Intravenous Use of Tranexamic Acid in Total Knee Arthroplasty with no Tourniquet / O uso endovenoso de ácido tranexâmico na artroplastia total de joelho sem uso de torniquete

Abstract Objective: To identify blood transfusion requirements and postoperative complications in patients undergoing total knee arthroplasty (TKA) with no tourniquet and intraoperative intravenous administration of tranexamic acid. Methods: This retrospective observational study analyzed 49 preopeative and postoperative medical records of patients undergoing TKA. A paired t-test compared changes in hemoglobin (HB) and packed cell volume (PCV), and an independent t-test with Welch correction compared HB and PCV changes between genders. A Spearman correlation test determined associations between age and days of postoperative hospitalization with HB and PCV changes. The significance level adopted was p < 0.05. Results: The patients' mean age was 71.9 ± 6.7 years; most subjects were women (73.5%). The right side (59.2%) was the most affected. Only one participant required a blood transfusion, while three subjects had complications during the postoperative follow-up. No patient had a thromboembolic event. The median length of postoperative hospital stay was 2 days (interquartile range [IQR] = 1.0). There were reductions in HB and PCV levels between the pre-operative and postoperative period, and female patients had a higher HB reduction. Conclusion: TKA with tranexamic acid and no tourniquet did not cause significant postoperative complications or require blood transfusions.

Resumo Objetivo: Identificar a necessidade de transfusão sanguínea e intercorrências inerentes ao pós-operatório de pacientes submetidos à artroplastia total de joelho (ATJ), a partir de manejos realizados sem o uso de torniquete e com administração de ácido tranexâmico endovenoso intra-operatório. Métodos: Trata-se de um estudo observacional retrospectivo, a partir da observação de 49 prontuários médicos de pacientes submetidos à ATJ em pré e pós-operatório. Foi utilizado o teste t pareado para fazer comparações das modificações de hemoglobina (HB) e hematócrito (HT) e o teste t independente com correção de Welch para comparar as modificações de HB e HT entre os sexos. As associações de idade e dias de internação no pós-operatório com as modificações de HB e HT foram testadas pela correlação de Spearman. O nível de significância adotado foi p < 0,05. Resultados: Os pacientes apresentaram idade média de 71,9 ± 6,7 anos. A maioria da amostra foi composta por mulheres (73,5%) e o lado direito (59,2%) foi o mais acometido. Apenas um participante necessitou de transfusão de sangue e três participantes apresentaram intercorrências durante o seguimento pós-operatório. Nenhum paciente apresentou evento tromboembólico. A mediana da duração da internação no pós-operatório foi de dois dias (IIQ= 1,0). Verificaram-se reduções nas dosagens de HB e HT entre o pré e pós-operatório, e pacientes do sexo feminino apresentaram maior redução de HB. Conclusão: ATJ com uso de ácido tranexâmico e sem uso de torniquete não acarretou complicações pós-operatórias ou necessidade de transfusão sanguínea significativas.

Effect of ACE2 deletion on vasoconstriction reactivity of aortic segments in mice with tourniquet shock / 中国病理生理杂志

AIM:To observe the effect of angiotensin-converting enzyme 2(ACE2)deletion on vasoconstric-tion reactivity of aortic segments in ACE2 knockout(KO)mice with tourniquet shock(TS).METHODS:The 8-month-old male mice with C57BL/6 background were divided into wild-type(WT)control group,WT-TS group,KO group and KO-TS group,with 10 mice in each group,of which five were used for determination of vascular reactivity,and the other five for the other assays.The hindlimbs of the mice in WT-TS group and KO-TS group were ligated with tourniquet for 2 h and loosened for 4 h.The mice in WT group and KO group were subjected to the same treatment except for tourniquet liga-tion.The vasoconstriction reactivity of the aorta was measured on tensiometer.The morphological damage of the aorta was evaluated by vascular histopathology.Western blot was used to detect the expression of AT1,MAS,ACE and ACE2 pro-teins in aorta.The serum levels of angiotensin(Ang)Ⅱ and Ang-(1-7)were determined by enzyme-linked immunosorbent assay.RESULTS:Compared with WT group,the mice in WT-TS group had lower vascular reactivity to norepinephrine(NE)and obvious vascular lesions.The expression of ACE protein increased significantly(P＜0.01),while the expres-sion of ACE2 decreased(P＜0.05).The expression of AT1 protein in aorta decreased significantly,the expression of MAS protein increased significantly,and the AT1/MAS ratio decreased(P＜0.01).Serum Ang II level increased,serum Ang-(1-7)level decreased,and Ang Ⅱ/Ang-(1-7)ratio increased(P＜0.05).Compared with WT group,vascular reactivity in KO group increased at low concentration of NE(＜10-7 mol/L),and decreased at high concentration(＞10-7 mol/L)without vascular lesion.The expression levels of aortic AT1,MAS and ACE were all elevated(P＜0.05).The serum level of Ang Ⅱ increased(P＜0.05),but the level of Ang-(1-7)had no obvious change.Compared with KO and WT-TS groups,the aortic reactivity in KO-TS group subtracted apparently(P＜0.05),representing its curve shifting to the right obviously.The morphological damage aggravated slightly,and the expression of AT1 and ACE increased slightly in KO-TS group com-pared with WT-TS group(P＜0.05).However,the expression of MAS increased significantly in vascular tissue(P＜0.01).The serum levels of Ang Ⅱ and Ang-(1-7)further increased and decreased,respectively,and the Ang Ⅱ/Ang-(1-7)ratio increased(P＜0.01).CONCLUSION:Deficiency of ACE2 induces severe aortic hyporeactivity to NE during TS,which may be related to the increased imbalance of renin-angiotensin system in ACE2 gene knockout mice.

