RESUMEN
Importance: Prophylactic administration of antibiotics before skin incision is an important component in the prevention of periprosthetic joint infection in arthroplasty surgery. For antibiotics to be effective, the local tissue concentration (LTC) must exceed the minimum inhibitory concentration of typical infecting organisms; however, the LTC of cefazolin during arthroplasty is poorly understood. Objective: To compare the systemic concentration of cefazolin in serum with the LTC in fat, synovium, and bone during primary total knee arthroplasty (TKA) while assessing the effect of tourniquet inflation. Design, Setting, and Participants: This prospective randomized clinical trial was conducted from March 1, 2022, to June 30, 2023, in patients undergoing TKA at a single academic center. Intervention: Total knee arthroplasty with or without a limb tourniquet. Main Outcomes and Measures: Systemic blood and local tissues from the surgical site (fat, synovium, and bone) were harvested at regular intervals during the surgery. The primary outcome was the LTC of cefazolin, quantified using the liquid chromatography-tandem mass spectrometry technique. Results: A total of 59 patients were included in the study, with 29 in the tourniquet group (mean [SD] age, 69.3 [9.6] years; 23 [79.3%] female) and 30 in the no tourniquet group (mean [SD] age, 69.9 [9.7] years; 21 [70.0%] female). In patients undergoing TKA without a tourniquet, the mean concentration of cefazolin in serum was 71.9 µg/mL (95% CI, 66.4-77.5 µg/mL), whereas the mean LTCs were 13.9 µg/g (95% CI, 12.1-15.7 µg/g) in fat, 27.7 µg/g (95% CI, 24.3-31.0 µg/g) in synovium, and 17.7 µg/g (95% CI, 14.8-20.5 µg/g) in bone. For patients undergoing TKA with a tourniquet, the mean concentration of cefazolin in serum was 72.0 µg/mL (95% CI, 66.3-77.7 µg/mL), and the mean LTCs were 9.9 µg/g (95% CI, 8.7-11.1 µg/g) in fat, 21.8 µg/g (95% CI, 18.7-25.0 µg/g) in synovium, and 13.0 µg/g (95% CI, 10.8-15.2 µg/g) in bone. The use of a tourniquet resulted in significantly lower mean LTCs by 60 minutes after cefazolin infusion (10.8 µg/g [95% CI, 9.1-12.4 µg/g] vs 16.9 µg/g [95% CI, 14.1-19.6 µg/g], P = .001 in fat; 18.9 µg/g [95% CI, 14.1-23.6 µg/g] vs 25.8 µg/g [95% CI, 21.4-30.3 µg/g], P = .03 in synovium; and 11.8 µg/g [95% CI, 9.3-14.2 µg/g] vs 19.4 µg/g [95% CI, 14.5-24.4 µg/g], P = .007 in bone). Conclusions and Relevance: In this randomized clinical trial, the concentration of cefazolin was lower in local tissues (fat, synovium, and bone) than in systemic blood, and the use of a limb tourniquet further significantly reduced these concentrations. Although the current prophylactic dosing regimen for cefazolin provides sufficient serum concentrations, the levels in the periarticular tissue during TKA may be insufficient to prevent periprosthetic joint infection. Trial Registration: ClinicalTrials.gov Identifier: NCT05604157.
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Antibacterianos , Artroplastia de Reemplazo de Rodilla , Cefazolina , Torniquetes , Humanos , Cefazolina/farmacocinética , Cefazolina/administración & dosificación , Cefazolina/sangre , Femenino , Masculino , Anciano , Antibacterianos/administración & dosificación , Antibacterianos/farmacocinética , Antibacterianos/análisis , Antibacterianos/uso terapéutico , Persona de Mediana Edad , Estudios Prospectivos , Infecciones Relacionadas con Prótesis/prevención & control , Profilaxis Antibiótica/métodos , Infección de la Herida Quirúrgica/prevención & controlRESUMEN
OBJECTIVE: Increasingly, medical schools integrate clinical skills into early didactic coursework. The Stop the Bleed® Campaign emphasizes prehospital hemorrhage control to reduce preventable deaths; however, this course overlooks team interactions. We assessed the impact of high-fidelity simulation during medical student orientation on identification and treatment of life-threatening hemorrhage in a team setting. DESIGN: In this mixed method, prospective pre-, post-, and follow-up survey analysis assessing student knowledge and attitudes, student teams encountered a standardized patient in a prehospital environment with pulsatile bleeding from an extremity wound. Individual students completed surveys assessing previous experience, willingness and ability to assist bleeding person(s), and knowledge and attitudes about tourniquets. Postscenario, faculty preceptors made qualitative observations on teamwork. SETTING: Medical student orientation at a tertiary care academic medical center with long-term follow-up. PARTICIPANTS: Medical students (Nâ¯=â¯150). RESULTS: Ninety students (60%) completed both pre- and postsimulation questionnaires. Sixteen (17%) students had previous tourniquet training experience although none had applied a tourniquet outside of training. Postsimulation, students reported increased likelihood of providing treatment until additional help arrived (pâ¯=â¯0.035), improved ability to identify life-threatening hemorrhage (p < 0.001), and more favorable opinions about tourniquet use (p < 0.001) and potential for limb-salvage (pâ¯=â¯0.018). Long-term follow-up respondents (nâ¯=â¯34, 23%) reported increased ability to identify life-threatening hemorrhage (pâ¯=â¯0.010) and universal willingness to intervene until additional help arrived. Follow-up survey responses elicited themes in hemorrhage control including recognition of the importance of continuous pressure, appropriate use of tourniquets, a desire for repeated team training, and the recognition of clerkship rotations as an optimal setting for skill reinforcement. Preceptors noted variable team responses but uniformly endorsed the exercise. CONCLUSIONS: High-fidelity bleeding simulation during medical student orientation improved students' knowledge and attitudes about treating life-threatening hemorrhage and served as an introduction to team-based emergency care. Future studies should further explore team training and hemorrhage control education.
