Prehospital tourniquet use: An evaluation of community application and outcome.

BACKGROUND: There is substantial investment in layperson and first responder training involving tourniquet use for hemorrhage control. Little is known however about prehospital tourniquet application, field conversion, or outcomes in the civilian setting. We describe the experience of a metropolitan region with prehospital tourniquet application. METHODS: We conducted a retrospective cohort study characterizing prehospital tourniquet use treated by emergency medical services (EMS) in King County, Washington, from January 2018 to June 2019. Emergency medical services and hospital records were abstracted for demographics, injury mechanism, tourniquet details, clinical care, and outcomes. We evaluated the incidence of tourniquet application, who applied the device (EMS, law enforcement, or layperson), and subsequent course. RESULTS: A total of 168 patients received tourniquet application, an incidence of 5.1 per 100,000 person-years and 3.48 per 1,000 EMS responses for trauma. Tourniquets were applied for penetrating trauma (64%), blunt trauma (30%), and bleeding ateriovenous fistulas (7%). A subset was critically ill: 13% had systolic blood pressures of <90 mm Hg, 8% had Glasgow Coma Scale score of <13, and 3% had cardiac arrest. Among initial applications, 48% were placed by law enforcement, 33% by laypersons, and 18% by EMS. Among tourniquets applied by layperson or law enforcement (n = 137), EMS relied solely on the original tourniquet in 45% (n = 61), placed a second tourniquet in 20% (n = 28), and removed the tourniquet without replacement in 35% (n = 48). Overall, 24% required massive transfusion, 59% underwent urgent surgery, and 21% required vascular surgery. Mortality was 3% (n = 4). At hospital discharge, the tourniquet limb was fully functional in 81%, partially functional in 10%, and nonfunctional in 9%; decreased function was not attributed to tourniquet application. CONCLUSION: The high rate of application, need for urgent hospital intervention in a subset, and low incidence of apparent complication suggest that efforts to increase access and early tourniquet use can provide public health benefit. LEVEL OF EVIDENCE: Therapeutic, level IV.

Implications of the national Stop the Bleed campaign: The swinging pendulum of prehospital tourniquet application in civilian limb trauma.

BACKGROUND: Prehospital tourniquet (PHT) utilization has increased in response to mass casualty events. We aimed to describe the incidence, therapeutic effectiveness, and morbidity associated with tourniquet placement in all patients treated with PHT application. METHODS: A retrospective observational cohort study was performed to evaluate all adults with a PHT who presented at two Level I trauma centers between January 2015 and December 2019. Medically trained abstractors determined if the PHT was clinically indicated (placed for limb amputation, vascular hard signs, injury requiring hemostasis procedure, or significant documented blood loss). Prehospital tourniquets were further designated as appropriately or inappropriately applied (based on PHT anatomic placement location, occurrence of a venous tourniquet, or ischemic time defined as >2 hours). Statistical analyses were performed to generate primary and secondary results. RESULTS: A total of 147 patients met study inclusion criteria, of which 70% met the criteria for trauma registry inclusion. Total incidence of PHT utilization increased from 2015 to 2019, with increasing proportions of PHTs placed by nonemergency medical service personnel. Improvised PHTs were frequently used. Prehospital tourniquets were clinically indicated in 51% of patients. Overall, 39 (27%) patients had a PHT that was inappropriately placed, five of which resulted in significant morbidity. CONCLUSION: In summary, prehospital tourniquet application has become widely adopted in the civilian setting, frequently performed by civilian and nonemergency medical service personnel. Of PHTs placed, nearly half had no clear indication for placement and over a quarter of PHTs were misapplied with notable associated morbidity. Results suggest that the topics of clinical indication and appropriate application of tourniquets may be important areas for continued focus in future tourniquet educational programs, as well as future quality assessment efforts. LEVEL OF EVIDENCE: Epidemiological, level III; Therapeutic, level IV.

Increased Use of Prehospital Tourniquet and Patient Survival: Los Angeles Countywide Study.