Effect of SAM junctional tourniquet on respiration when applied in the axilla: A swine model / 中华创伤杂志(英文版)

PURPOSE@#SAM junctional tourniquet (SJT) has been applied to control junctional hemorrhage. However, there is limited information about its safety and efficacy when applied in the axilla. This study aims to investigate the effect of SJT on respiration when used in the axilla in a swine model.@*METHODS@#Eighteen male Yorkshire swines, aged 6-month-old and weighing 55 - 72 kg, were randomized into 3 groups, with 6 in each. An axillary hemorrhage model was established by cutting a 2 mm transverse incision in the axillary artery. Hemorrhagic shock was induced by exsanguinating through the left carotid artery to achieve a controlled volume reduction of 30% of total blood volume. Vascular blocking bands were used to temporarily control axillary hemorrhage before SJT was applied. In Group I, the swine spontaneously breathed, while SJT was applied for 2 h with a pressure of 210 mmHg. In Group II, the swine were mechanically ventilated, and SJT was applied for the same duration and pressure as Group I. In Group III, the swine spontaneously breathed, but the axillary hemorrhage was controlled using vascular blocking bands without SJT compression. The amount of free blood loss was calculated in the axillary wound during the 2 h of hemostasis by SJT application or vascular blocking bands. After then, a temporary vascular shunt was performed in the 3 groups to achieve resuscitation. Pathophysiologic state of each swine was monitored for 1 h with an infusion of 400 mL of autologous whole blood and 500 mL of lactated ringer solution. Tb and T0 represent the time points before and immediate after the 30% volume-controlled hemorrhagic shock, respectively. T30, T60, T90 and T120, denote 30, 60, 90, and 120 min after T0 (hemostasis period), while T150, and T180 denote 150 and 180 min after T0 (resuscitation period). The mean arterial pressure and heart rate were monitored through the right carotid artery catheter. Blood samples were collected at each time point for the analysis of blood gas, complete cell count, serum chemistry, standard coagulation tests, etc., and thromboelastography was conducted subsequently. Movement of the left hemidiaphragm was measured by ultrasonography at Tb and T0 to assess respiration. Data were presented as mean ± standard deviation and analyzed using repeated measures of two-way analysis of variance with pairwise comparisons adjusted using the Bonferroni method. All statistical analyses were processed using GraphPad Prism software.@*RESULTS@#Compared to Tb, a statistically significant increase in the left hemidiaphragm movement at T0 was observed in Groups I and II (both p < 0.001). In Group III, the left hemidiaphragm movement remained unchanged (p = 0.660). Compared to Group I, mechanical ventilation in Group II significantly alleviated the effect of SJT application on the left hemidiaphragm movement (p < 0.001). Blood pressure and heart rate rapidly increased at T0 in all three groups. Respiratory arrest suddenly occurred in Group I after T120, which required immediate manual respiratory assistance. PaO2 in Group I decreased significantly at T120, accompanied by an increase in PaCO2 (both p < 0.001 vs. Groups II and III). Other biochemical metabolic changes were similar among groups. However, in all 3 groups, lactate and potassium increased immediately after 1 min of resuscitation concurrent with a drop in pH. The swine in Group I exhibited the most severe hyperkalemia and metabolic acidosis. The coagulation function test did not show statistically significant differences among three groups at any time point. However, D-dimer levels showed a more than 16-fold increase from T120 to T180 in all groups.@*CONCLUSION@#In the swine model, SJT is effective in controlling axillary hemorrhage during both spontaneous breathing and mechanical ventilation. Mechanical ventilation is found to alleviate the restrictive effect of SJT on thoracic movement without affecting hemostatic efficiency. Therefore, mechanical ventilation could be necessary before SJT removal.