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Competencia Clínica , Educación de Pregrado en Medicina , Hemorragia , Humanos , Hemorragia/terapia , Hemorragia/prevención & control , Estudios Prospectivos , Educación de Pregrado en Medicina/métodos , Femenino , Masculino , Estudios de Seguimiento , Autoinforme , Torniquetes , Enseñanza Mediante Simulación de Alta Fidelidad/métodos , Estudiantes de MedicinaRESUMEN
Aims: Pneumatic tourniquets are often used during the surgical treatment of unstable traumatic ankle fractures. The aim of this study was to assess the risk of reoperation after open reduction and internal fixation of ankle fractures with and without the use of pneumatic tourniquets. Methods: This was a population-based cohort study using data from the Danish Fracture Database with a follow-up period of 24 months. Data were linked to the Danish National Patient Registry to ensure complete information regarding reoperations due to complications, which were divided into major and minor. The relative risk of reoperations for the tourniquet group compared with the non-tourniquet group was estimated using Cox proportional hazards modelling. Results: A total of 4,050 ankle fractures treated with open reduction and internal fixation between 15 March 2012 and 31 December 2016 were included, with 669 (16.5%) undergoing surgery with a tourniquet and 3,381 (83.5%) without a tourniquet. The overall reoperation risk was 28.2% with an adjusted relative risk of 1.46 (95% CI 0.91 to 2.32) for group comparison. The reoperation risk due to major complications was 3.1% with a tourniquet and 4.4% without a tourniquet, resulting in an adjusted relative risk of 1.45 (95% CI 0.91 to 2.32). For minor complications, there were 24.7% and 23.9% reoperations, resulting in an adjusted relative risk of 0.99 (95% CI 0.84 to 1.17). Conclusion: We found no significant difference in the reoperation rate when comparing ankle fractures treated surgically with and without the use of pneumatic tourniquets.
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Fracturas de Tobillo , Fijación Interna de Fracturas , Reoperación , Torniquetes , Humanos , Reoperación/estadística & datos numéricos , Fracturas de Tobillo/cirugía , Masculino , Femenino , Persona de Mediana Edad , Fijación Interna de Fracturas/métodos , Fijación Interna de Fracturas/efectos adversos , Adulto , Anciano , Dinamarca/epidemiología , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Reducción Abierta/métodos , Sistema de Registros , Adulto Joven , AdolescenteRESUMEN
BACKGROUND: Excessive intraoperative bleeding remains a challenge in limb surgeries. The exsanguination tourniquet ring has emerged as a potential solution for effective exsanguination and hemostasis. This study aims to evaluate its efficacy and safety compared to the conventional exsanguination and hemostasis approach (pneumatic tourniquet combined with Esmarch bandage). METHODS: This randomized controlled trial evaluates the exsanguination tourniquet ring's effectiveness and safety versus the conventional approach in 220 participants undergoing various limb surgeries. Allocation included experimental and control groups, assesses through efficacy (including intraoperative and total blood loss, hemoglobin levels, and exsanguination and hemostasis effectiveness) and safety (adverse event occurrence) indicators. RESULTS: The experimental group (n = 110) utilizes the exsanguination tourniquet ring, while the control group (n = 110) employs the conventional approach. As for intraoperative blood loss, the experimental group is non-inferior to the control group (p-value < 0.001). While no significant difference is found in total blood loss (for the full analysis set, p-value = 0.442; for the per protocol set, p-value = 0.976) and differences in postoperative and preoperative hemoglobin levels (for the full analysis set, p-value = 0.502; for the per protocol set, p-value = 0.928). Regarding exsanguination and hemostasis effectiveness, the full analysis set reveals significantly superior ratings in the experimental group compared to the control group (p-value = 0.002 < 0.05), while the per protocol set analysis indicates no significant difference between the groups (p-value = 0.504). As for safety indicators, adverse events related to the device are minimal in two groups, with only one severe event unrelated to the device. CONCLUSIONS: The exsanguination tourniquet ring is an effective and safe device for intraoperative blood loss control in various limb surgeries. TRIAL REGISTRATION: Comparison of Exsanguination and Hemostasis Devices for Limb Surgery A Prospective Multicenter Randomized Controlled Study, ChiCTR2300077998, 11/27/2023.
