Authors: John B Holcomb, Warren C Dorlac, Brendon G Drew...

We have highlighted the issue of overuse of tourniquets and described why tourniquet conversion and replacement should be taught and done in the prehospital setting.

Topics: Tourniquets; Emergency Medical Services

PubMed: 37678162
DOI: 10.1097/TA.0000000000004134

Review

Authors: Brian A Parsons, Odunayo Kalejaiye, Mustafa Mohammed...

Tourniquets are commonly used in penile surgery to achieve a bloodless operating field or produce artificial erections intraoperatively. Several techniques have been described, but there is a paucity of data and a lack of guidelines to direct their safe use. In penile surgery, it is the local rather than systemic effects of tourniquet use that are the main concern. Tourniquet time should be kept to a minimum, as the limited data available suggests that reperfusion injury can occur even after short periods of ischaemia. High risk groups such as diabetics and arteriopaths are at particular risk. Further studies are needed to determine safe tourniquet times and pressures.

Topics: Humans; Ischemia; Male; Penis; Practice Guidelines as Topic; Reperfusion Injury; Time Factors; Tourniquets

PubMed: 23542140
DOI: 10.1038/aja.2012.164

Randomized Controlled Trial

Authors: Rachel Lefebvre, Landon Cohen, Harrison Ford Kay...

BACKGROUND

In distal upper extremity surgeries, there can be a choice to use an upper arm or forearm tourniquet. This study examines discomfort and tolerance in healthy volunteers to determine whether one is more comfortable.

METHODS

Forty healthy, study participants were randomized to an upper extremity laterality and site. Tourniquets were inflated to 100 mm Hg over systolic blood pressure. Participants experienced an upper arm and a forearm tourniquet sequentially. Visual analog scores (VAS) were recorded at 2-minute intervals. Time until request and VAS at tourniquet deflation were recorded. Time until the complete resolution of paresthesias was also recorded. Participants subjectively stated which tourniquet felt more comfortable.

RESULTS

Tourniquets were inflated longer on the forearm than the upper arm (mean 16.1 minutes versus 12.2 minutes; P < 0.0001). VAS at tourniquet removal was not different between the sites (means 7.3 and 7.3) (P = 0.839). Time until paresthesia resolution after the tourniquet was deflated was not different (means 8.1 and 7.7 minutes) (P = 0.675). Time until paresthesia resolution was proportional to tourniquet inflation time for both sites (regression coefficient 0.41; P < 0.00001). Participants found the forearm more comfortable (95% confidence interval, 0.63 to 0.92).

CONCLUSION

Forearm placement allows the tourniquet to be inflated for an average of 4 minutes longer. Forearm tourniquet is subjectively more comfortable.

Topics: Arm; Forearm; Humans; Paresthesia; Tourniquets; Upper Extremity

PubMed: 35167505
DOI: 10.5435/JAAOSGlobal-D-21-00229

Observational Study

Authors: Krithika Kamath, Surendra Umesh Kamath, Purnachandra Tejaswi...

PURPOSE

The use of tourniquet in orthopedic surgery facilitates operation by establishing a bloodless surgical field. However, many complications following the use of tourniquets have been reported. Tourniquet pain is the most common complication. This study aimed to find the actual incidence of pain associated with tourniquet use in orthopedic surgery and the various factors.

METHODS

It is a prospective observational study conducted on 132 consecutive cases. Patients aged 18-70 years with musculoskeletal problems of the forearm and leg requiring surgery were included in the study. Patients with open injuries or contraindications such as diabetes mellitus, compromised circulatory states, neurological deficit, compartment syndrome and unable to give informed consent were excluded. The parameters assessed included duration of tourniquet use, tourniquet pressure, type of anesthesia, any interval release of the tourniquet and reapplication after a reperfusion period, whether upper or lower limb surgery, severity of tourniquet pain, timing of tourniquet release and complications. Chi-square and non-parametric Mann-Whitney U test were used for data analysis.

RESULTS

In upper limb surgeries, if duration of surgery was less than 60 min, 14 (51.8%) cases experienced tourniquet pain and 13 (48.1%) had no pain, and if duration of surgery was more than 60 min, 24 (60.0%) had pain and 16 (40.0%) experienced no pain. In lower limb surgeries if duration of surgery was less than 60 min, 2 (7.7%) experienced pain and 24 (92.3%) had no pain, and if duration of surgery was more than 60 min, 14 (35.8%) experienced pain and 25 (64.8%) had no pain. Degree of tourniquet pain increases with the duration of surgery. Statistically, there was significant association between tourniquet inflation time and tourniquet pain in both upper and lower limbs (p = 0.034 and 0.024, respectively) CONCLUSION: Incidence of tourniquet pain was in direct proportion to the duration of tourniquet use and was higher in cases with regional anesthesia. Other risk factors assessed including tourniquet pressure, upper or lower limb surgery, tourniquet release time and interval had no significant contribution to the incidence or severity of tourniquet pain.