Ventajas y limitaciones del uso del torniquete en ortopedia y traumatología / Advantages and Limitations of the Use of Tourniquet in Orthopedics and Traumatology

Introducción: El torniquete es ampliamente usado en la cirugía ortopédica y traumatológica con el objetivo de disminuir las pérdidas sanguíneas intraoperatorias y mejorar la visibilidad de las estructuras anatómicas, aunque su empleo es controversial. Objetivo: Describir las aplicaciones prácticas y las limitaciones del torniquete en la cirugía ortopédica y traumatológica. Método: Se realizó una revisión no sistemática de la literatura en bases de datos científicas como Cochrane Database of Systematic Reviews, Pubmed/Medline, EMBASE, Scopus, Web of Science, EBSCOhost, ScienceDirect, OVID y el buscador académico Google Scholar, en el mes de septiembre de 2020. Conclusiones: Aunque el torniquete es ampliamente utilizado durante la cirugía ortopédica y traumatológica, debido a que contribuye a reducir las pérdidas hemáticas intraoperatorias, se ha demostrado su efecto en el aumento de las pérdidas sanguíneas totales, así como su asociación con dolor perioperatorio, pérdida de la fuerza muscular del miembro, lesiones de nervios periféricos, trombosis venosa profunda y daño a órganos a distancia por el fenómeno de isquemia-reperfusión(AU)

Introduction: Although controversial, tourniquets are widely used in orthopedic and trauma surgery with the aim of reducing intraoperative blood losses and improving the visibility of anatomical structures. Objective: To describe the practical applications and limitations of tourniquets in orthopedic and trauma surgery. Method: A non-systematic review of the literature was carried out, in scientific databases such as Cochrane Database of Systematic Reviews, Pubmed / Medline, EMBASE, Scopus, Web of Science, EBSCOhost, ScienceDirect, OVID and the academic search engine Google Scholar, in the month of September 2020. Conclusions: Although tourniquets are widely used during orthopedic and trauma surgery, since they contribute to reducing intraoperative blood loss, the effect on increasing total blood loss has been demonstrated, as well as the association with perioperative pain, blood loss, limb muscle strength, peripheral nerve injuries, deep vein thrombosis and damage to distant organs due to the ischemia-reperfusion phenomenon(AU)

Incidence and risk factors for acute kidney injury: a prospective, randomized, single-blind clinical trial comparing total knee arthroplasty with and without tourniquet / Incidencia y factores de riesgo para lesión renal aguda: Un ensayo clínico ciego, prospectivo y aleatorizado comparando la artroplastía total de rodilla con y sin torniquete

Abstract: Purpose: Identify the incidence and risk factors for acute kidney injury (AKI) following total knee arthroplasty (TKA) with and without tourniquet. Material and methods: 100 patients were randomized into two groups. Postoperative AKI was defined as the postoperative creatinine level ≥ 0.3 mg/dl compared with baseline. Potential variables associated with AKI were analyzed by multivariate logistic regression model to identify the AKI risk factors in TKA patients with and without tourniquet. Results: AKI rate was 22%, tourniquet use (OR = 2.66, p = 0.014), blood loss > 500 cm3 (OR = 3.99, p = 0.001), postoperative Hb < 10 g/dl (OR = 2.68, p = 0.008), blood transfusions (OR = 2.86, p = 0.012) and diabetes (OR = 2.80, p = 0.006) were associated with increased risk of postoperative AKI. Conclusions: The use of tourniquet should be indicated with caution and should not be used routinely in patients with other risk factors for the development of acute kidney dysfunction, other measures to achieve trans-surgical hemostasis should be implemented in our environment to reduce the incidence of acute kidney dysfunction related to the use of the tourniquet.

Resumen: Propósito: Identificar la incidencia y factores de riesgo para lesión renal aguda (LRA) después de la artroplastia total de rodilla (ATR) con y sin uso de torniquete. Material y métodos: Se dividieron 100 pacientes en dos grupos. Se definió la LRA como una elevación postoperatoria de la creatinina ≥ 0.3 mg/dl comparada con el nivel basal preoperatorio. Las potenciales variables asociadas con la DRA fueron analizadas con un modelo de regresión logística multivariada para identificar los factores de riesgo de DRA en pacientes sometidos a ATR con y sin torniquete. Resultados: La incidencia de LRA fue de 22%. El uso de torniquete (OR = 2.66, p = 0.014), pérdida sanguínea > 500 cm3 (OR = 3.99, p = 0.001), Hb postoperatoria < 10 g/dl (OR = 2.68, p = 0.008), transfusión sanguínea (OR = 2.86, p = 0.012) y la diabetes (OR = 2.80, p = 0.006) fueron asociados a un mayor riesgo postoperatorio de LRA. Conclusiones: El uso de torniquete debe estar indicado con precaución y no debe utilizarse de forma rutinaria en pacientes con otros factores de riesgo para el desarrollo de disfunción renal aguda, otras medidas para lograr la hemostasia transquirúrgica deben implementarse en nuestro entorno para reducir la incidencia de disfunción renal aguda relacionada con el uso del torniquete.

Incidence and factors influencing tourniquet pain / 中华创伤杂志(英文版)

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.