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Pérdida de Sangre Quirúrgica , Exsanguinación , Torniquetes , Humanos , Femenino , Masculino , Persona de Mediana Edad , Pérdida de Sangre Quirúrgica/prevención & control , Torniquetes/efectos adversos , Adulto , Exsanguinación/etiología , Extremidades/cirugía , Hemostasis Quirúrgica/instrumentación , Hemostasis Quirúrgica/métodos , Anciano , Resultado del Tratamiento , Estudios ProspectivosRESUMEN
BACKGROUND: Post-ischemia reperfusion can lead to oxidative stress and an increase in oxidative markers. Employing preventive strategies and antioxidant agents may help mitigate ischemia-reperfusion injury (IRI). The use of a tourniquet in extremity surgery has been associated with IRI. This study aims to investigate the impact of three different approaches- brachial plexus block, total intravenous anesthesia (TIVA), and inhalation anesthesia-on IRI during upper extremity surgery using a tourniquet. METHODS: Patients aged 18 to 45 with American Society of Anesthesiologists (ASA) I-II scores were randomly assigned to one of three groups: Group A received an axillary block with bupivacaine; Group I underwent inhalation anesthesia with sevoflurane; and Group T received TIVA with propofol and remifentanil infusion. Blood samples were collected to measure glucose, lactate, total anti-oxidant status (TAS), total oxidant status (TOS), and ischemia-modified albumin (IMA) levels at various time points: before anesthesia (t1), 1 minute before tourniquet release (t2), 20 minutes after tourniquet release (t3), and 4 hours after tourniquet release (t4). RESULTS: In Group I, lactate levels at t3, and glucose levels at t2 and t3, were higher compared to the other groups. Group A exhibited lower IMA levels at t2, t3, and t4 than the other groups. Additionally, Group I had lower IMA levels at t2, t3, and t4 compared to Group T. TAS levels were higher in Group I at t2, t3, and t4 compared to the other groups. TOS levels at t2 and t3 were lower in Group A than in Group I. CONCLUSION: Axillary anesthesia results in a sympathetic block, promoting better perfusion of the upper extremity. This study demonstrated lower levels of oxidative stress markers with axillary plexus block. Therefore, these results suggest that the axillary block has the potential to mitigate IRI.
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Anestesia Intravenosa , Bloqueo del Plexo Braquial , Propofol , Daño por Reperfusión , Sevoflurano , Torniquetes , Extremidad Superior , Humanos , Daño por Reperfusión/prevención & control , Daño por Reperfusión/etiología , Adulto , Masculino , Femenino , Anestesia Intravenosa/métodos , Bloqueo del Plexo Braquial/métodos , Persona de Mediana Edad , Extremidad Superior/irrigación sanguínea , Extremidad Superior/cirugía , Sevoflurano/administración & dosificación , Adulto Joven , Propofol/administración & dosificación , Adolescente , Anestesia por Inhalación/métodos , Anestésicos por Inhalación/administración & dosificación , Bupivacaína/administración & dosificación , Remifentanilo/administración & dosificación , Éteres Metílicos/administración & dosificación , Anestésicos Locales/administración & dosificación , Estrés Oxidativo/efectos de los fármacos , Anestésicos Intravenosos/administración & dosificación , Piperidinas/administración & dosificaciónRESUMEN
OBJECTIVE: Pneumatic tourniquets are among the most essential equipment for controlling bleeding in orthopedic surgeries. However, incorrect application of pneumatic tourniquets is accompanied by many hazards and complications for patients. Evaluation of surgical teams' use of pneumatic tourniquets and establishment of protocols can play an important role in improving patient safety, minimizing risks, and increasing the lifetime of this equipment. Accordingly, the present study was conducted to develop and assess the psychometric properties of a pneumatic tourniquet work standards scale. METHODS: The present study is a methodological work carried out in two stages. In the first stage, an initial version of the scale was developed based on existing research and panel reviews. In the second stage, the psychometric properties of the scale were tested in terms of face validity (measured qualitatively and quantitatively), content validity (measured qualitatively and quantitatively), item analysis, construct validity, and reliability (internal consistency and stability). RESULTS: The initial version of the scale consisted of 91 items. After several meetings of the research team, the number of items decreased to 81. In the course of face and content validity testing, 40 items were eliminated, leaving 41 items on the scale when it entered the construct validity testing stage. For evaluation of construct validity, a sample of 300 operating room nurses was recruited. The Exploratory Factor Analysis (EFA) results showed a structure supported by seven factors and 41 items. The reliability of the scale was confirmed by internal consistency analysis, with a good Cronbach's alpha (0.85), and test-retest analysis, with good values of ICC (0.95). CONCLUSION: The present instrument is a reliable and valid scale which fills the gap in assessment of surgical team members' use of pneumatic tourniquets. The developed scale can be employed by researchers and managers of medical centers to identify hazards in applying pneumatic tourniquets and devise educational programs to eliminate or reduce the existing issues.
