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Background: We aimed to evaluate the effectiveness of i.v. acetaminophen (with or without tourniquet application) in comparison with that of lidocaine for the prevention of propofol-induced pain du...

Surgical site infections (SSIs) are associated with substantial patient morbidity and death. It is estimated that 750,000-1 million SSIs occur in the U.S. each year, utilizing 3.7 million extra hospital days and costing more than $1.6 billion in excess hospital charges.Review of pertinent English-language literature.The Surgical Care Improvement Project (SCIP) was embraced as a "one-size-fits-all" strategy to reduce postoperative infectious morbidity 25% by 2010. Unfortunately, the evidence suggests that SCIP by itself has had little efficacy in reducing the overall risk of SSI. Whereas the SCIP initiative represents a first national effort to focus on reducing postoperative infectious morbidity and deaths, it fails to consider salient risk factors such as body mass index and selected surgical practices, including tourniquet application prior to incision.Rather than focus on a single risk-reduction strategy, future efforts to improve surgical outcomes should embrace a "SCIP-plus" multi-faceted, tiered interventional strategy that includes pre-admission antiseptic showering, state-of-the-art skin antisepsis, innovative antimicrobial technology, active staphylococcal surveillance, and pharmacologic-physiologic considerations unique to selective patient populations.

Tourniquet application has become first-line treatment for extremity hemorrhage on the battlefield and has seen increased use in the civilian arena. We hypothesized that an effective windlass tourniquet could be removed after application of a hemostatic dressing in a swine model of peripheral vascular injury. A tourniquet was placed proximally in 50 forelimb-injured swine after 30 seconds of hemorrhage with cessation of hemorrhage in all cases. Hemcon®, ActCel, Quikclot®, Celox™, or standard gauze was then placed over the wound with direct pressure for three minutes. The tourniquet was then removed. Success was determined if no bleeding was identified. Standard gauze resulted in a 100 per cent failure rate with active bleeding present after each application. Celox™ was successful in maintaining hemostasis in 6 of 10 (60%) subjects. Quikclot® succeeded in 80 per cent of subjects. ActCel maintained hemostasis in nine (90%) subjects, whereas HemCon® was successful in all instances (100%). All four hemostatic dressings were superior to gauze in maintaining hemostasis after removal of an effective tourniquet. Use of hemostatic dressings in conjunction with a tourniquet may reduce tourniquet times and improve outcomes in peripheral vascular injury and warrants further study.

Ischemic monogenic neuropathy (IMN) reported mostly in diabetics with peripheral neuropathy or peripheral vascular disease is a rare condition .Usually seen after AV fistula for haemodialysis, it is a preventable entity. We describe a rare case of ischemic monomelic neuropathy (IMN) in a young girl with involvement of all three nerves developing after preventive tourniquet application in a presumed snake bite.

We have recently demonstrated that the use of a tourniquet to locate the vein prior to blood sampling may affect red blood cell (RBC) deformability and aggregation, even if the tourniquet is quickly removed after insertion of the needle into the vein. However, in clinical practice, the tourniquet is usually kept in place until blood sampling is completed. The present study tested the effects of tourniquet application during the blood sampling period on RBC deformability and aggregation. We compared blood samples obtained at 5, 30, 60 and 90 seconds following the tourniquet application; a control blood sample was obtained without applying a tourniquet. RBC deformability was slightly increased at 5 seconds (7.6% mean, 1-5 Pa) and at 60 seconds (5.9% mean, 1-30 Pa) but not at 30 or 90 seconds, with the increase inversely related to shear stress. The RBC aggregation index was slightly but significantly decreased at 5, 30 and 60 seconds, with no changes observed for either amplitude or half-time of aggregation. These very modest yet significant effects of tourniquet application on hemorheological parameters may not be meaningful in terms of pathophysiology, but may become important in data interpretation or for specific subjects.

This study was undertaken to evaluate tourniquet tolerance in healthy people. An arm tourniquet was inflated to 100 mmHg above systolic blood pressure for 21 minutes. We measured pain and grip strength before, during and at various times after deflation. We tested 40 subjects (20 women and 20 men) with an average age of 38 (range 22–58) years. Eight individuals did not tolerate the tourniquet for this length of time and the test was stopped. Visual analogical scale had a globally linear increase during tourniquet application. We noted a sensation of well-being just after deflation, quickly replaced by pain in the tested limb due to limb reperfusion. We also noted a significant loss of strength in the tested limb, which completely recovered by 48 hours. We also observed a significant loss of strength in the contralateral hand, which also recovered by 48 hours. The possible reasons for these temporary losses of strength in both the ipsilateral and contralateral limbs are discussed.