Neuromuscular Functional Changes of the Quadriceps after Anterior Cruciate Ligament Reconstruction

ABSTRACT Objective: To determine the factors related to quadriceps weakness, to evaluate electromyo-graphic changes in the quadriceps and to attempt to determine the neuromuscular restoration period after anterior cruciate ligament (ACL) repair. Methods: A total of 30 patients (28 males and 2 females) who underwent surgery conducted by two surgeons were reviewed prospectively. All ACLs were reconstructed arthroscopically with anterior tibial tendon allograft, using an anteromedial portal. The patients' quadriceps muscles' neuromuscular activity was determined with electromyography at early and late periods (1-3 months and 6-12 months, respectively). Results: A significant difference was observed (p < 0.01) in the quadriceps circumference between the operated extremities (average, 48.4 cm) and the healthy limbs (average, 50.6 cm), according to measurements obtained on the sixth month after surgery. The tourniquet time was greater than 50 minutes in patients with quadriceps atrophy. A significant elongation was observed in the motor unit potential duration of the operated ipsilateral side, compared to the contralateral side (p < 0.001) at the early-term period. Differences were observed between the ipsilateral MUP amplitude and the durations of early- and late-term patients, but were not significant. Conclusion: Our study demonstrated that atrophies are significantly overcome in the first year after surgery. The electromyographic examinations indicated that tourniquet use not only caused functional harm in the quadriceps muscle but it also caused structural damage. However, these structural injuries did not result in negative effects on the clinical success.

Effect of dexmedetomidine combined with femoral nerve and sciatic nerve block on tourniquet application in lower limb surgery / 中国综合临床

Objective:To investigate the effect of dexmedetomidine on alleviating tourniquet pain for lower limb surgery under femoral nerve combined with sciatic nerve block and effect of systemic sedation.Methods:A prospective double-blind randomized controlled study was conducted. From January 2020 to December 2020, 80 patients who scheduled for lower extremity surgery (emergency and elective surgery) in The Second Hospital of Tangshan were randomly divided into dexmedetomidine group (group A) and control group (group B). Dexmedetomidine was used through i.v. pump in group A after successful femoral nerve and sciatic nerve block, and the same volume saline was given to group B. The changes of heart rate, mean arterial pressure (MAP), respiratory rate and oxygen saturation (SpO 2) in the two groups were observed and recorded. The main observation indexes were intraoperative sedation (Ramsay score) and tourniquet pain score (VAS score). Results:The highest Ramsay score was 4 (4,4) in group A, 2 (2,3) in group B, the difference was statistically significant ( Z=7.339, P<0.001).The lowest Ramsay score was 2 (2,2) in group A and 1 (1,1) in group B, The difference was statistically significant ( Z=7.304, P<0.001). Intraoperative VAS score was 0 (0,1) in group A and 8 (7,8) in group B, the difference was statistically significant ( Z=6.610, P<0.001). The lowest HR was (58.1±5.5) times per minute in group A and (70.0±10.6) times per minute in group B; The highest HR was (85.2±7.1) times per min in group A and (98.1±11.0) times per minute in group B ( t values were 14.453 and 4.038, respectively;and P values were <0.001 and 0.048, respectively). The lowest value of MAP was (80.3±6.0) mmHg in group A and (92.1±4.2) mmHg in group B ( t=5.009, P=0.028), there was no significant difference in the highest value of MAP, the lowest value of RR and the lowest value of SpO 2 between groups A and B (all P>0.05). Conclusion:Intravenous dexmedetomidine combined with femoral nerve and sciatic nerve block can effectively alleviate the discomfort of long-term application of lower limb tourniquet.

Application of pueumatic tourniquet in the operation of lower tibiofibular fracture / 中国骨伤

OBJECTIVE@#To investigate the complications of tourniquet in the clinical application of lower tibiofibular fracture.@*METHODS@#From June 2018 to September 2019, 33 cases of closed lower tibiofibular fractures (AO type 43A) were treated with plates and screws and were divided into two groups according to whether pueumatic tourniquet was used:16 cases in the observation group, 13 males and 3 females, aged 18 to 69 (38.8±17.0) years, the operation time after injury was (6.9±1.7) days, and tourniquet was not used during operation. There were 17 cases in the control group, 13 males and 4 females, aged from 21 to 71 (43.8±12.4) years, the operation time after injury was (6.5±1.0) days, automatic pneumatic tourniquetwas routinely used in the operation. The operation time, blood loss, postoperative swelling, pain and other complications were compared between two groups.@*RESULTS@#Total of 33 patients were followed up for an average of 15 months. There was no significant difference in operation time and blood loss between two groups (@*CONCLUSION@#The fracture of lower tibiofibular segment is superficial and easy to be exposed and fixed during operation. In order to avoid tourniquet complications, it is not recommended to use air bag tourniquet routinely or minimize the application time of tourniquet.

Tourniquet application in snake bite: are we aware?