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Psicometría , Torniquetes , Humanos , Femenino , Masculino , Adulto , Reproducibilidad de los Resultados , Procedimientos Ortopédicos , Persona de Mediana Edad , Encuestas y Cuestionarios , Adulto JovenRESUMEN
INTRODUCTION: Pneumatic tourniquets (PTs) play a crucial role in hemostasis during orthopedic surgery. This study aimed to investigate the current knowledge, attitudes, and practices (KAP) of orthopedic operating room personnel concerning the use of PTs. METHODS: This cross-sectional study was conducted from Jul. 2023 to Aug. 2023. An online questionnaire was used to collect demographic information and KAP score data of the orthopedic operating room personnel from Hangzhou Regional Hospitals. RESULTS: A total of 336 participants included orthopedic physicians (37.8%), orthopedic nurses (31.5%), anesthesiologists (8.9%), operating room nurses (19.9%) and medical students (1.8%). The median knowledge score was 28.5 (24, 32), with a maximum score of 38; the median attitude score was 31 (28, 35), of a maximum of 35; the median practice score was 41 (36, 44), of a maximum of 45. Correlation analysis showed links between knowledge and attitude (r = 0.388, p<0.001), knowledge and practice (r = 0.401, p<0.001), and attitude and practice (r = 0.485, p<0.001). Multivariate logistic regression analysis confirmed that female gender (OR = 0.294, 95% CI: 0.167-0.520; p<0.001), working in a specialized hospital (OR = 0.420, 95% CI: 0.219-0.803; p = 0.009), and occupation as a surgical anesthesiologist (OR = 3.358, 95% CI: 1.466-7.694; p = 0.004) were associated with better knowledge scores. A higher educational degree (OR = 0.237, 95% CI: 0.093-0.608; p = 0.003) was associated with better practice scores. No previous training was associated with lower knowledge (OR = 0.312, 95% CI: 0.187-0.520; p<0.001) and practice (OR = 0.325, 95% CI: 0.203-0.521; p<0.001) scores. CONCLUSION: Orthopedic personnel in this study had acceptable knowledge, attitude, and practice concerning the use of PTs; additional training and guidance might enhance proficiency.
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Conocimientos, Actitudes y Práctica en Salud , Quirófanos , Torniquetes , Humanos , Femenino , Masculino , Adulto , Estudios Transversales , Encuestas y Cuestionarios , Procedimientos Ortopédicos , Anestesiólogos/psicología , Persona de Mediana Edad , Estudiantes de Medicina/psicología , Actitud del Personal de SaludRESUMEN
BACKGROUND: Extremity tourniquets have proven to be lifesaving in both civilian and military settings and should continue to be used by first responders for trauma patients with life-threatening extremity bleeding. This is especially true in combat scenarios in which both the casualty and the first responder may be confronted by the imminent threat of death from hostile fire as the extremity hemorrhage is being treated. Not every extremity wound, however, needs a tourniquet. One of the most important aspects of controlling life-threatening extremity bleeding with tourniquets is to recognize what magnitude of bleeding requires this intervention and what magnitude of bleeding does not. Multiple studies, both military and civilian, have shown that tourniquets are often applied when they are not medically indicated. Overuse of extremity tourniquets has not caused excess morbidity in either the recent conflicts in Iraq and Afghanistan or in the US urban civilian setting. In the presence of prolonged evacuation, however, applying a tourniquet when it is not medically indicated changes tourniquet application from being a lifesaving intervention to one that may cause an avoidable amputation and the development of an array of metabolic derangements and acute kidney injury collectively called prolonged tourniquet application syndrome. METHODS: The recent literature was reviewed for papers that documented the complications of tourniquet use resulting from the prolonged casualty evacuation times being seen in the current Russo-Ukrainian war. The literature was also reviewed for the incidence of tourniquet application that was found to not be medically indicated, in both the US civilian setting and from Ukraine. Finally, an in-person meeting of the US/Ukraine Tourniquet Working Group was held in Warsaw, Poland, in December of 2023. RESULTS: Unnecessary loss of extremities and life-threatening episodes of prolonged tourniquet application syndrome are currently occurring in Ukrainian combat forces because of nonindicated tourniquet use combined with the prolonged evacuation time seen in the Russo-Ukrainian war. Specific numbers of the complications experienced as a result of tourniquet