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.

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.

Rhabdomyolysis after the free fibular flap operation for mandibular reconstruction: a case report / 대한악안면성형재건외과학회지

BACKGROUND: Free fibular flap is one of the most useful methods in the hard tissue reconstruction of the maxilla-mandible. Free fibular flap presents some advantages in which the reconstruction of both soft and hard tissues can be done at the same time. It also provides a safe and successful bone graft for the reconstruction, along with a low rate of complications. Despite these advantages and the rarity of a postoperative complication, particularly in oral and maxillofacial surgery procedures, a prolonged operation might exhibit some complications related with rhabdomyolysis. We experienced the rare event of rhabdomyolysis after oral cancer surgery. CASE PRESENTATION: In this article, we report the case of a patient who developed rhabdomyolysis after undergoing free fibular flap surgery. CONCLUSIONS: Despite the advantages of the free fibular flap operation, clinicians must be aware of the risk of complications because there are multiple factors that could result in rhabdomyolysis, such as duration of operation, position of the subject, and pre-existing conditions of diabetes and hypertension. Once the diagnosis of rhabdomyolysis is confirmed, a prompt treatment plan should be made and applied as soon as possible. This will increase the chance of a full recovery for the patient who is exhibiting symptoms of rhabdomyolysis.

Evaluación del sangrado y tiempo quirúrgico en artroplastía total de rodilla con y sin torniquete: Estudio comparativo / Assessment of bleeding and operative time in total knee arthroplasty with and without tourniquet: Comparative study

Antecedentes: La utilización de torniquete neumático (TN) en la artroplastía total de rodilla (ATR) ha sido tema de controversia, describiendo ventajas, desventajas y complicaciones asociadas. Con la finalidad de evaluar los beneficios de su utilización se estudió el tiempo quirúrgico, volumen de sangrado transquirúrgico, postquirúrgico y total, así como los valores de hemoglobina y hematocrito pre y postquirúrgicos de pacientes a los que se les realizo ATR primaria utilizando TN y se compararon con un grupo control. Material y métodos: Se realizó un análisis retrospectivo de expedientes clínicos de casos sometidos a ATR; en apego a los criterios de inclusión se obtuvo un grupo de estudio (n = 19) y control (n = 19) según la utilización o no de TN. Se compararon el tiempo quirúrgico, el sangrado transquirúrgico y postquirúrgico así como el sangrado total; valores de hemoglobina y hematocrito iniciales y finales. Resultados: Se obtuvieron diferencias significativas a favor del grupo en quienes se utilizó TN en 7 de 8 variables estudiadas, siendo el tiempo empleado (t = 2.08 p < 0.050); sangrado transquirúrgico (t = -6.44, p < 0.010); postquirúrgico (t = -2.170 p < 0.050) y total (t = /7.52, p < 0.010), las más relevantes. Conclusiones: Los resultados mostraron que los sujetos a quienes se les aplicó TN durante la ATR requirieron menos tiempo quirúrgico y que el sangrado total, trans y postquirúrgico, así como la perdida sanguínea calculada fueron menores que los controles. Mayores conjeturas sobre los beneficios del TN ameritan la realización de más investigaciones prospectivas.

Background: The use of the pneumatic tourniquet (PT) in total knee arthroplasty (TKA) has been controversial; its advantages, disadvantages and associated complications have been described. In order to assess its benefits we analyzed operative time; intraoperative, postoperative and total bleeding volume, as well as pre- and postoperative hemoglobin and hematocrit values in patients who had undergone primary TKA using the PT, and they were compared with a control group. Material and methods: A retrospective analysis of the clinical records of cases who underwent TKA was conducted. Based on the inclusion criteria and the use or non-use of PT, two groups were formed: a study group (n = 19) and a control group (n = 19). The following variables were compared: operative time, intra and postoperative bleeding and total bleeding; initial and final hemoglobin and hematocrit values. Results: Significant differences in favor of the group with PT use were obtained in 7 out of the 8 variables studied. The most relevant ones were operative time (t = 2.08 p < 0.050); intraoperative bleeding (t = -6.44, p < 0.010); postoperative bleeding (t = -2.170 p < 0.050) and total bleeding (t = /7.52, p < 0.010). Conclusions: The results showed that patients in whom PT was used during TKA had a shorter operative time, and their total, intra- and postoperative bleeding and the estimated blood loss were lower than in controls. Additional suppositions on the benefits of PT warrant the conduction of more prospective research studies.