Topics: Humans; Incidence; Orthopedic Procedures; Pain; Pain Measurement; Tourniquets

PubMed: 34281783
DOI: 10.1016/j.cjtee.2021.05.002

Review

Authors: Carmen Hinojosa-Laborde, Ian L Hudson, Evan Ross...

Saving lives of wounded military warfighters often depends on the ability to resolve or mitigate the pathophysiology of hemorrhage, specifically diminished oxygen delivery to vital organs that leads to multiorgan failure and death. However, caring for hemorrhaging patients on the battlefield presents unique challenges that extend beyond applying a tourniquet and giving a blood transfusion, especially when battlefield care must be provided for a prolonged period. This review describes these challenges and potential strategies for treating hemorrhage on the battlefield in a prolonged casualty care situation.

Topics: Hemorrhage; Humans; Military Medicine; Military Personnel; Tourniquets; Warfare

PubMed: 35001653
DOI: 10.1152/physiol.00028.2021

Authors: Kenneth A Eilertsen, Morten Winberg, Elisabeth Jeppesen...

OBJECTIVES

Terrorist attacks and civilian mass-casualty events are frequent, and some countries have implemented tourniquet use for uncontrollable extremity bleeding in civilian settings. The aim of this study was to summarize current knowledge on the use of prehospital tourniquets to assess whether their use increases the survival rate in civilian patients with life-threatening hemorrhages from the extremities.

DESIGN

Systematic literature review in Medline (Ovid), Embase (Ovid), Cochrane Library, and Epistemonikos was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Guidelines. The search was performed in January 2019.

SETTING

All types of studies that examined use of tourniquets in a prehospital setting published after January 1, 2000 were included.

PRIMARY/SECONDARY OUTCOMES

The primary outcome was mortality with and without tourniquet, while adverse effects of tourniquet use were secondary outcomes.

RESULTS

Among 3,460 screened records, 55 studies were identified as relevant. The studies were highly heterogeneous with low quality of evidence. Most studies reported increased survival in the tourniquet group, but few had relevant comparators, and the survival benefit was difficult to estimate. Most studies reported a reduced need for blood transfusion, with few and mainly transient adverse effects from tourniquet use.

CONCLUSION

Despite relatively low evidence, the studies consistently suggested that the use of commercial tourniquets in a civilian setting to control life-threatening extremity hemorrhage seemed to be associated with improved survival, reduced need for blood transfusion, and few and transient adverse effects.

Topics: Emergency Medical Services; Extremities; Hemorrhage; Humans; Mass Casualty Incidents; Tourniquets

PubMed: 33138876
DOI: 10.1017/S1049023X20001284

Review

Authors: Joseph Meyerson, Yangshu L Pan, Maya Spaeth...

Ganglion cysts are the most common type of soft tissue tumors of the hand. In the pediatric population, monitoring may be appropriate unless cysts are painful, interfering with range of motion or parental concerns exist. Reported recurrence rates after surgical removal of pediatric ganglion cysts vary widely in the literature. Notably, recurrence rates are higher for children than adults, ranging from as low as 6% to as high as 35%. A retrospective review was performed of a single pediatric hand surgeon's patients undergoing excision of primary and recurrent ganglion cysts from 2010 to 2015. Variables measured included patient age at diagnosis of ganglion cyst, time to presentation, location of cyst, hand dominance, previous therapy, previous surgery, length of surgery, tourniquet time, length of follow-up, any associated complications, and recurrence of cyst. Ninety-six patients were identified with an average age of diagnosis 10.2 years. Indications for surgery: 95.8% for pain or decreased range of motion, 4.2% for cosmetic or parental concern. About 75% of the cysts were dorsally located, with the remaining 24.2% being volar. A total of 5 (5.3%) recurrences were recorded. Tourniquet time was on average 9.8 minutes longer for cases that resulted in recurrence. Multivariate analysis of the data demonstrated a 25% increased risk of recurrence with patients who had a previous aspiration. This is a retrospective review of a single pediatric hand surgeon's outcomes of pediatric wrist ganglion cysts. Our recurrence rate of 5.3% is low for a pediatric population indicating potential merit in this surgeon's operative and postoperative techniques. We demonstrate significantly increased rates of recurrence when a cyst had been previously aspirated, possibly indicating scarring and disruption of planes resulting in difficult dissection, increased tourniquet times, and incomplete excision.