use by Ukrainian forces in the current conflict are treated as classified information and are not available, but multiple sources from the Ukrainian military medical personnel and from the US advisors providing medical assistance to Ukraine have all agreed that the problem is substantial. CONCLUSION: Unnecessary tourniquet morbidity might also occur in US forces in a variety of potential future combat scenarios in which evacuation to surgical care is delayed. Prehospital trauma training programs, including but not limited to tactical combat casualty care, place insufficient emphasis on the need to avoid leaving tourniquets in place when they are not medically indicated. This aspect of training should receive emphasis in future Tactical Combat Casualty Care (TCCC) and civilian first responder curriculum development. An interim ad hoc training solution on this topic is available at the websites noted in this articles. Additional training modalities may follow in the near future. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level V.
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Hemorragia , Torniquetes , Humanos , Hemorragia/terapia , Hemorragia/etiología , Ucrania , Heridas Relacionadas con la Guerra/terapia , Guerra , Medicina Militar , Extremidades/irrigación sanguínea , Extremidades/lesionesRESUMEN
INTRODUCTION: Ultrasound is used for peripheral intravenous (PIV) cannulation in patients with difficult landmark-guided IV access in the Emergency Department. Distal-to-proximal application of an Esmarch bandage on the target limb has been suggested as a method for increasing vein size and ease of cannulation. METHODS: This study was a single-blinded crossover randomized controlled trial comparing basilic vein size under ultrasound with use of an Esmarch bandage in addition to standard IV tourniquet ("tourniquet + Esmarch") compared to use of a standard IV tourniquet alone. Participant discomfort with the tourniquet + Esmarch was also compared to that with standard IV tourniquet alone. RESULTS: Twenty-two healthy volunteers were used to measure basilic vein size with and without the Esmarch bandage. There was no difference in basilic vein size between the two groups, with a mean diameter of 6.0 ± 1.5 mm in the tourniquet + Esmarch group and 6.0 ± 1.4 mm in the control group, p = 0.89. Discomfort score (from 0 to 10) was different between the groups, with a mean discomfort score of 2.1 in the tourniquet + Esmarch group and 1.1 in the standard IV tourniquet alone group (p < 0.001). CONCLUSIONS: This study showed that the use of an Esmarch bandage does not increase basilic vein size in healthy volunteers but is associated with a mild increase in discomfort.
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Cateterismo Periférico , Estudios Cruzados , Voluntarios Sanos , Torniquetes , Venas , Humanos , Masculino , Femenino , Adulto , Método Simple Ciego , Venas/anatomía & histología , Venas/diagnóstico por imagen , Cateterismo Periférico/métodos , Vendajes , Adulto Joven , Ultrasonografía Intervencional/métodos , Persona de Mediana EdadRESUMEN
Lifeguards are the first responders to any type of aquatic incident, including rapid rescue situations such as boating and sporting accidents, animal bites/attacks, and cases involving massive bleeding. In their line of work, rescue boats such as Rescue Water Craft (RWC) are commonly utilized the aim of this study is to evaluate the time and technique of placing a tourniquet on the sled of an RWC navigating at full speed. METHODS: A randomized crossover study design was used with a sample of 44 lifeguards. The inclusion criteria required that participants be certified lifeguards with experience in RWC operations and possess knowledge of responding to massive bleeding. Two CAT tourniquet placement tests were performed. In the 1) Beach-Tourniquet (B-TQ) test: it was performed on land and in the 2) Rescue Water Craft-tourniquet (RWC-TQ) test, sailing at a cruising speed of 20 knots. The evaluation was recorded in a checklist on the steps and timing of the correct application TQ by direct observation by an expert instructor. RESULTS: The tourniquet placement on RWC was an average of 11 s slower than when placed on the beach (BT-TQ 35.7 ± 8.0 vs. 46.1 ± 10.9 s, p > 0.001). In the percentage analysis of the results on correct execution of the skills, higher values are obtained for the B-TQ test than in RWC-TQ in Distance to the wound (into 5-7 cm), band adjustment, checking the radial pulse and reporting the time of tourniquet placement (p > 0.005). CONCLUSION: The placement of a tourniquet on a RWC navigating at 20 knots is feasible, relatively quick, and technically well executed.