BACKGROUND: Recent trends in prehospital tourniquet use remain underreported. In addition, the impact of prehospital tourniquet use on patient survival has not been evaluated in a population-level study. We hypothesized that prehospital tourniquets were used more frequently in Los Angeles County and their use was associated with improved patient survival. STUDY DESIGN: This is a retrospective cohort study using a database maintained by the Los Angeles County Emergency Medical Services Agency. We included patients who sustained extremity vascular injuries between October 2015 and July 2019. Patients were divided into the following study groups: prehospital tourniquet and no-tourniquet group. Our primary end point was in-hospital mortality. The secondary outcomes included 4- and 24-hour transfusion requirements and delayed amputation. RESULTS: A total of 944 patients met our inclusion criteria. Of those, 97 patients (10.3%) had prehospital tourniquets placed. The rate of tourniquet use increased linearly throughout our study period (goodness of fit, p = 0.014). In multivariable analysis, prehospital tourniquet use was significantly associated with improved mortality (adjusted odds ratio 0.32; 95% CI, 0.16 to 0.85; p = 0.032). Similarly, transfusion requirements were significantly lower within 4 hours (regression coefficient -547.76; 95% CI, -762.73 to -283.49; p < 0.001) and 24 hours (regression coefficient -1,389.82; 95% CI, -1,824.88 to -920.97; p < 0.001). There was no significant difference in delayed amputation rates (adjusted odds ratio 1.07; 95% CI, 0.21 to 10.88; p < 0.097). CONCLUSIONS: Prehospital tourniquet use has been on the rise in Los Angeles County. Our results suggest that the use of prehospital tourniquets for extremity vascular injuries is associated with improved patient survival and decreased blood transfusion requirements, without an increase in delayed amputations.

Tourniquet use for civilian extremity hemorrhage: systematic review of the literature.

INTRODUCTION: extremity tourniquet (TQ) use has increased in the civilian setting; the beneficial results observed in the military has influenced acceptance by EMS and bystanders. This review aimed to analyze extremity TQ types used in the civilian setting, injury site, indications, and complications. METHODS: a systematic review was conducted based on original articles published in PubMed, Embase, and Cochrane following PRISMA guidelines from 2010 to 2019. Data extraction focused on extremity TQ use for hemorrhage control in the civilian setting, demographic data, study type and duration, mechanism of injury, indications for use, injury site, TQ type, TQ time, and complications. RESULTS: of the 1384 articles identified, 14 were selected for review with a total of 3912 civilian victims with extremity hemorrhage and 3522 extremity TQ placements analyzed. The majority of TQs were applied to male (79%) patients, with blunt or penetrating trauma. Among the indications for TQ use were hemorrhagic shock, suspicion of vascular injuries, continued bleeding, and partial or complete traumatic amputations. Upper extremity application was the most common TQ application site (56%), nearly all applied to a single extremity (99%), and only 0,6% required both upper and lower extremity applications. 80% of the applied TQs were commercial devices, and 20% improvised. CONCLUSIONS: TQ use in the civilian setting is associated with trauma-related injuries. Most are single-site TQs applied for the most part to male adults with upper extremity injury. Commercial TQs are more commonly employed, time in an urban setting is under 1 hour, with few complications described.

Tourniquet use for civilian extremity hemorrhage: systematic review of the literature / Uso de torniquete nas hemorragias de extremidades na população civil: revisão sistemática da literatura

ABSTRACT Introduction: extremity tourniquet (TQ) use has increased in the civilian setting; the beneficial results observed in the military has influenced acceptance by EMS and bystanders. This review aimed to analyze extremity TQ types used in the civilian setting, injury site, indications, and complications. Methods: a systematic review was conducted based on original articles published in PubMed, Embase, and Cochrane following PRISMA guidelines from 2010 to 2019. Data extraction focused on extremity TQ use for hemorrhage control in the civilian setting, demographic data, study type and duration, mechanism of injury, indications for use, injury site, TQ type, TQ time, and complications. Results: of the 1384 articles identified, 14 were selected for review with a total of 3912 civilian victims with extremity hemorrhage and 3522 extremity TQ placements analyzed. The majority of TQs were applied to male (79%) patients, with blunt or penetrating trauma. Among the indications for TQ use were hemorrhagic shock, suspicion of vascular injuries, continued bleeding, and partial or complete traumatic amputations. Upper extremity application was the most common TQ application site (56%), nearly all applied to a single extremity (99%), and only 0,6% required both upper and lower extremity applications. 80% of the applied TQs were commercial devices, and 20% improvised. Conclusions: TQ use in the civilian setting is associated with trauma-related injuries. Most are single-site TQs applied for the most part to male adults with upper extremity injury. Commercial TQs are more commonly employed, time in an urban setting is under 1 hour, with few complications described.