The use of a tourniquet to control bleeding is a necessity in both surgical and prehospital settings. Tourniquet application, if performed properly, can be a lifesaving procedure, particularly in a traumatic setting such as the battlefield. A tourniquet is easily applied and requires the use of a relatively uncomplicated piece of equipment. However, improper or prolonged placement of a tourniquet because of poor medical training can lead to serious injuries, such as nerve paralysis and limb ischemia. Here we present five case reports of improper tourniquet applications on the battlefield that resulted in nerve damage. We conclude that there is a need for improved training among medical personnel in the use of tourniquets, as well as a need for an adjustable-pressure, commercial-type sphygmomanometer cuff with a large surface area that is appropriate for application to all limbs parts. We also recommend that, in cases requiring the use of a tourniquet, the caregiver remove the tourniquet every 2 hours and assess the bleeding; if the bleeding has stopped, then the tourniquet should be replaced with a pressure bandage to minimize tissue damage.

Tourniquets are an effective means of arresting life‐threatening external haemorrhage from limb injury. Their use has not previously been accepted practice for pre‐hospital civilian trauma care because of significant concerns regarding the potential complications. However, in a few rare situations tourniquet application will be necessary and life‐saving. This review explores the potential problems and mistrust of tourniquet use; explains the reasons why civilian pre‐hospital tourniquet use may be necessary; defines the clear indications for tourniquet use in external haemorrhage control; and provides practical information on tourniquet application and removal. Practitioners need to familiarise themselves with commercial pre‐hospital tourniquets and be prepared to use one without irrational fear of complications in the appropriate cases.

Sterile elastic exsanguination tourniquets (HemaClear; OHK Medical Devices, Haifa, Israel) are relatively new on the market but are widely used because of the ease and speed of their application. The sterile elastic exsanguination tourniquet consists of a silicon ring wrapped in a stockinet sleeve with pull straps. The physician places the ring on the patient's fingers or toes and then pulls the straps proximally. The silicon ring rolls up the limb, and the stockinet sleeve unrolls onto the limb. During proximal rolling, the device displaces blood out of the limb (exsanguination). When the elastic ring reaches the preferred occlusion location, the pulling motion is stopped. The ring exerts suprasystolic pressure on the limb, thereby blocking arterial blood flow into the limb and thus acts as a tourniquet. HemaClear tourniquets are thin and sterile and therefore provide a large operative field. The authors report 2 cases of pulmonary embolism after HemaClear tourniquet application in patients with traumatic injuries (fractures of the patella and tibial plateau). Exsanguination applies mechanical stress that might dislodge a preexisting deep venous thrombosis, leading to the serious complication of pulmonary embolism. The authors want to increase awareness of this possible fatal complication during procedures performed on the lower limbs, when the HemaClear tourniquet is used for exsanguination of the affected limb. Careful consideration should be given to the use of HemaClear tourniquets in high-risk patients and those with traumatic injuries, especially when there has been a delay in surgery. [ Orthopedics. 2015; 38(12):e1160–e1163.]

There is a great deal of controversy about the effect of tourniquets on development of deep vein thrombosis (DVT) after total knee arthroplasty (TKA).We investigated the incidence of postoperative DVT after TKA with or without the use of a tourniquet. The patients were 48 consecutive patients undergoing primary ipsilateral cemented TKA for osteoarthritis. Group A (21 patients) underwent the operation without a tourniquet, and Group B (27 patients) underwent the operation with a tourniquet. Ultrasonography to assess DVT was performed before and after the operation.Group B had less intraoperative and total blood loss than Group A. Postoperative DVT was detected in 81.3% of all cases, and symptomatic pulmonary embolism occurred in 1.7%. Most of DVT was found in the calf vein. There was no significant difference in the incidence of postoperative DVT between the two groups.We conclude that the use of a tourniquet is beneficial, because it decreases perioperative blood loss and does not increase the risk of DVT. The incidence of DVT after TKA is considerably high with or without use of a tourniquet. Therefore, prevention and early detection of DVT are important for prevention of fatal pulmonary thromboembolism.