Topics: Aftercare; Biopsy, Fine-Needle; Child; Female; Ganglion Cysts; Hand; Humans; Male; Operative Time; Pain; Range of Motion, Articular; Recurrence; Retrospective Studies; Soft Tissue Neoplasms; Tourniquets; Treatment Outcome; Wrist

PubMed: 29310457
DOI: 10.1177/1558944717751195

Review

Authors: Prangmalee Leurcharusmee, Passakorn Sawaddiruk, Yodying Punjasawadwong...

Ischemia and reperfusion (I/R) injury induced by tourniquet (TQ) application leads to the release of both oxygen free radicals and inflammatory cytokines. The skeletal muscle I/R may contribute to local skeletal muscle and remote organ damage affecting outcomes after total knee arthroplasty (TKA). The aim of the study is to summarize the current findings associated with I/R injury following TKA using a thigh TQ, which include cellular alterations and protective therapeutic interventions. The PubMed database was searched using the keywords "ischemia reperfusion injury," "oxidative stress," "tourniquet," and "knee arthroplasty." The search was limited to research articles published in the English language. Twenty-eight clinical studies were included in this qualitative review. Skeletal muscle I/R reduces protein synthesis, increases protein degradation, and upregulates genes in cell stress pathways. The I/R of the lower extremity elevates local and systemic oxidative stress as well as inflammatory reactions and impairs renal function. Propofol reduces oxidative injury in this I/R model. Ischemic preconditioning (IPC) and vitamin C may prevent oxygen free radical production. However, a high dose of -acetylcysteine possibly induces kidney injury. In summary, TQ-related I/R during TKA leads to muscle protein metabolism alteration, endothelial dysfunction, oxidative stress, inflammatory response, and renal function disturbance. Propofol, IPC, and vitamin C show protective effects on oxidative and inflammatory markers. However, a relationship between biochemical parameters and postoperative clinical outcomes has not been validated.

Topics: Animals; Arthroplasty, Replacement, Knee; Biomarkers; Humans; Oxidative Stress; Reperfusion Injury; Tourniquets

PubMed: 30524661
DOI: 10.1155/2018/8087598

Authors: Daniel Souza Lima, Yuri Augusto da Silva Almeida, Danielle Maria Camelo Cid...

OBJECTIVE

to present a low-cost model for bleeding control training with the use of a tourniquet and the results of the training evaluation.

METHOD

low-cost and easy-to-purchase materials, such as upholstery foam, ethylene-vinyl acetate (EVA) sheet, plastic propulsion pump, saline container, water, school paint, serum equipment, rubber tubing for tourniquet, and a leg and an arm of a ghost mannequin, were used. In the model assembly, we created an active bleeding simulation system, which could only be controlled with the correct application of the tourniquet. The model was submitted to professional and academic evaluation.

RESULTS

the model was similar to human anatomy, proved to be practical in the bleeding control training with the use of a tourniquet, and had low cost.

CONCLUSION

the model for bleeding control training had excellent acceptability, was considered viable for educational purposes of tourniquet use, and had low cost.

Topics: Adult; Equipment Design; Female; Health Personnel; Hemorrhage; Humans; Male; Simulation Training; Surveys and Questionnaires; Tourniquets

PubMed: 31967244
DOI: 10.1590/0100-6991e-20192324

Meta-Analysis

Authors: Imran Ahmed, Amit Chawla, Martin Underwood...

BACKGROUND

Many surgeons prefer to perform total knee replacement surgery with the aid of a tourniquet. A tourniquet is an occlusive device that restricts distal blood flow to help create a bloodless field during the procedure. A tourniquet may be associated with increased risk of pain and complications.

OBJECTIVES

To determine the benefits and harms of tourniquet use in knee replacement surgery.

SEARCH METHODS

We searched MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) up to 26 March 2020. We searched clinicaltrials.gov, the World Health Organization trials portal, and several international registries and joint registries up to March 2020.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing knee replacement with use of a tourniquet versus without use of a tourniquet and non-randomised studies with more than 1000 participants. Major outcomes included pain, function, global assessment of success, health-related quality of life, serious adverse events (including venous thromboembolism, infection, re-operation, and mortality), cognitive function, and survival of the implant. Minor outcomes included blood loss, economic outcomes, implant stability, and adverse events.