Background: To assess the use of tourniquets as mentioned in National Snake Bite Management Protocol among peripheral health care providers.Methods: This was a prospective cross-sectional study conducted in a tertiary care institute between June 2016 to June 2017. A total of 36 patients of snake bite referred from peripheral health facility were enrolled in the study and were evaluated for : date and time of bite, site of bite, weather snake was seen, type of envenomation, first aid given in Govt facility/alternative practitioner, tourniquet applied/not applied, anti snake venom given/not given as first aid and outcome.Results: The mean age of the study population was 39 years (17.38) range 18 years to 75 years. 18 patients were male and 18 were female. 30 (83.3%) patients had site of bite over the extremities’. The venom was hemotoxic in 12 (33.3%) patients and neurotoxic 21 (58.3%). 30 (83.3%) patients  received first aid in the Government health facility  manned by qualified in healthcare practitioner and 6 (16.7%) were treated by traditional healers. 29 (80.6%) patients had a tight tourniquet tied to the site of the bite when seen in emergency department of institute. None of the patients had their limbs splinted. 31 (86.1%) patients had received anti snake venom (ASV) at the peripheral health facility. The mortality rate was 5.6% with only 2 deaths.Conclusions: The majority of peripheral health care providers both qualified and unqualified use tourniquets in patients suffering with snake bite. The peripheral health care providers are not aware of importance of limb splinting and immobilisation. Though the rate of instilling ASV is good, the health care providers in the peripheral institutes should be made aware of recommendations of national snake bite management protocol with regard to use of tourniquets and limb splitting in snake bite patients.

Tourniquets used in peripheral venipuncture as a potential vehicle for transmission of microorganisms: scoping review / Torniquetes utilizados en la venopunción periférica como potencial vehículo de transmisión de microorganismos: revisión de alcance

Introduction: The tourniquet used in venipuncture appears as a potential vehicle for the transmission of microorganisms that interferes with safety and the quality of clinical services. Objective: Mapping the scientific evidence on the microbiological contamination of the tourniquets used in peripheral venipuncture. Methodology: Scoping review following the Joanna Briggs Institute methodology. Results: 20 studies have been included, in which of 1477 tourniquets were analyzed. The rates of microbiological contamination varied between 10-100% and 19 studies reported the presence of S. aureus, 11 of them detected methicillin-resistant strains with prevalence between 3.3-58.3%. Conclusion: The contamination rate in the majority of studies was ≥70%, including 4 studies which had sampled ≥100 tourniquets. The evidence of our study is that the tourniquets are reservoirs of potential pathogens and can be transmitted to patient on staff hands. We recommend studies that confirm the reusable tourniquets can be responsible to healthcare associated infections.

Introducción: El torniquete utilizado en la venopunción aparece como potencial vehículo para transmisión de microorganismos que entorpece la seguridad y calidad de los servicios clínicos. Objetivo: Mapear pruebas científicas sobre contaminación microbiológica de los torniquetes utilizados en la venopunción periférica. Metodología: Revisión de acuerdo con la metodología del Instituto Joanna Briggs. Resultados: Se han incluido 20 estudios, en los que se analizó un total de 1477 torniquetes. Las tasas de contaminación microbiológica variaron entre 10-100% y 19 estudios informaron la presencia de S. aureus, 11 detectaron cepas resistentes a meticilina con prevalencia entre 3.3-58.3%. Conclusión: La tasa de contaminación en mayoría de los estudios fue ≥70%, 4 estudios que habían muestreado ≥100 torniquetes. Nuestro estudio evidencia que los torniquetes son reservorios de patógenos y pueden transmitirse al paciente en manos del personal. Recomendamos estudios que confirmen que los torniquetes pueden ser responsables de las infecciones asociadas a la atención médica.

Hair tourniquet syndrome of labia minora in 14 year teen: a rare case report

Hair tourniquet syndrome (HTS) is rare clinical phenomenon in which body appendage is circumferentially entangled by string of hair leading to ischemia and necrosis or even autoamputation of the appendage. HTS commonly affects toes, finger or genitalia. Early diagnosis and prompt intervention lead to good outcome.  This article presents a case of hair tourniquet syndrome of labia minora, a rare presentation in 14 year child.

Innovative use of tourniquet in the management of an advanced abdominal pregnancy to achieve an unusually normal postoperative outcome: a case report

Mrs. UVG was an un-booked G3P1+1 petty trader, who presented with an obstetric ultrasound scan report, with an incidental diagnosis of abdominal pregnancy at 32 weeks of gestation with the placenta attached to the fundus of the uterus. Her admission packed cell volume was 24%. She had pre-operative preparation and 2 units of compatible blood were transfused to correct the anemia. Four additional units of compatible blood were made available before she was scheduled for an exploratory laparotomy at 33 weeks of gestation. A grossly normal male infant weighing 2.2 kg was delivered from the peritoneal cavity with Apgar scores of 2 at 1 minute and the same at 5 minutes. The placenta which was attached to the fundus of the uterus was removed manually completely after a tourniquet had been applied distal to the point of separation. Intra-operative blood loss was 1000 ml. The infant died 1 hour after delivery due to respiratory failure. Autopsy report revealed massive intracerebral hemorrhage and pulmonary hypoplasia. The post-operative period was uneventful and the decline in serum assay of β-human chorionic gonadotrophin postpartum was normal. She was discharged home on the 8th post-operative day and seen at the postnatal clinic twice at weekly intervals with normal serum assay of β-human chorionic gonadotrophin. Her 6 weeks postnatal visit was also uneventful.