The use of tourniquets in total knee arthroplasty (TKA) for patients with knee osteoarthritis is controversial. Although surgical techniques are more easily applied in a shorter time; there are some disadvantages associated with tourniquet use in orthopedic surgery. The aim of this study was to evaluate the effect of the tourniquet time on quadriceps strength by isokinetic muscle strength measurements in patients undergoing TKA. Prospective controlled study. Twenty-five knees of 25 patients with primary degenerative joint disease who underwent TKA were evaluated preoperatively and postoperatively at weeks 6 and 12 and month 6 by isokinetic knee extensor muscle strength testing at and American Knee Society Score (AKSS). The tourniquet time of all patients was recorded, and the preoperative results of all patients were compared with those postoperatively. The mean 60º/s angular velocity quadriceps peak torque was significantly lower postoperatively in patients with a longer tourniquet time. Isokinetic tests showed a significant negative correlation between the tourniquet time and mean muscle strength (week 6: r = 0.718, p < 0.01; week 12: r = 0.651, p < 0.01; month 6: r = 0.672, p < 0.01). The highest correlation with tourniquet time was obtained 6 weeks after surgery. Additionally, strong negative correlations were observed between the AKSS and tourniquet times (Knee Score: r = 0.904, p < 0.01; Knee Functional Score: r = 0.878, p < 0.01). Lower postoperative mean quadriceps strength in patients with a longer tourniquet time, suggesting that the tourniquet time affects the quadriceps muscle strength witl longer times resulting lower muscle strength. [Med-Science 2017; 6(1.000): 86-90]

Inguinal bleeding is a common and preventable cause of death on the battlefield. Four FDA-cleared junctional tourniquets (Combat Ready Clamp [CRoC], Abdominal Aortic and Junctional Tourniquet [AAJT], Junctional Emergency Treatment Tool [JETT], and SAM Junctional Tourniquet [SJT]) were assessed in a laboratory on volunteers in order to describe differential performance of models.To examine safety and effectiveness of junctional tourniquets in order to inform the discussions of device selection for possible fielding to military units.The experiment measured safety and effectiveness parameters over timed, repeated applications. Lower extremity pulses were measured in 10 volunteers before and after junctional tourniquet application aimed at stopping the distal pulse assessed by Doppler auscultation. Safety was determined as the absence of adverse events during the time of application.The CRoC, SJT, and JETT were most effective; their effectiveness did not differ (p0.05). All tourniquets were applied safely and successfully in at least one instance each, but pain varied by model. Subjects assessed the CRoC as most tolerable. The CRoC and SJT were the fastest to apply. Users ranked CRoC and SJT equally as performing best.The CRoC and SJT were the best-performing junctional tourniquets using this model.

The lower extremity tourniquet failure rate remains significantly higher in combat than in preclinical testing, so we hypothesized that tourniquet placement accuracy, speed, and effectiveness would improve during training and decline during simulated combat. Navy Hospital Corpsman (N = 89), enrolled in a Tactical Combat Casualty Care training course in preparation for deployment, applied Combat Application Tourniquet (CAT) and the Special Operations Forces Tactical Tourniquet (SOFT-T) on day 1 and day 4 of classroom training, then under simulated combat, wherein participants ran an obstacle course to apply a tourniquet while wearing full body armor and avoiding simulated small arms fire (paint balls). Application time and pulse elimination effectiveness improved day 1 to day 4 (p0.005). Under simulated combat, application time slowed significantly (p0.001), whereas accuracy and effectiveness declined slightly. Pulse elimination was poor for CAT (25% failure) and SOFT-T (60% failure) even in classroom conditions following training. CAT was more quickly applied (p0.005) and more effective (p0.002) than SOFT-T. Training fostered fast and effective application of leg tourniquets while performance declined under simulated combat. The inherent efficacy of tourniquet products contributes to high failure rates under combat conditions, pointing to the need for superior tourniquets and for rigorous deployment preparation training in simulated combat scenarios.

Due to advances in prehospital care, improved hospital care, and aeromedical evacuation, mortality from modern military trauma is at an all time low. Advances in prehospital treatment includes early tourniquet application, the use of hemostatic dressings, prevention of hypothermia, and early administration of antibiotics. Improved hospital care has included damage control surgery, the use of fresh whole blood, administration of rFactor VIIa, and better pain control modalities. Finally, the ability to aeromedically evacuate trauma patients has revolutionized trauma and burn treatment. Critical Care Air Transport has broadened this capability to include Intensive Care level patients.