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Estudios Cruzados , Trabajo de Rescate , Torniquetes , Humanos , Trabajo de Rescate/métodos , Masculino , Adulto , Hemorragia/terapia , Femenino , Factores de Tiempo , Navíos , Urgencias Médicas , Persona de Mediana Edad , SocorristasRESUMEN
The use of tourniquet is common in orthopaedic surgeries as it reduces blood loss, enhances visualization of the operating field, and leads to quicker procedures. However, the use of tourniquet has certain risks which can be avoided by following guidelines like British Orthopaedic Association Standards for Trauma (BOAST) guidelines for safe use of tourniquet. This audit study was done in a District general hospital to check the compliance of two trauma theatres with BOAST guidelines. The audit found that there was poor documentation of tourniquet details in the operation notes (10%). Regarding tourniquet time and pressure, the compliance in the two theatres was 95 % & 97.5 %. The recommendations of this audit were to use a template to improve documentation of tourniquet details in the operation notes and training of theatre staff on BOAST guidelines for safe use of tourniquet.
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Hospitales de Distrito , Auditoría Médica , Procedimientos Ortopédicos , Torniquetes , Humanos , Procedimientos Ortopédicos/efectos adversos , Reino Unido , Quirófanos/normas , Adhesión a Directriz/estadística & datos numéricos , Pérdida de Sangre Quirúrgica/prevención & controlRESUMEN
INTRODUCTION: External bleeding is the leading cause of preventable trauma-related death. In certain circumstances, tourniquet application over clothing may be necessary. Therefore, the aim of this study was to assess the effectiveness of tourniquets over different clothing setups. METHODS: Three windlass tourniquets (CAT, SAMXT, SOFTT-W) were applied over nine different clothing setups and without clothing on the Hapmed™ Tourniquet Trainer. We compared each tourniquet in each clothing setup to the tourniquet trainer that was not dressed, and we compared the three tourniquets within each clothing setup concerning blood loss, applied pressure and application time. Regression analysis of the effect of thickness, mean weight, mean deformation, application time, and applied pressure on blood loss was performed. RESULTS: Although blood loss was significantly greater in the CAT and SAMXT tourniquets when they were applied over leather motorcycle trousers, the overall findings showed that the clothing setups significantly reduced or did not affect blood loss. The mean blood loss was the lowest with CAT and the highest with SOFTT-W. The measured mean pressures were lower than 180 mmHg in four out of nine clothing setups with SOFTT-W, but CAT and SAMXT always exceeded this threshold. CAT had the fastest application time. Blood loss was significantly influenced by applied pressure and application time but was influenced to a far lesser degree by clothing parameters. CONCLUSION: The effects of the clothing setups were of little clinical relevance, except for leather motorcycle trousers. The effects of rugged protective equipment, e.g., hazard suits, are conceivable and need to be tested for specific garments with the tourniquet intended for use. No clothing parameter for predicting tourniquet effectiveness could be identified.
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Vestuario , Hemorragia , Torniquetes , Humanos , Hemorragia/prevención & control , Hemorragia/terapia , Hemorragia/etiología , Diseño de EquipoRESUMEN
LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Explain the most important benefits of wide-awake surgery to patients. 2. Tumesce large parts of the body with minimal pain local anesthesia injection technique to eliminate the need for sedation for many operations. 3. Apply tourniquet-free surgery to upper and lower limb operations to avoid the sedation required to tolerate tourniquet pain. 4. Move many procedures out of the main operating room to minor procedure rooms with no increase in infection rates to decrease unnecessary cost and solid waste in surgery. SUMMARY: Three disruptive innovations are changing the landscape of surgery: (1) minimally painful injection of large-volume, low-concentration tumescent local anesthesia eliminates the need for sedation for many procedures over the entire body; (2) epinephrine vasoconstriction in tumescent local anesthesia is a good alternative to the tourniquet and proximal nerve blocks in extremity surgery (sedation for tourniquet pain is no longer required for many procedures); and (3) evidence-based sterility and the elimination of sedation enable many larger procedures to move out of the main operating room into minor procedure rooms with no increase in infection rates. This continuing medical education article explores some of the new frontiers in which these changes affect surgery all over the body.