Relationship of extrusion and elevation of blood-expelling methods during total knee arthroplasty with postoperative complications / 中国组织工程研究

BACKGROUND: At present, extrusion is widely used in total knee arthroplasty. Studies have shown that extrusion can aggravate early pain and increase the risk of complications after operation. Therefore, a safer and more effective method it is urgently needed in clinic. OBJECTIVE: To observe the effects of elevation and extrusion of blood-expelling method on clinical outcomes during total knee arthroplasty. METHODS: Sixty-four patients who were scheduled to undergo unilateral total knee arthroplasty for the first time were randomly divided into two groups. During total knee arthroplasty, the control group received extrusion method, while the experimental group received elevation method. The main outcomes of the two groups were compared: Visual analogue scale score, knee joint swelling, C-reactive protein, serum creatine kinase activity and postoperative complications; secondary outcomes: Tourniquet use time, Hospital for Special Surgery score, and SF-36 score. RESULTS AND CONCLUSION: (1) Visual analogue scale scores in the experimental group were significantly lower than those in the control group on the first day, the seventh day, the first month and the third month after operation (P 0.05). (5) Hospital for Special Surgery score and SF-36 score were assessed at 1, 3 and 6 months. The results showed that it was better than before, but there was no significant difference between the two groups (P > 0.05). (6) In conclusion, elevation of blood-expelling method could alleviate early pain response, reduce inflammation reaction and soft tissue injury, and decrease the incidence of skin tension blisters and thromboembolism. It is in line with the concept of rapid recovery. Therefore, during total knee arthroplasty, elevation of blood-expelling method is a safer and more effective method than extrusion.

Intra-articular concentration of gentamicin administered by intravenous regional limb perfusion in healthy horses / Concentração intra-articular de gentamicina administrada por perfusão regional intravenosa em membros de equinos sadios

ABSTRACT: Intravenous regional limb perfusion (IRLP) is an efficient method to treat horses with synovial infections. However, information on the dose, volume, and intervals of administration is lacking. The aim of this study was to evaluate the intra-articular concentration of gentamicin administered by IRLP in horses over 24 h post-administration and evaluate the influence of the total perfused volume. Twenty horses were assigned to two treatment groups. Gentamicin 60 group (G60, n=10) and Gentamicin 250 group (G250, n=10) received IRLP of 6.6 mg/kg of gentamicin diluted in Ringer's lactate for a total volume of 60 ml (G60) and 250 ml (G250), respectively. Synovial fluid harvests were performed in the metacarpophalangeal joint before (0) and 4, 8, 12, 16, 20, and 24 hours after IRLP. Agar diffusion was the assay for measuring gentamicin concentrations. Four hours after IRLP, the intra-articular concentration of gentamicin was 47.58±49.21 μg/ml in G60 and 10.92±6.11 μg/ml in G250. During the 24 h of harvest, the intra-articular concentration of gentamicin remained above the minimum inhibitory concentration for horses (MIC; 2 μg/ml) in both experimental groups. In G60, the concentration of gentamicin in synovial fluid reached the maximal concentration and remained 8 to 10-fold higher than the MIC (Cmax: 16 to 20 μg/ml) during 12 h after IRLP. These findings support that IRLP with 6.6 mg/kg of gentamicin diluted to a volume of 60 ml promotes intra-articular concentrations higher than 250 ml, remaining above the MIC for 24 h and at the maximum concentration for 12 h.

RESUMO: A perfusão regional intravenosa (PRI) em membros de equinos é um método comprovadamente eficiente para o tratamento de infecções sinoviais, porém ainda existem lacunas quanto à dose, volume e intervalos de administração a serem utilizados. Neste estudo, objetivou-se avaliar a concentração intra-articular da gentamicina administrada por PRI em equinos, ao longo de 24 horas pós-administração, bem como avaliar a influência do volume total perfundido. Vinte equinos foram distribuídos em dois grupos experimentais, Grupo Gentamicina 60 (G60) e Grupo Gentamicina 250 (G250), representados por 10 equinos em cada grupo que receberam, por PRI, 6,6 mg/kg de gentamicina diluída em Ringer lactato para um total de 60 ml (G60) ou 250 ml (G250). As colheitas de líquido sinovial foram realizadas, na articulação metacarpo-falangeana, antes do início do experimento e após 4, 8, 12, 16, 20, e 24 horas. Difusão em ágar foi o método para doseamento das concentrações de gentamicina. Quatro horas após a PRI, a concentração intra-articular da gentamicina era de 47,58±49,21 µg/ml no G60 e 10,92±6,11 µg/ml no G250. Durante as 24 horas de colheita, a concentração intra-articular de gentamicina permaneceu acima da concentração inibitória mínima (CIM) (2 μg/ml) em ambos os grupos experimentais. No G60, as concentrações de gentamicina no líquido sinovial atingiram a concentração máxima e mantiveram-se 8 a 10 vezes mais elevadas que a CIM (Cmáx: 16 a 20 μg/ml) durante 12 horas após a PRI. Conclui-se que a PRI em membros, com 6,6 mg/kg de gentamicina diluída para o volume de 60 ml, promove concentrações intra-articulares mais elevadas que o volume de 250 ml, permanecendo acima da CIM durante 24 horas e em concentração máxima durante 12 horas.