RESUMO Introdução: o uso de torniquete em extremidades (TQ) aumentou no ambiente civil; os resultados benéficos observados nas forças armadas influenciaram a aceitação por equipes de pré-hospitalar (PH) assim como pela população leiga. Esta revisão teve como objetivo analisar os tipos de TQ de extremidades usados em ambiente civil, local da lesão, indicações e complicações. Métodos: revisão sistemática foi conduzida com base em artigos originais publicados no PubMed, Embase e Cochrane seguindo as diretrizes do PRISMA de 2010 a 2019. Extração de dados focada no uso de TQ de extremidade para controle de hemorragia em ambiente civil, dados demográficos, tipo de estudo e duração, mecanismo de lesão, indicações de uso, local da lesão, tipo de TQ, tempo de TQ e complicações. Resultados: dos 1.384 artigos identificados, 14 foram selecionados para revisão com total de 3.912 vítimas civis com hemorragia nas extremidades e 3.522 colocações de extremidades TQ analisadas. A maioria foi aplicado em pacientes do sexo masculino (79%), com trauma contuso ou penetrante. Entre as indicações estavam choque hemorrágico, suspeita de lesões vasculares, sangramento contínuo e amputações traumáticas parciais ou completas. A aplicação na extremidade superior foi o local de aplicação mais comum (56%), quase todos aplicados a uma única extremidade (99%), e apenas 0,6% requereram aplicações nas extremidades superior e inferior. 80% dos TQs aplicados eram dispositivos comerciais e 20% improvisados. Conclusões: o uso de TQ em ambientes civis está associado a traumas. Os TQs comerciais são mais utilizados, com tempo menor que uma hora de uso e poucas complicações.

Plasma flow distal to tourniquet placement provides a physiological mechanism for tissue salvage.

Military literature has demonstrated the utility and safety of tourniquets in preventing mortality for some time, paving the way for increased use of tourniquets in civilian settings, including perioperatively to provide a bloodless surgical field. However, tourniquet use is not without risk and the subsequent effects of tissue ischemia can impede downstream rehabilitative efforts to regenerate and salvage nerve, muscle, tissue and bone in the limb. Limb ischemia studies in both the mouse and pig models have indicated not only that there is residual flow past the tourniquet by means of microcirculation, but also that recovery from tissue ischemia is dependent upon this microcirculation. Here we expand upon these previous studies using portable Near-Infrared Imaging to quantify residual plasma flow distal to the tourniquet in mice, pigs, and humans and leverage this flow to show that plasma can be supersaturated with oxygen to reduce intracellular hypoxia and promote tissue salvage following tourniquet placement. Our findings provide a mechanism of delivery for the application of oxygen, tissue preservation solutions, and anti-microbial agents prior to tourniquet release to improve postoperative recovery. In the current environment of increased tourniquet use, techniques which promote distal tissue preservation and limb salvage rates are crucial.

Assessment of the Efficacy and Safety of a Novel, Low-Cost, Junctional Tourniquet in a Porcine Model of Hemorrhagic Shock.

INTRODUCTION: Commercially available junctional tourniquets (JTQs) have several drawbacks. We developed a low-cost, compact, easy to apply JTQ. The aim of this study was to assess the tourniquets' safety and efficacy in a swine model of controlled hemorrhage. MATERIALS AND METHODS: Five pigs were subjected to controlled bleeding of 35% of their blood volume. Subsequently, the JTQ was applied to the inguinal area for 180 minutes. Afterwards, the tourniquet was removed for additional 60 minutes of follow up. During the study, blood flow to both hind limbs and blood samples for tissue damage markers were repeatedly assessed. Following sacrifice, injury to both inguinal areas was evaluated microscopically and macroscopically. RESULTS: Angiography demonstrated complete occlusion of femoral artery flow, which was restored following removal of the tourniquet. No gross signs of tissue damage were noticed. Histological analysis revealed mild necrosis and infiltration of inflammatory cells. Blood tests showed a mild increase in potassium and lactic acid levels throughout the protocol. CONCLUSIONS: The tourniquet achieved effective arterial occlusion with minimal tissue damage, similar to reports of other JTQs. Subjected to further human trials, the tourniquet might be a suitable candidate for widespread frontline deployment because of its versatility, compactness, and affordable design.

Tourniquet Use in Wide-Awake Carpal Tunnel Release.