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Anestesia Local , Epinefrina , Humanos , Anestesia Local/métodos , Epinefrina/administración & dosificación , Anestésicos Locales/administración & dosificación , Torniquetes , Vasoconstrictores/administración & dosificaciónRESUMEN
BACKGROUND: Tourniquets are common adjuncts in the operating theatre but can be associated with post-operative pain. This study was designed to compare what effect pre-tourniquet Esmarch bandage exsanguination has on pain, compared to pre-tourniquet exsanguination by elevation alone. METHODS: 52 volunteers (104 lower limbs) were included in this study with each volunteer acting as their own matched control. The primary outcome was patient reported pain, measured in both legs simultaneously using area under curve. Secondary outcomes were pain score during inflation and deflation, cumulative pain score, duration of recovery and blood pressure during testing. RESULTS: Pain after Esmarch was superior to elevation as measured by area under pain curve (68.9 SD 26.1 vs 77.2 SD 27.3, p = 0.0010), independent of leg dominance. Cumulative pain scores demonstrated the same superiority after inflation (50.7 SD 17.1 vs 52.9 SD 17.0, p = 0.026) but not after deflation (p = 0.59). Blood pressure was not significantly different. Time to full recovery of the lower limb was the same for both groups-7.6 min (SD 2.1 min, p = 0.80). CONCLUSION: Previous studies describe a positive effect on pain when Esmarch bandage was used prior to tourniquet inflation for upper limb. Our findings suggest the same benefit from Esmarch when it was used on lower limbs-particularly during inflation of tourniquet. In addition to pain profiles, surgeon preference and patient factors need to be considered when deciding between elevation and Esmarch bandage.
Asunto(s)
Extremidad Inferior , Dolor Postoperatorio , Torniquetes , Humanos , Masculino , Femenino , Adulto , Dolor Postoperatorio/etiología , Dolor Postoperatorio/prevención & control , Exsanguinación/etiología , Exsanguinación/terapia , Vendajes , Persona de Mediana Edad , Adulto Joven , Dimensión del Dolor/métodosRESUMEN
BACKGROUND: Blood loss during and after total knee arthroplasty (TKA) can lead to substantial morbidity and the need for blood transfusions. There are several methods to minimize blood loss and decrease transfusion rates in patients undergoing TKA. Tranexamic acid, an antifibrinolytic agent with known efficacy for achieving these goals, is combined with tourniquets to reduce bleeding in arthroplasty surgeries. Our study investigated the effects of various combinations of tranexamic acid and tourniquet use on bleeding in knee arthroplasty in 558 patients. AIM: We aimed to determine the method that would provide the least blood loss and transfusion need in knee arthroplasty surgery. METHODS: Between January 2018 and December 2022, 558 patients aged between 55 and 85 years underwent TKA surgery for grade 4 gonarthrosis in our clinic, and their decrease in hemoglobin value and whether they were transfused or not were analyzed. The patients were divided into four groups based on use of tranexamic acid and tourniquet. Demographic variables and patient data (body mass index, INR values, and preoperative hemoglobin values) were recorded. RESULTS: There were 558 patients with a mean age of 68.19 (67 ± 6.949) years. In group 1, tranexamic acid was not used in 128 patients and tourniquet was used only during cementation; in group 2, in 132 patients, tranexamic acid was not used and tourniquet was used throughout the surgery; in group 3, in 158 patients, tranexamic acid was used and tourniquet was used throughout the surgery; in group 4, in 140 patients, tranexamic acid was used and tourniquet was used only during cementation. The decrease in hemoglobin value and transfusion rate was lowest in group 3 and highest in group 1. Besides, there was a greater decrease in hemoglobin value in group 2 than in group 4 and the transfusion rate was similar. CONCLUSIONS: This clinical study showed that using tranexamic acid and a tourniquet throughout surgery significantly reduced the decrease in hemoglobin value and the need for transfusion.