Estrategias de ahorro de sangre en artroplastía total de rodilla primaria / Blood-saving strategies in total primary knee replacement

Resumen: Introducción: El objetivo del presente estudio fue realizar una actualización sobre las diferentes estrategias en el ahorro de sangre en cirugía protésica de rodilla primaria, a través de una revisión bibliográfica; así como conocer qué estrategias se siguen en diferentes centros hospitalarios de nuestro ámbito, mediante un estudio multicéntrico. Material y métodos: Se realizó un estudio observacional, transversal, descriptivo, basado en una encuesta hecha a 64 cirujanos y una búsqueda bibliográfica sobre los distintos aspectos incluidos en la encuesta. Resultados: Los cirujanos refieren que cuentan con protocolos de ahorro sanguíneo prequirúrgicos implantados en su hospital en 48.4% (31/64). La utilización del ácido tranexámico (ATX) es bastante generalizada en 71.9% de los encuestados (46/64). Éste se administra vía endovenosa previa a la cirugía en 26.6% (17/64) de los casos, de manera intraarticular en 21.9% (14/64) y en una combinación de ambas en 23.4% (15/64). El momento preferido para la colocación de la isquemia por los cirujanos es en 57.8% (37/64) previo a preparar el campo, mientras que 39.1% (25/64) prefiere colocarla en estéril. En 3.1% (2/64) de cirujanos afirma implantar las prótesis sin utilizar isquemia en la cirugía. Discusión: Se está imponiendo la aplicación de ATX como principal estrategia de ahorro de sangre en la artroplastía total de rodilla (ATR). No existe consenso en cuanto a la dosis óptima ni a su vía de administración. La eficacia del ATX está influyendo en la eliminación de los drenajes postquirúrgicos y en la implementación de programas de rehabilitación precoz.

Abstract: Introduction: The objective of this study was to make an update on the different strategies in the blood saving in prosthetic primary knee surgery, through a bibliographical review; As well as to know what strategies are followed in different hospitals in our field, through a survey. Material and methods: We carried out a descriptive transversal observational study based on a survey of 64 surgeons and a bibliographical research on the different aspects included in the survey. Results: Surgeons refer that they have presurgical blood-saving protocols implanted in their Hospital at 48.4%. The use of tranexamic acid (ATX) is quite widespread 71.9% of respondents (46/64). It is administered intravenously prior to surgery in 26.6% of cases, intraarticularly by 21.9% and in a combination of both in 23.4%. The preferred time for the placement of ischemia by surgeons is 57.8% prior to painting the field, while a 39.1% prefer to place it in sterile conditions. 3.1% of surgeons claim to implant the prosthesis without using ischemia in surgery. Discussion: The use of ATX as the primary blood-saving strategy in TKR is being imposed. There is No consensus as to the optimal dose or its route of administration. The efficacy of the ATX is influencing the elimination of post-surgical drainage and the implementation of early rehabilitation programs.

The role of tourniquet in myomectomy: an observational study

Background: Leimymoma is one of the commonest benign tumours encountered in women during the reproductive age. One quarter of these women may be symptomatic. When surgical management is indicated, myomectomy may be considered as the procedure of choice. Myomectomy can be complicated by severe intraoperative haemorrhage. One of the methods to reduce blood loss during myomectomy is the mechanical application of tourniquet.Methods: A prospective observational single arm study was done with 24 women who underwent open myomectomy to determine the utility of tourniquet in reducing blood loss during the procedure.  Women of reproductive age group, having symptomatic fibroid, not responding to medical therapy, not completed their family and with total uterine size not exceeding 20 weeks were included in the study while those with pregnancy, concomitant adenomyosis, cervical or broad ligament fibroid, bleeding diathesis were excluded. The 7-French pediatric feeding tube was used as tourniquet. Our primary end point was intra-operative blood loss. Secondary outcome measures included operative morbidity and blood transfusion rates.Results: It was seen that application of the tourniquet considerably reduced the amount of blood loss and made resection of the myoma much easier. 83.3% patients had a blood loss less than 200ml and the rest between 200ml and 400ml. For majority of the patients (75%) the postoperative change of PCV was between 1 and 2%.Conclusions: The infant feeding tube form of tourniquet is cheap, safe, readily available, effectively reduces blood loss during myomectomy while not adding to the complications due to the operation.