Povidone-Iodine related Chemical Burn under the Tourniquet (A Case Report) / 대한족부족관절학회지

In the extremity surgery, pneumatic tourniquet and povidone-iodine solution are commonly used to provide an aseptic, bloodless field, and their complication rate has remained low. However, chemical burn under tourniquet has been rarely reported. Patients sustained burn injuries over the dependent, weight-bearing regions such as posterior neck, back, buttocks and posterior thighs. This rare adverse complication occurred in a 22-year-old man who underwent modified Brostrom operation with arthroscopic os trigonum excision. 10% povidone-iodine was used as topical antiseptic, and full thickness burn occurred underneath the area of tourniquet application. Main causes of povidone-iodine related chemical burn are considered maceration, irritation of the skin, long term use of the tourniquet and pressure. To reduce the complications like chemical burn, awareness of the risk and the possible pathogenesis as well as the preventive measures is important in surgical practice.

Eficacia del ácido tranexámico en la reducción del sangrado post operatorio en artroplastía total de rodilla / Efficacy of the tranexamic acid in the reduction of the postoperative bleeding in total knee replacement

We investigated the effect of the tranexamic acid in the reduction of the post operative bleeding in patients undergoing a total knee replacement. A prospective study was performed, 20 patients made up the study group, these individuals received an intravenous dose of 15 mg/kg weight just before the surgery and a second dose equal to the first one, before the release of the pneumatic tourniquet. The control group included 20 patients who underwent a total knee replacement and did not receive any kind of antifibrinolytic therapy. Patients who received the tranexamic acid had a mean postoperative bleeding of 383 mls +/- 236 versus the control group who had a mean of 1.025 mls +/- 281 of bleeding. The difference between both groups was statistically relevant according to the Mann Whitney test. There were no cases of clinical deep vein thrombosis (DVT), neither pulmonary thromboembolism. Based on the results reported in the literature and obtained in our study, we recommend the routinary use of the tranexamic acid in patients undergoing a total knee replacement.

Investigamos el efecto del ácido tranexámico en el sangrado post operatorio de pacientes sometidos a artroplastía total de rodilla. Este es un estudio prospectivo que contó con un grupo de 20 casos en los que se administró una dosis de 15 mgs/kg peso justo antes del inicio de la cirugía y se repitió antes de la deflación del torniquete neumático. Los pacientes que recibieron ácido tranexámico presentaron un sangrado postoperatorio promedio medido en el receptáculo del drenaje de 383 mls +/- 236 versus el grupo control que tuvo un sangrado promedio de 1.025 mls +/- 281. La diferencia fue estadísticamente significativa entre ambos grupos de acuerdo al test de Mann Whitney. No se registraron casos de trombosis venosa profunda clínica, ni de tromboembolismo pulmonar. Recomendamos el uso de este fármaco de manera rutinaria en este tipo de procedimientos dados los beneficios reportados en la literatura y comprobados en nuestro estudio.