Asunto(s)
Antifibrinolíticos , Artroplastia de Reemplazo de Rodilla , Pérdida de Sangre Quirúrgica , Transfusión Sanguínea , Torniquetes , Ácido Tranexámico , Humanos , Ácido Tranexámico/uso terapéutico , Femenino , Masculino , Anciano , Antifibrinolíticos/uso terapéutico , Pérdida de Sangre Quirúrgica/prevención & control , Artroplastia de Reemplazo de Rodilla/métodos , Artroplastia de Reemplazo de Rodilla/efectos adversos , Persona de Mediana Edad , Anciano de 80 o más Años , Transfusión Sanguínea/estadística & datos numéricos , Hemoglobinas/análisis , Resultado del Tratamiento , Estudios RetrospectivosRESUMEN
BACKGROUND: Traumatic hemorrhage is a prevalent cause of death nationally, with >50% of civilian deaths estimated to be preventable with more timely intervention. This study investigated the efficacy of training large and diverse audiences in bleeding control methods including tourniquets in community health fair settings. METHODS: A booth was utilized for bleeding control training at community health fairs via direct demonstrations of pressure, wound packing, and commercial and improvised tourniquet application followed by hands-on practice. Participants self-rated their perceived abilities while instructors rated the participant competency. RESULTS: 117 community members participated during two fairs, though not every person completed every portion of the training. Average age was 33 (range 6-82) and the majority were female (65.0%). There was no difference in self-perceived skill compared to trainer grading of participant's ability to identify life-threatening bleeding (112 (97.4%) vs 106 (97.2%); P = 1), apply pressure (113 (98.3%) vs 106 (97.2%); P = .68), and pack a wound (102 (88.7%) vs 92 (84.4%); P = .43). No difference in difficulty was noted in placing commercial vs improvised tourniquets (16 (43%) vs 14 (45%); P = .87). However, participants were overconfident in their ability to place tourniquets compared to trainer grading, respectively (112 (98.2%) vs 100 (91.7%; P = .03)). DISCUSSION: Community fair classes provide opportunities to train large and diverse audiences in bleeding control techniques. However, participants overestimated their ability to appropriately apply tourniquets. Further investigation is needed into best educational approaches to optimize the impact of bleeding control kits that have been distributed in multiple states.
Asunto(s)
Hemorragia , Torniquetes , Humanos , Femenino , Masculino , Adulto , Hemorragia/prevención & control , Hemorragia/terapia , Persona de Mediana Edad , Anciano , Adolescente , Anciano de 80 o más Años , Adulto Joven , Técnicas HemostáticasRESUMEN
Ulnar nerve release is often performed under general anaesthesia. Wide Awake Local Anaesthesia No Tourniquet (WALANT) is a new anaesthetic method increasingly used by hand surgeons in an outpatient setting. It has advantages such as the possibility to shift surgical interventions out of the regular surgical theatre settings into an outpatient clinical setting, no risk of complications or side effects resulting from regional and general anesthesia and decreased costs. The use of WALANT has not been investigated extensively in elbow surgery. This study aims to evaluate clinical outcomes after ulnar nerve release under WALANT 27 patients with ulnar nerve release for cubital tunnel syndrome were included. The primary outcome was the presence of (remaining) symptoms after ulnar nerve release. Data was extracted from medical records. 13 out of 27 patients had (mild) remaining symptoms after ulnar nerve release, and 1 complication (superficial wound infection) was seen. Ulnar nerve release under WALANT is safe and effective in patients with primary ulnar nerve entrapment that have failed conservative therapy.
Asunto(s)
Procedimientos Quirúrgicos Ambulatorios , Anestesia Local , Anestésicos Locales , Síndrome del Túnel Cubital , Humanos , Anestesia Local/métodos , Masculino , Femenino , Persona de Mediana Edad , Síndrome del Túnel Cubital/cirugía , Adulto , Procedimientos Quirúrgicos Ambulatorios/métodos , Anestésicos Locales/administración & dosificación , Anciano , Nervio Cubital/cirugía , Torniquetes , Resultado del Tratamiento , Estudios RetrospectivosRESUMEN
This study investigates the impact of perioperative tourniquet on skeletal muscle cells during total knee arthroplasty (TKA) and its effects on the gene expression of apoptotic, inflammatory, and angiogenic pathways. The randomized controlled trial included 44 patients undergoing TKA. The patients were randomized to undergo surgery with (n = 23) or without (n = 21) tourniquet. The tourniquet was inflated before skin incision and deflated before wound closure in the tourniquet group. Biopsies from the lateral vastus muscle were obtained from both groups before wound closure and 8 weeks after surgery. The messenger ribonucleic acid (mRNA) expression and protein levels of angiopoietin-like 4 (ANGPTL4), Hypoxia-inducible Factor 1α, and Vascular Endothelial Growth Factor Alpha (VEGF-A) in the biopsies were examined by reverse transcription-quantitative polymerase chain reaction and tissue microarray, respectively. Differences in mean values (ΔCt for mRNA expression and staining positivity for protein expression) were compared with t-tests. The apoptotic marker BID and the angiogenic marker VEGF-A were significantly lower in the tourniquet group compared to the control group (p = 0.03, p = 0.047). However, there was a significant upregulation of VEGF-A 8 weeks after surgery in the tourniquet group compared to perioperative biopsies (p = 0.002), indicating persistent changes. A significant upregulation in protein expression of the angiogenic marker ANGPTL4 was found perioperatively in the tourniquet group (p = 0.02). Our results demonstrate that the angiogenic gene expression is significantly altered by the tourniquet, the effects of which might contribute to postoperative interstitial edema, increased pain, and decreased muscle strength. These effects could lead to delayed rehabilitation and ultimately reduced patient satisfaction after TKA.