Effect of pneumatic tourniquet on perioperative blood loss in total knee arthroplasty / 中国修复重建外科杂志

Objective: To evaluate the effect of pneumatic tourniquet on perioperative period of total knee arthroplasty (TKA). Methods: The perioperative period data of 116 patients over 60 years old with severe knee osteoarthritis treated with TKA between January 2018 and January 2019 were retrospectively analyzed. According to whether pneumatic tourniquet was used during operation, the patients were divided into trial group (49 cases, pneumatic tourniquet was not used during operation) and control group (67 cases, pneumatic tourniquet was used during operation). There was no significant difference in gender, age, body mass index, lesion side, disease duration, and preoperative hemoglobin between the two groups ( P>0.05). The operation time, actual total blood loss, overt blood loss, hidden blood loss, and percentage of hidden blood loss, knee swelling at 3 days after operation, and range of motion of knee at 2 weeks after operation were recorded and compared between the two groups. Results: The operation time of the trial group was significantly longer than that of the control group ( t=14.013, P=0.000). The actual total blood loss, hidden blood loss, and percentage of hidden blood loss in the trial group were significantly lower than those in the control group ( P<0.05); there was no significant difference in the overt blood loss between the two groups ( t=-1.293, P=0.200). The knee swelling degree in the trial group was significantly slighter than that in the control group at 3 days after operation, and the range of motion of knee in the trial group was significantly better than that in the control group at 2 weeks after operation ( P<0.05). Conclusion: Pneumatic tourniquet can reduce the operation time of TKA significantly. However, it may increase the hidden blood loss and knee swelling, and negatively impact the recovery of knee function in the early postoperative stage of TKA.

Analysis of limb swelling and pain caused by a tourniquet after total knee arthroplasty / 医学研究生学报

The advantages of the tourniquet in total knee arthroplasty are favored by surgeons. However, tourniquets can aggravate the swelling and pain of postoperative limbs，which is not good for early functional exercise. Researchers conducted many related studies which only stayed in clinical manifestations and did not clarify the causes and mechanisms of swelling and pain，So there are no positive effect on the prevention and treatment of swelling and pain. Tourniquets can cause ischemia, hypoxia and reperfusion injury in limbs, leading to local tissue inflammatory reactions, vascular injury, microcirculatory disorders, abnormal coagulation, deep venous thrombosis, lymphatic drainage disorders, joint cavity occult hemorrhage, effusion and the damage of distant organs, which eventually exacerbated the degree of swelling and pain of the limb. Therefore, the above factors are reviewed in this article.

Effect of transcutaneous electrical acupoint stimulation on pulmonary function and oxidative stress response in lower extremity surgery patients using tourniquet / 针刺研究

OBJECTIVE: To investigate the effect of transcutaneous electrical acupoint stimulation (TEAS) on pulmonary function, superoxide dismutase (SOD) activity, and malondialdehyde (MDA) content in patients using tourniquet after lower extremity surgery. METHODS: A total of 40 patients who underwent lower extremity surgery were equally randomized into control group and TEAS group by using a random number table. All patients underwent lumbar epidural anesthesia combined with block anesthesia. The patients in the TEAS group were given TEAS at Zusanli (ST36) and Sanyinjiao (SP6) beginning from 30 min before surgery to the end of surgery, and those in the control group received TEAS at the same acupoints with minimum current intensity. Mean arterial pressure (MAP) and heart rate (HR) were recorded at each time point (T0: pre-surgery /TEAS, T1: 5 min after anesthesia, T2: 1 min before tourniquet-loosening, T3: 1 min after tourniquet-loosening, T4: 5 min after tourniquet-loosening, and T5: 6 h after tourniquet-loosening). Blood samples (4 mL) was collected from the radial artery before TEAS and 6 h after loosening tourniquet for analyzing blood gas parameters as partial pressure of caron dioxide(PCO2), arterial partial pressure of oxygen (PaO2), alveolar partial pressure of oxygen (PAO2), alveolar-arterial oxygen pressure difference (PA-aDO2) and respiratory index (RI) by using a blood gas analyzer, and plasma SOD activity and MDA content were assayed by using xanthine oxidase method and thiobarbituric acid colorimetry method, respectively. RESULTS: Intra-group comparison showed that compared with T0, a significant increase was found in PA-aDO2 and RI at T5 and a significant reduction in PaO2 and PaO2/ PAO2 (a/A) ratio in the control group (P<0.05), and the same changes in the TEAS group (P<0.05) except a/A ratio. Comparison between two groups showed that at T5, both PaO2 and a/A levels were significantly higher in the TEAS group than in the control group (P<0.05), and both PA-aDO2 and RI levels were obviously lower in the TEAS group than in the control group (P<0.05), suggesting an improvement of the pulmonary function after TEAS. At T5, plasma SOD activity was significantly decreased and plasma MDA content was remarkably increased in the control group relevant to T0 (P<0.05), SOD activity was significantly higher in the TEAS group than in the control group (P<0.05), and MDA content was evidently lower in the TEAS group than in the control group (P<0.05), suggesting a reduction of oxidative stress response after TEAS. CONCLUSION: TEAS at ST36 and SP6 can improve pulmonary function and attenuate oxidative stress response in patients using tourniquet after lower extremity surgery.