〔目的〕本研究の目的はターニケットによる駆血時間の違いがラットヒラメ筋の萎縮に与える影響を明らかにすることである。〔対象・方法〕8週齢のWistar系雌ラットを，30分駆血群，60分駆血群，90分駆血群に分けた。実験期間は2週間とした。3群とも実験初日に右後肢の駆血を行った後，2週間ギプス固定した。〔結果〕その結果，駆血によるヒラメ筋線維径の減少は60・90分の駆血で発生することが明らかとなった。一方，ヒラメ筋相対体重比は，駆血時間の違いによる影響が認められなかった。〔結語〕駆血時間の違いは筋萎縮に影響を与えること，また60分の駆血は筋萎縮を惹起することを明らかにした。

Autogenous vein bypasses manifest a substantial late stenosis and occlusion rate due, at least in part, to the hostile conditions of the arterial milieu. The present study was undertaken to evaluate flow-mediated dilation (FMD)-a putative measure of endothelial health and, potentially, long-term function-in chronically implanted vein grafts performed for critical lower-extremity ischemia. Eleven patients, four men, seven women (mean age: 64 ±14 years; range: 30 to 81 years), with saphenous vein bypasses performed for critical lower-extremity ischemia a mean of 346 ±457 days previously (range: 47 to 1640 days), had their grafts studied in the resting state, following 5 minutes' tourniquet application to produce hyperemia, and following administration of nitroglycerin. Baseline and maximal postischemic brachial artery and vein graft diameters were determined ultrasonographically. An Atherosclerosis Risk Score (ARS) was calculated by assigning one point for each of six established risk factors for atherosclerosis (smoking, diabetes, hypertension, hypercholesterolemia, male gender, and age >60 years). Vein graft flow and diameter increased significantly with hyperemia (20% ±23%; p=0.04, and 3% ±3%; p=0.01 by paired t-test, respectively). Mean ARS was 3.6 ±1.2 (range: 2 to 5). FMD in vein grafts correlated inversely with ARS (r=-0.66, p=0.03). Seven of the 11 vein grafts demonstrated FMD >1% of baseline diameter. No differences were observed between the seven patients with “reacting” grafts and four with “non-reacting” grafts except in the mean ARS (2.9 ±0.9 vs. 4.3 ±0.5, respectively, p=0.05) and in the frequency of diabetes (33% vs. 100%; p=0.05). Chronically implanted saphenous vein grafts performed for limb-threatening ischemia exhibit FMD. FMD in vein grafts appears to be influenced adversely by concurrent atherosclerotic risk factors, and is reduced compared to FMD reported in other vessels.

Background: Frequently, the result of only a single determination of total homocysteine in plasma (P-Hcy) is used to distinguish between the probability of the presence or absence of risk for vascular disease. A prerequisite for the interpretation of a single P-Hcy test is knowledge of the magnitude of within-person variation and the possible effects of preanalytical variables. However, data on within-person variation are still sparse and inconsistent, and data for the effect on P-Hcy of posture and tourniquet application during venipuncture are not available. Methods: The within-person variation of P-Hcy and the effects of posture and tourniquet application during venipuncture were studied in 24 healthy subjects. The analytical imprecision of our stable-isotope dilution assay was 3.1%. Results: The within-person variation (CV) was 8.1%. Daily supplementation with 0.4 mg of folic acid for 2 weeks produced a small but significant decrease in P-Hcy, but there were no significant changes in within-person variation before and after supplementation. After 30 min in the horizontal posture, P-Hcy declined by 6.3%. A 3-min tourniquet application caused a 2.8% increase of P-Hcy. Conclusions: Our value for within-person variation is consistent with results from studies reported recently in the literature. A 3-min tourniquet application does not add appreciable variation to the measurement of P-Hcy, but the posture of the subject during venipuncture contributes considerably to the within-person variation. We recommend that blood collection when the patient is in a supine position be avoided.

Individual finger tourniquets are appropriate to the management of a wide range of conditions presenting to an accident and emergency department. They are simpler and more comfortable to use than upper arm pneumatic tourniquets and commercially available digital tourniquets are not readily available in the accident and emergency unit. However, if a finger tourniquet is overlooked, ischaemia of the digit results, and gangrene may follow if the problem is not defused early enough, leading to potential disaster. 1 – 3 We present one case where a digit was salvaged after 4 days of tourniquet application, using medicinal leeches.