Background: Carpal tunnel syndrome is a common cause of upper extremity discomfort. Surgical release of the median nerve can be performed under general or local anesthetic, with or without a tourniquet. Wide-awake carpal tunnel release (CTR) (local anesthesia, no sedation) is gaining popularity. Tourniquet discomfort is a reported downside. This study reviews outcomes in wide-awake CTR and compares tourniquet versus no tourniquet use. Methods: Wide-awake, open CTRs performed from February 2013 to April 2016 were retrospectively reviewed. Patients were divided into 2 cohorts: with and without tourniquet. Demographics, comorbidities, tobacco use, operative time, estimated blood loss, complications and outcomes were compared. Results: A total of 304 CTRs were performed on 246 patients. The majority of patients were male (88.5%), and the mean age was 59.9 years. One hundred patients (32.9%) were diabetic, and 92 patients (30.2%) were taking antithrombotics. Seventy-five patients (24.7%) were smokers. A forearm tourniquet was used for 90 CTRs (29.6%). Mean operative time was 24.97 minutes with a tourniquet and 21.69 minutes without. Estimated blood loss was 3.16 mL with a tourniquet and 4.25 mL without. All other analyzed outcomes were not statistically significant. Conclusion: Operative time was statistically longer and estimated blood loss was statistically less with tourniquet use, but these findings are not clinically significant. This suggests that local anesthetic with epinephrine is a safe and effective alternative to tourniquet use in CTR. The overall rate of complications was low, and there were no major differences in postoperative outcomes between groups.

Pediatric Ganglion Cysts: A Retrospective Review.

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

Prehospital tourniquet use in penetrating extremity trauma: Decreased blood transfusions and limb complications.

BACKGROUND: Despite increasing popularity of prehospital tourniquet use in civilians, few studies have evaluated the efficacy and safety of tourniquet use. Furthermore, previous studies in civilian populations have focused on blunt trauma patients. The objective of this study was to determine if prehospital tourniquet use in patients with major penetrating trauma is associated with differences in outcomes compared to a matched control group. METHODS: An 8-year retrospective analysis of adult patients with penetrating major extremity trauma amenable to tourniquet use (major vascular trauma, traumatic amputation and near-amputation) was performed at a Level I trauma center. Patients with prehospital tourniquet placement (TQ) were identified and compared to a matched group of patients without tourniquets (N-TQ). Univariate analysis was used to compare outcomes in the groups. RESULTS: A total of 204 patients were matched with 127 (62.3%) in the prehospital TQ group. No differences in patient demographics or injury severity existed between the two groups. Average time from tourniquet application to arrival in the emergency department (ED) was 22.5 ± 1.3 minutes. Patients in the TQ group had higher average systolic blood pressure on arrival in the ED (120 ± 2 vs. 112 ± 2, p = 0.003). The TQ group required less total PRBCs (2.0 ± 0.1 vs. 9.3 ± 0.6, p < 0.001) and FFP (1.4 ± 0.08 vs. 6.2 ± 0.4, p < 0.001). Tourniquets were not associated with nerve palsy (p = 0.330) or secondary infection (p = 0.43). Fasciotomy was significantly higher in the N-TQ group (12.6% vs. 31.4%, p < 0.0001) as was limb amputation (0.8% vs. 9.1%, p = 0.005). CONCLUSION: This study demonstrated that prehospital tourniquets could be safely used to control bleeding in major extremity penetrating trauma with no increased risk of major complications. Prehospital tourniquet use was also associated with increased systolic blood pressure on arrival to the ED, decreased blood product utilization and decreased incidence of limb related complications, which may lead to improved long-term outcomes and increased survival in trauma patients. LEVEL OF EVIDENCE: Therapeutic, level IV.

Tourniquet use in the prehospital setting: Are they being used appropriately?