The Effects of Tourniquet Pressure on the Postoperative Thigh Pain and Blood Loss in Total Knee Arthroplasty

PURPOSE: We wanted to analyze the effects of tourniquet pressure on the postoperative thigh pain and blood loss of patients who undergo total knee arthroplasty. MATERIALS AND METHODS: This prospective randomized study focused on one-hundred sixty-one unilateral total knee arthroplasties that were done with using a tourniquet. The tourniquet pressures were 300 mmHg in group I (seventy-four cases) and 100 mmHg higher than the systolic blood pressure in group II (eighty-seven cases). We analyzed the postoperative thigh pain with using a visual analog scale (VAS), and we assessed the hemoglobin levels and the hematocrits. RESULTS: The incidence of postoperative thigh pain in group II was statistically lower than that of group I. The intensity of the postoperative thigh pain of group II was lower than that of group I at both 6 hours and 72 hours after surgery. There were no statistical differences in blood loss between the two groups. CONCLUSION: Using a tourniquet pressure of 100 mmHg above the systolic blood pressure during total knee arthroplasty can reduce the postoperative thigh pain. When comparing the above technique with a TKA using 300 mmHg of tourniquet pressure, there was no statistically significant difference of the postoperative blood loss.

Quantification and Comparison of D-dimer after Pneumatic Tourniquet Release in Patients Undergoing Arthroscopic Knee Surgery on General Anesthesia and Epidural Anesthesia / 대한마취과학회지

BACKGROUND: Several studies have indicated that lumbar epidural anesthesia may decrease the incidence of deep vein thrombosis and pulmonary embolism, particulary after total hip replacement. Moreover venous thromboembolism also occurs after the release of a tourniquet in orthopedic surgery. The d-dimer test has been reported to be useful for predicting lower limb DVT and PE. Of the d-dimer test methods, the latex agglutination method shows excellent sensitivity and specificity. METHODS: We compared the quantity of d-dimer for General (n = 21) and Epidural (n = 20) anesthesia after tourniquet release in patients undergoing arthroscopic knee surgery. RESULTS: D-dimer significantly increased after tourniquet release in both groups, whereas the increase of d-dimer in the Epidural group was no smaller than that in the General group. Epidural group showed a correlation between tourniquet application and d-dimer. CONCLUSIONS: The present data suggest that DVT and PE after tourniquet release could occur during arthroscopic knee surgery and that epidural anesthesia may increase the fibrinolysis of a tourniquet induced thrombus.

Tourniquet Induced Hypertension and Vital Sign Changes in Elderly Patients Associated with Tourniquet Use under General or Epidural Anesthesia for Total Knee Arthroplasty / 대한마취과학회지

BACKGROUND: Tourniquet is associated with tourniquet induced hypertension (T-HTN) and with occasional circulatory collapse. These changes can be well tolerated by young healthy patients; however, in elderly patients with reduced physiologic cardiovascular reserve and blunted baroreflex, these alterations could be significantly detrimental. So we studied that whether there was any difference in hemodynamic changes in elderly patients receiving general or epidural anesthesia. METHODS: One hundred twenty patients underwent total knee arthroplasty were classified into four groups; general anesthesia in control ( or = 65 years, group II, n=30), epidural anesthesia in control (group III, n=30), epidural anesthesia in elderly (group IV, n=30). Mean blood pressure (MAP), heart rate (HR) and PETCO2 were recorded throughout the experiments. RESULTS: MAP in the general anesthesia was higher than that in the epidural anesthesia after tourniquet inflation and there was pronounced occurrence of T-HTN in the group II (43.3%). After tourniquet deflation, MAP was more reduction in the group II than that in the group IV (23.3+/-10.9% vs 17.4+/-9.4%, p<0.05), and heart rate was increased in all groups except group II. Tourniquet time did not correlate with the magnitude of the changes in MAP and HR associated with tourniquet application. CONCLUSIONS: In elderly patients associated with general anesthesia, occurrence of "tourniquet hypertension" is more frequent and reduction in MAP after deflation is more marked without compensatory increasing of HR than epidural.