DATA COLLECTION AND ANALYSIS

Two review authors screened abstracts and full texts, extracted data, performed risk of bias assessments, and assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included 41 RCTs with 2819 participants. Trials included from 20 to 199 participants. Mean age ranged between 58 and 84 years. More than half of the RCTs had unclear risk of selection bias and unclear risk of performance and detection bias due to absence of blinding of participants and surgeons. Major outcomes Pain: at postoperative day 1, pain (on a scale from zero to 10, with higher scores indicating worse pain) was ranked at 4.56 points after surgery without a tourniquet and at 1.25 points (MD) higher (95% CI 0.32 higher to 2.19 higher) with a tourniquet (8 studies; 577 participants), for an absolute difference of 12.5% higher pain scores (95% CI 3.2% higher to 21.9% higher) and a relative difference of 19% higher pain scores (95% CI 3.4% higher to 49% higher) with a tourniquet. Evidence for these findings was of moderate certainty, downgraded due to risk of bias. Knee replacement with a tourniquet probably led to higher postoperative pain scores at day 1, although this difference may or may not be noticeable to patients (based on a minimal clinically important difference (MCID) of 1.0). Function: at 12 months, tourniquet use probably makes little or no difference to function, based on an MCID of 5.3 for Knee Society Score (KSS) and 5.0 for Oxford Knee Score (OKS). Mean function (on a scale from 0 to 100, with higher scores indicating better outcomes) was 90.03 points after surgery without a tourniquet and was 0.29 points worse (95% CI 1.06 worse to 0.48 better) on a 0 to 100 scale, absolute difference was 0.29% worse (1.06% worse to 0.48% better), with a tourniquet (5 studies; 611 participants). This evidence was downgraded to moderate certainty due to risk of bias. Global assessment of success: low-certainty evidence (downgraded due to bias and imprecision) indicates that tourniquet use may have little or no effect on success. At six months, 47 of 50 (or 940 per 1000) reported overall successful treatment after surgery without a tourniquet and 47 of 50 (or 940 per 1000) with a tourniquet (risk ratio (RR) 1.0, 95% CI 0.91 to 1.10) based on one study with 100 participants. Health-related quality of life: at six months, tourniquet may have little or no effect on quality of life. The 12-Item Short Form Survey (SF-12) score (mental component from zero to 100 (100 is best)) was 54.64 after surgery without a tourniquet and 1.53 (MD) better (95% CI 0.85 worse to 3.91 better) with a tourniquet (1 study; 199 participants); absolute difference was 1.53% better (0.85% worse to 3.91% better). Evidence was of low certainty, downgraded due to risk of bias and small number of participants. Serious adverse events: the risk of serious adverse events was probably higher with tourniquet; 26 of 898 (29 per 1000) reported events following surgery without a tourniquet compared to 53 of 901 (59 per 1000) with a tourniquet (RR 1.73, 95% CI 1.10 to 2.73) in 21 studies (1799 participants). Twenty-nine more per 1000 patients (95% CI 3 to 50 more per 1000 patients) had a serious adverse event with a tourniquet. Forty-eight (95% CI 20 to 345) participants would need to have surgery without a tourniquet to avoid one serious adverse event. This evidence was downgraded to moderate certainty due to risk of bias. Cognitive function: one study reported cognitive function as an outcome; however the data were incompletely reported and could not be extracted for analysis. Survival of implant: it is uncertain if tourniquet has an effect on implant survival due to very low certainty evidence (downgraded for bias, and twice due to very low event rates); 2 of 107 (19 per 1000) required revision surgery in the surgery with a tourniquet group compared to 1 of 107 (9 per 1000) without a tourniquet group at up to two years' follow-up (RR 1.44, 95% CI 0.23 to 8.92). This equates to a 0.4% (0.7% lower to 7% more) increased absolute risk in surgery with a tourniquet.

AUTHORS' CONCLUSIONS

Moderate certainty evidence shows that knee replacement surgery with a tourniquet is probably associated with an increased risk of serious adverse events. Surgery with a tourniquet is also probably associated with higher postoperative pain, although this difference may or may not be noticeable to patients. Surgery with a tourniquet does not appear to confer any clinically meaningful benefit on function, treatment success or quality of life. Further research is required to explore the effects of tourniquet use on cognitive function and implant survival, to identify any additional harms or benefits. If a tourniquet continues to be used in knee replacement surgery, patients should be informed about the potential increased risk of serious adverse events and postoperative pain.

Topics: Aged; Aged, 80 and over; Arthroplasty, Replacement, Knee; Female; Humans; Male; Middle Aged; Pain Measurement; Pain, Postoperative; Prosthesis Failure; Quality of Life; Randomized Controlled Trials as Topic; Selection Bias; Tourniquets; Treatment Outcome

PubMed: 33316105
DOI: 10.1002/14651858.CD012874.pub2