OBJECTIVE: The objective of this study was to evaluate tourniquet use in the Hartford prehospital setting during a 34-month period after the Hartford Consensus was published, which encouraged increasing tourniquet use in light of military research. DESIGN: This was a retrospective review of patients with bleeding from a serious extremity injury to determine appropriateness of tourniquet use or omission. SETTING: Level II trauma center between April 2014 and January 2017. PARTICIPANTS: Eighty-four patients met inclusion criteria and were stratified based on tourniquet use during prehospital care. MAIN OUTCOME MEASURES: Five of the 84 patients received a tourniquet. All five of those tourniquets (100 percent of the group, 6.0 percent of the population) were not indicated and deemed inappropriate. Three of the 84 patients did not receive a tourniquet when one was indicated (3.8 percent of the group, 3.6 percent of the population) and these omissions were also deemed inappropriate. Total error rate was 9.5 percent (8/84). RESULTS: There was a significant association between Mangled Extremity Severity Score (MESS) and likelihood of requiring a tourniquet (p = 0.0013) but not between MESS and likelihood of receiving a tourniquet (p = 0.1055). There was also a significant association between wrongly placed tourniquets and the type of providers who placed them [first responders, p = 0.0029; Emergency Medicine Technicians (EMTs), p = 0.0001]. CONCLUSIONS: Tourniquets are being used inappropriately in the Hartford prehospital setting. Misuse is associated with both EMTs and first responders, highlighting the need for better training and more consistent protocols.

Use of Tourniquets in Limb Trauma Surgery.

Although tourniquets are commonly used in patients with limb trauma patients, both in the acute and elective settings, no set protocols exist for their indications, contraindications, or proper use. This article addresses the current literature on optimal pressure, timing, cuff design, and complications of tourniquets in trauma patients. General issues are discussed, followed by those specific to upper and lower extremities. Lastly, serious complications, such as pulmonary embolism, are described.

Systematic review of prehospital tourniquet use in civilian limb trauma.

BACKGROUND: Military enthusiasm for limb tourniquet use in combat casualty care has resulted in acceptance by the trauma community for use in the prehospital care of civilian limb injuries. To date, there has been no report synthesizing the published data on civilian tourniquet use. The objective of this systematic review was to compile and analyze the content and quality of published data on the civilian use of tourniquets in limb trauma. METHODS: The MEDLINE database was searched for studies on civilian limb tourniquet use in adults published between 2001 and 2017. Search terms were tourniquet, trauma, and injury. Military reports and case series lacking systematic data collection were excluded. Counts and percentages were aggregated and weighted for analysis. RESULTS: Reports were included from six regional trauma centers and one interregional collaboration (total of 572 cases). One national prehospital database report was included but analyzed separately (2,048 cases). All were retrospective cohort studies without prospective data collection. Three reports defined a primary outcome, two had a nontourniquet control group, and no two articles reported the same variables. Limb injury severity and characteristics were inconsistently and incompletely described across reports, as were tourniquet indications and effectiveness. Arterial injury was reported in two studies and was infrequent among cases of tourniquet use. Mortality was low, and limb-specific complications were infrequent but variably reported. CONCLUSION: The rapid increase in the civilian use of tourniquets for limb hemorrhage control has occurred without a large amount or high quality of data. Adoption of a multicenter registry with standardized data collection specific to limb trauma and tourniquet use can serve to improve the trauma community's understanding of the safety and effectiveness of tourniquet use in civilian trauma settings. LEVEL OF EVIDENCE: Systematic review, level IV.

Application of tourniquet in civilian trauma: Systematic review of the literature.

INTRODUCTION: The effectiveness of a tourniquet (TQ) in case of extremity haemorrhages is well recognised to prevent deaths on the battlefield. However, little is known about the usefulness of TQ in civilian trauma settings, including terrorist attack situations. The aim of this systematic review was to analyse the evidence-based medical literature in order to precise the use of TQ in the management of extremity haemorrhages in civilian setting. METHODS: Analysis of all studies published until 12/31/2016 on the Embase, Medline and Opengrey databases. To be included, studies had to contain descriptions, discussions or experiences of TQ application in civilian setting. The quality of the studies was evaluated using the PRISMA and the STROBE criteria. RESULTS: Of the 380 studies identified, 24 were included. The overall level of evidence was low. Three thousand and twenty eight TQ placements were reported. Most of them concerned the Combat Application Tourniquet CAT. Haemorrhages implied in the use of TQ were almost exclusively traumatic, most of the time regarding young men (27-44 years old). Effectiveness rates of TQ varied between 78% and 100%. Complications rates associated with the use of TQ remained low, even when used in elderlies or patients with comorbidities. Finally, caregivers reported a common fear of adverse effects, while reported complications were rare (<2%). CONCLUSION: This systematic review revealed TQ to be an effective tool for the management of extremity haemorrhages in civilian trauma, associated with few complications. Larger studies and dedicated training courses are needed to improve the use of TQ in the civilian standards of care.