In this study, 459 lower extremity surgeries were evaluated to assess and improve the quality of patient care at the Carnegie Surgery Center, Cleveland, Ohio. Two aspects of surgery were studied: the antibiotic usage and tourniquet application. The authors analyzed the rate of infection and the number of tourniquet complications that resulted from the surgeries. The infection rate was 0.65%, and there were no tourniquet complications. Using the information learned from the study and reviewing pertinent literature, recommendations were made to further enhance patient care.

Hyperkalemia and acute renal failure are the life-threatening complications of crush injuries. Vigilant prehospital emergency care is vital to reduce the complications. We report and discuss 2 cases diagnosed as crush syndrome after earthquake, in order to illustrate the value of prehospital application of tourniquets to prevent hyperkalemia accompanying extremity crush injuries. The victim in case 1 died of hyperkalemia shortly after extrication without tourniquet. The prehospital tourniquet had been used to avoid uncontrollable hemorrhage and release of toxic metabolites into the circulation in case 2. Providers need to be fully aware of the risk of hyperkalemia in the field for patients with crush syndrome. Tourniquet application is strongly recommended in the prehospital setting for severe crush injuries.

To determine the best field tourniquet for Medical Technician (Med Tech) use in the Canadian Forces (CF).We conducted a prospective controlled trial, comparing the efficacy and ease of applicability of 3 types of commercially available windlass tourniquets in 4 tactical situations on simulated patients. The primary outcome was time to tourniquet application with secondary outcomes including effectiveness and Med Tech satisfaction.The overall finding of this study indicates that the Combat Application Tourniquet (C-A-T) was applied the fastest in each scenario and was also significantly the most effective in occluding distal blood flow. The survey results show that the 3 tourniquet types are similar in many of the measures of ease of learning and application, with the C-A-T scoring highest in self-application and the Special Operations Forces Tactical Tourniquet Wide having the lowest scores for both durability and effectiveness.When tested on a group of CF Med Techs, the C-A-T remained the CF field tourniquet of choice, based on the assessed criteria. Although there is inherent bias in the approach of this study, it reflects the process required to determine if a new piece of kit is superior to what is already considered the standard to a trained and equipped military.

Laboratory data illustrative of preanalytical errors such as the effect of improper storage of sample, the type and concentration of anticoagulant used for specimen collection, the lability of an improperly preserved sample, and the effect of infusion are presented. Strategies to detect preanalytical errors by delta checks are illustrated. Physiological variables such as the effect of age, sex, diet, smoking, menstrual cycle, pregnancy, and specimen collection variables such as posture, duration of tourniquet application, diurnal effects and exercise introducing preanalytical error are discussed. The types of post analytical errors ranging from improper entry of data to errors in strategies used for the interpretation of laboratory data are also highlighted.

The authors evaluated the location of peripheral venous lines and changes in opacification of cephalic and axillary veins at fluoroscopically guided venography after tourniquet application. Results suggested that tourniquet application effectively reduces the superficial venous flow and consequently enhances the opacification of the axillary veins. Tourniquet application is a simple and effective way of facilitating axillary venous puncture.

Background With currently available effective interventional methods to treat superficial venous insufficiency, it becomes particularly important to have a simple and reliable method to evaluate the location and severity of venous reflux. To date, there are few studies that evaluated plethysmography with and without tourniquet application to differentiate superficial from deep venous incompetence. Objectives To determine if strain gauge plethysmography (SGP) with and without tourniquet application can be used to distinguish between the superficial and deep venous components of venous incompetence. Methods We conducted a prospective study using SGP with and without tourniquet application and duplex ultrasound (duplex US) to assess the severity and location of venous incompetence in 62 patients (85 limbs, 42 women, with an age range of 32–81 years) referred to our vascular laboratory for haemodynamic evaluation. Based on duplex US results, patients were diagnosed with superficial (SVI), deep and superficial (mixed) and deep vein incompetence (DVI). Results Mixed incompetence was the most common type. Twenty-three out of 33 limbs in the SVI group normalized their refill rate (RR) with tourniquet application (69.6%). Normalization of the RR with tourniquet application was less common in the mixed ( n: 17 out of 40, 42.5%) and DVI ( n: 2 out of 6, 33.3%) groups. Conclusion SGP with tourniquet application is a simple and fast technique that can identify patients with SVI, based on RR improvement, who probably would benefit more from ablation procedures. Further studies evaluating impact of SGP with tourniquet test results on clinical outcome of SVI invasive treatment are warranted