Changes of Serum Myoglobin at Tourniquet Application / 대한마취과학회지

Serum myoglobin concentrations were studied in 46 patients during orthopedic and plastic operations that required the application of a pneumatic limb tourniquet. Serum myoglobin was measured at preoperation, during tourniquet and after touriquet release. In the general anesthesia patients, serum myoglobin was after tourniquet release(172.72+/-29.49 ng/ml) significantly increased(p<0.01) than at preoperation(103.06+/-24.03 ng/ml). In the regional block patients, serum myoglobin after tourniquet release(117.69+/-10.08ng/ml) also increased(p<0.05) than at preoperation(67.08+/-14.99ng/ml). In the male patients, serum myoglobin was significantly increased(p<0.05) during tourniquet and after tourniquet release(123.36+/-15.42ng/ml & 158.86+/-21.10ng/ml) than at preoperation (93.58+/-17.11ng/ml). In the female patients, there was no significant difference to regardless of tourniquet application. In the patients that tourniquet application time was within one hour, serum myoglohin was significantly increased(p<0.01) during tourniquet and after tourniquet release(125.66+/-18.86 & 126.20+/-14.99ng/ml) than at preoperation(86.12+/-15.29ng/ml). In the patients that tourniquet application time was over one hour, serum myoglobin was sig- nificantly increased(p<0.01) during tourniquet(l05.92+/-21.84ng/ml) than at preoperation(91.16+/-31.17ng/ml) and in the after tourniquet release(183.88+/-40.96ng/ml), serum myoglobin was more significantly(p<0.05) increased than during tourniquet.

The Changes of Metabolic and Acid - base Status and Respiratory Gases Elicited by Pneumatic Tourniquet for Lower Extremity Surgery / 대한마취과학회지

For extremity surgery, tourniquet is placed routinely. With deflation of the tourniquet, the metabolic product is flushed into the systemic circulation and theoretically poses a potential for toxic reactions. In actual fact, these are rare events with this technique. Vigilant monitoring will detect cardiovascular depression at this time. By the tourniquet application, lactic acidemia, abnormal coagulopathy, hypotention, hyperkalemia, increased PaCO2, and production of noxious oxygen free radicals were reported following the release of the tourniquet. But the serial changes of metabolic derangement, degree of lactic acidemia following the use of the tourniquet were not exactly known. To confirm the safety of the pneumatic tourniquet use for two hours, the serial changes of lactic acid levels, acid-base status, potassium concentration, concentration of respiratory gaaes (arterial and end-tidal CO2,) and also hypotension, dysrhythmias and respiratory pattern following release of the tourniquet were studied. Patients were anesthetized with 1% halothane, 50% nitrous oxide and 50% oxygen. Ventilation was maintained by the ventilator to keep the end-tidal CO2, to 4.0% just before the release, and then respiratory parameters (respiratory rate, tidal volume) were constantly maintained through the study. The data were measured from arterial samples or monitors with the following interval; just before tourniquet apply (BTA), before tourniquet release (BTR), at 1, 3, 5, 15 and 30 minutes after the tourniquet release (ATR 1 m, 3m, 5 m, 15 m 30 m). Data measured before the tourniquet apply were used as control values. All data were analyzed by the paired t-test with control. Changes of mean values of each time in one parameter were analyzed by one-way ANOVA. Correlationships between the parameters and duration of ischemia induced by the tourniquet were analyzed by simple regression. The results of this study were as follows; 1) The arterial concentration of lactic acid was maximally increased at 3 minutes after tourniquet release and not returned to control value until 30 minutes after tourniquet release. 2) End-tidal CO, was reached to maximal values of 5.3% at 5 minutes after release of tourniquet. Accompanying theses changes, spontaneous respiration was recovered from the controlled ventilation in 11 patients out of 13 and fought with mechanical ventilator due to asynchronism of respiratory cycles. 3) Mild metabolic acidosis showing the decreased arterial pH and increased PaCO2, in arterial blood gas analysis was maintained in 30 minutes following the release of tourniquet. 4) There were no significant changes of concentrations of potassium. 5) Three episodes of mild hypotension were observed out of 13 patients, but dysrhythmias and other significant clinical changes not observed through the study. The above results showed the possibility of lactic acidemia and changes of respiratory pattern by increased PaCO2, after release of the tourniquet may occur. More intent monitoring is needed to the patients who have had the metabolic derangement in acid-base balance and increased intracranial pressure in application of tourniquet on limbs.