减慢,肺泡-动脉血氧分压差、血ET-1浓度升高幅度降低(P＜0.05).结论:NO和ET-1参与止血带诱发的肺换气功能损伤过程,参麦注射液有改善肺换气功能,其机制可能与参麦注射液有提高NO、降低ET-1水平有关.     

Battle Casualty Survival with Emergency Tourniquet Use to Stop Limb Bleeding

Background

In a previous study conducted at a combat support hospital in Iraq, we reported the major lifesaving benefits of emergency tourniquets to stop bleeding in major limb trauma. Morbidity associated with tourniquet use was minor.

Study Objectives

The objective of this study is to further analyze emergency tourniquet use in combat casualty care.

Design and Setting

This report is a continuation of our previous study of tourniquet use in casualties admitted to a combat support hospital (NCT00517166 at www.ClinicalTrials.gov).

Methods

After verifying comparable methodologies for the first study and the current study, we compared patient results for these two time periods and then pooled data to analyze outcomes with a larger sample size.

Results

The total study population was 499 (232 in the previous study and 267 in the current study). In all, 862 tourniquets were applied on 651 limbs. Survival was 87% for both study periods. Morbidity rates for palsies at the level of the tourniquet were 1.7% for study 1 and 1.5% for study 2; major limb shortening was 0.4% for both. Survival was associated with prehospital application (89% vs. 78% hospital, p < 0.01) and application before the onset of shock (96% vs. 4% after).

Conclusions

This study shows consistent lifesaving benefits and low risk of emergency tourniquets to stop bleeding in major limb trauma.     

止血带使用及相关损伤研究进展

应用止血带有利于控制动脉损伤出血,并在手术中提供清晰的手术视野;但止血带的使用有很多注意事项及禁忌证,止血带使用不当还会引起疼痛、肌肉损伤、麻痹、血栓、筋膜间隙综合征等并发症,甚至出现导致多脏器功能障碍、心跳骤停等严重问题。究竟止血带的应用存在哪些可能的损伤？在急救时或手术中使用止血带,其应用的原则如何？其使用的压力、时间有怎样的约束？目前尚存在争议。本文就不同情形下止血带使用的原则及方法、止血带损伤进行了综述,并提出了今后对止血带研究的建议。     

Female Genital Hair-Thread Tourniquet Syndrome: A Case Report and Literature Systematic Review

“Hair-thread tourniquet syndrome” (HTTS) describes the condition in which fibers of hair or thread wrap around an appendage (ie, toes, fingers, genital structures, tongue, uvula, and neck), eventually causing ischemia and tissue necrosis. To date, few cases of female genitalia HTTS have been described. We report a case of female genitalia HTTS in a 5-year-old girl and report the state of the art by systematically reviewing all existing evidence about female genital HTTS. A total of 29 studies, describing a total of 34 patients, were identified. The presence of a hair-thread wrapping genitalia should be suspected in prepubertal girls complaining of genital pain associated with vulvar/vaginal swelling, wide-based gait, and voiding symptoms. Genital examination disclosing an extremely tender, swollen, and erythematous lesion on the clitoris or labia minora encircled by a hair confirms the diagnosis. The aim of the management is to remove the hair-thread in the shortest time possible, with the use of forceps, scissors, or scalpels, and this is often performed under sedation/anesthesia because of the patient's pain reaction. When the hair-thread is difficult to find or when the lesion is necrotic, excision of the lesion itself can be the only option. Complications include partial or total amputation because of tissue necrosis and recurrence.     