The trauma center is too late: Major limb trauma without a pre-hospital tourniquet has increased death from hemorrhagic shock.

BACKGROUND: To date, no civilian studies have demonstrated that pre-hospital (PH) tourniquets improve survival. We hypothesized that late, trauma center (TC) tourniquet use would increase death from hemorrhagic shock compared to early (PH) placement. METHODS: All patients arriving to a Level 1, urban TC between October 2008 and January 2016 with a tourniquet placed before (T-PH) or after arrival to the TC (T-TC) were evaluated. Cases were assigned the following designations: indicated (absolute indication [vascular injury requiring repair/ligation, operation within 2 hours for extremity injury, or traumatic amputation] or relative indication [major musculoskeletal/soft tissue injury requiring operation 2-8 hours after arrival, documented large blood loss]) or non-indicated. Outcomes were death from hemorrhagic shock, physiology upon arrival to the TC, and massive transfusion requirements. After univariate analysis, logistic regression was carried out to assess independent predictors of death from hemorrhagic shock. RESULTS: A total of 306 patients received 326 tourniquets for injuries to 157 upper and 147 lower extremities. Two hundred eighty-one (92%) had an indication for placement. Seventy percent of patients had a blunt mechanism of injury. T-TC patients arrived with a lower systolic blood pressure (SBP, 101 [86, 123] vs. 125 [100, 145] mm Hg, p < 0.001), received more transfusions in the first hour of arrival (55% vs. 34%, p = 0.02), and had a greater mortality from hemorrhagic shock (14% vs. 3.0%, p = 0.01). When controlling for year of admission, mechanism of injury and shock upon arrival (SBP ≤90 mm Hg or HR ≥120 bpm or base deficit ≤ 4) indicated T-TC had a 4.5-fold increased odds of death compared to T-PH (OR 4.5, 95% CI 1.23-16.4, p = 0.02). CONCLUSIONS: Waiting until TC arrival to control hemorrhage with a tourniquet was associated with worsened blood pressure and increased transfusion within the first hour of arrival. In routine civilian trauma patients, delaying to T-TC was associated with 4.5-fold increased odds of mortality from hemorrhagic shock. LEVEL OF EVIDENCE: Level IV.

Intravenous and Topical Tranexamic Acid Alone Are Superior to Tourniquet Use for Primary Total Knee Arthroplasty: A Prospective, Randomized Controlled Trial.

BACKGROUND: Tourniquet use during primary total knee arthroplasty is thought to reduce intraoperative blood loss and improve visibility. Our goal was to investigate whether tourniquet use is necessary for controlling intraoperative blood loss when alternatives such as tranexamic acid (TXA) are available. METHODS: One hundred and fifty patients were equally randomized to 3 groups. Group A was treated with a tourniquet as well as multiple doses of intravenous TXA (20 mg/kg 5 to 10 minutes before the skin incision and 10 mg/kg 3, 6, 12, and 24 hours later) along with 1 g of topical TXA, Group B was treated the same as Group A but without the tourniquet, and Group C was treated with the tourniquet only. RESULTS: The amount of intraoperative blood loss was similar for the 3 groups. Group B had significantly less hidden blood loss than Group A (p = 0.018) and Group C (p < 0.001). No significant differences (p > 0.05) were observed between Group A and Group B with regard to total blood loss, drainage volume, intraoperative blood loss, transfusion rate, or maximum change in the hemoglobin (Hb) level. We also found significantly more benefits for Group B compared with Groups A and C with regard to postoperative swelling ratio, levels of inflammatory biomarkers, visual analog scale (VAS) pain scores, range of motion at discharge, Hospital for Special Surgery (HSS) score, and patient satisfaction. There were no significant differences (p > 0.05) in the deep venous thrombosis or pulmonary embolus rates among the 3 groups. More wound secretion was observed in the groups in which a tourniquet was used. CONCLUSIONS: Patients treated with multiple doses of intravenous and topical TXA without a tourniquet had less hidden blood loss, a lower ratio of postoperative knee swelling, less postoperative knee pain, lower levels of inflammatory biomarkers, better early knee function, and even better early satisfaction than those treated with a tourniquet. Long-term follow-up should be performed to evaluate the effects on prosthetic fixation and long-term survival of total knee arthroplasty performed without a tourniquet. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.