气压止血带并发症及其护理进展

气压止血带在骨科四肢手术中普遍应用,可最大限度地制止创面出血,使手术野干净无血,有利于准确解剖和避免重要微小结构的损伤。但止血带使用不当极易造成止血带麻痹、止血带休克、止血带疼痛以及皮肤损伤等并发症的发生[1]。所潜     

止血带辅助下点式剥脱术治疗原发性大隐静脉曲张

目的探讨止血带、驱血带辅助下大隐静脉高位结扎点式剥脱术治疗大隐静脉曲张的效果。方法止血带、驱血带辅助下采用大隐静脉高位结扎点式剥脱术治疗大隐静脉曲张病人126例共156条患肢。结果单侧患肢手术时间55~90 min,平均（60±10）min;术中出血5~15 mL,平均（10±3）mL;术后6 h均能下床活动,曲张静脉全部消失;腹股沟Ⅰ类切口均一期甲级愈合,其中6条（3.8%）患肢术后当天切口有少量渗血,8条（5.1%）患肢术后出现小腿内侧皮下血肿,于3~6个月内吸收软化。10条（6.4%）患肢术后出现足靴区麻木感,均于6个月内麻木感消失。126例病人获随访110例129条患肢,随访率为87.3%。随访时间3~15个月,平均8个月,疗效满意。结论止血带、驱血带辅助下大隐静脉高位结扎点式剥脱手术操作简单,手术时间短,出血少,易于掌握,且疗效理想,值得推广。     

Preliminary uterine artery ligation versus pericervical mechanical tourniquet in reducing hemorrhage during abdominal myomectomy

Objective

To compare the effectiveness of preliminary uterine artery ligation versus pericervical mechanical tourniquet in reducing hemorrhage during myomectomy.

Methods

A total of 103 patients undergoing myomectomy were randomly allocated to undergo preliminary uterine artery ligation (52 patients) or pericervical tourniquet (51 patients). The primary outcome measure was estimated blood loss. Secondary outcomes included duration of the operation, duration of hospital stay, postoperative hemoglobin, and the need for postoperative analgesia.

Results

Operative blood loss was significantly less with uterine artery ligation compared with tourniquet (433.80 ± 285.21 vs 823.23 ± 237.33 mL, P < 0.001). The mean duration of the operation was lower in the uterine artery ligation group compared with the tourniquet group (50.5 ± 8.7 vs 76.3 ± 9.4 minutes, P < 0.001). Postoperative hospital stay was significantly shorter in the uterine artery ligation group compared with the tourniquet group (4.1 ± 0.1 vs 5.1 ± 0.2 days; P < 0.001). Postoperative hemoglobin concentrations and the need for postoperative analgesia were higher in the uterine artery ligation group (P = 0.012 and P < 0.001, respectively).

Conclusion

Uterine artery ligation was more effective than pericervical tourniquet as a preliminary step in reducing blood loss during abdominal myomectomy.     

止血带下克林霉素在兔肌肉组织中的分布特性

目的 建立高效液相色谱法测定兔肌肉组织中的克林霉素,并对止血带下肌肉组织中克林霉素的分布特征进行研究。方法 色谱条件为乙腈-四氢呋喃-磷酸盐缓冲液(30∶1∶70,pH=5)为流动相;柱温：40 ℃;流速：0.8 mL·min^-1;替硝唑为内标,Luna C₁₈柱(250 mm×4.6 mm,5 μm)进行分离,检测波长为205 nm。测定静脉注射克林霉素30,60,90,120 min后上止血带分别阻断血液循环30,60,90 min实验组与未止血对照组的肌肉组织中药物含量。结果 克林霉素在10.58~264.5 μg·mL^-1内线性关系良好,日内RSD≤2.58%,日间RSD≤4.20%。实验组克林霉素含量与对照组比较,P<0.01;相同止血时机,不同止血时间药物含量比较,P>0.05;不同止血时机(30,60,90,120 min)药物含量比较,P<0.01;给药后60 min上止血带阻断肢体血液循环,克林霉素在肌肉组织的含量最高,为39.30 µg·g^-1。结论 方法准确可靠、简便、重复性好;实验组克林霉素含量与对照组有显著性差异;围手术期预防感染,上止血带时机是影响克林霉素组织分布的主要因素,给药后60 min止血,药物可充分分布到肌肉软组织中,提高预防感染效果。