Purpose Exsanguinators and tourniquets are regularly used in orthopaedic theatres. A good understanding of their application and contraindications must be ensured to prevent injury to limb or life. However, the level of staff understanding is not well documented. The aims of this study were to assess knowledge of their use between theatre personnel and assess their sterility at our institution. Methods A previously published questionnaire was distributed to various orthopaedic theatre personnel responsible for exsanguinator and tourniquet application. Microbiology culture and sensitivity swabs were also taken. Results Mean questionnaire score for all participants was 30.9%. None of the 74 participants scored more than 49% in the questionnaire. Exsanguinators grew more positive cultures than the tourniquets. Conclusions Exsanguinators and tourniquets are used widely in the field of orthopaedics. Lack of their understanding amongst operating theatre personnel involved with their use strongly supports the need for providing and ensuring adequate education to provide the best patient care. In consideration of our findings, we propose a solution addressing these issues.

Summary1. A method for producing tourniquet shock in rats is described. The method yields graded and reproducible results.2. The percentage survival of rats to tourniquet shock was progressively decreased as the time of tourniquet application was increased. Following 3% hours of tourniquets 100% of the rats survived, while after 4 hours of tourniquets only 3% survived.3. Rats which had tourniquets applied for 4 hours with periods of release for 1 to 6 hours, followed by a second application of tourniquets, showed 100% in contrast to 3% survival for those without replacement, while 87.5% survived when the tourniquets were replaced after 7 hours.4. The degree of hemoconcentration developing in rats in tourniquet shock was approximated by hemoglobin determinations. Increases in hemoglobin ranged between 27 and 52%.

A prospective investigation was performed on the effect of the tourniquet on intraoperative patellofemoral tracking during primary total knee arthroplasty (TKA). A total of 75 TKAs in 67 patients were performed by 1 surgeon in a consecutive series using the same technique. Using strict criteria, patellar tracking was assessed both before and after tourniquet release. Patients were placed into 1 of 3 groups: Group I were knees that tracked properly both before and after tourniquet release. Group II were knees that maltracked with the tourniquet inflated and subsequently corrected with the tourniquet released. Group III were knees that maltracked both before and after tourniquet release, therefore requiring a lateral release. Knees were categorized as group I, 34 of 75 (45.3%); group II, 36 of 75 (48.0%); and group III, 5 of 75 (6.7%). Using this criterion, lateral release was avoided in all group II knees. Tourniquet application alters intraoperative patellofemoral tracking during TKA. When contemplating lateral release, tourniquet deflation and reevaluation of patellofemoral tracking should be considered.

Tourniquet application is the standard method for the control of severe trauma haemorrhage. However, it may result in severe ischaemic injuries when used for a long time. In this study, we developed a modified ethyl-2-cyanoacrylate-based aerosol (ECA) aerosol spray and determined its efficacy for short-time control of bleeding of large wounds in pigs when used in combination with tourniquet application.A large wound model with a femoral arterial injury was made in the middle of either thigh of the pig. Thirty white female hybrid pigs were divided evenly and randomly into three groups, including tourniquet application only group (group A), tourniquet-ECA group (group B, a combination of ECA with tourniquet application) and tourniquet-ECA with wound cleaning group (group C, a combination of ECA with tourniquet application plus wound cleaning).The success rates of haemostasis were 0%, 30%and 90% in groups A, B and C, respectively (P0.05). The incidence of haematoma and the membrane forming time were 100% and 20%, and 5.9+/-1.0min and 8.3+/-1.1min, respectively, in groups B and C (both P0.05). The haemostatic time and the thickness of membrane were 11.9+/-1.8min and 10.2+/-1.4min, and 0.68+/-0.29mm and 0.79+/-0.25mm, respectively, in the two groups (P0.05, both).The ECA spray achieves haemostasis within a very short time when it is used in combination with tourniquet application in a large wound model with an arterial injury. It may effectively prevent the wound from bleeding without the need for any long-term pressure bandage to wrap the wound, and it is easy to be disposed in debridement. Therefore, it may serve as an optimal choice for the first aid of large wounds with an arterial injury.

We present a case of emergency tourniquet use of unusually long duration. The patient was wounded during combat operations, and the subsequent battle and evacuation caused a significant delay in surgical treatment of his wounds. Emergency tourniquets can be lifesaving, but are not benign interventions. In general, the extent of tourniquet injury increases with increasing time of application. Despite having a tourniquet in place for 16 hours, the limb was salvaged and significant functional recovery was accomplished. We conducted a search of the published literature including the Medline database, and present a review of the relevant articles concerning emergency tourniquet use, tourniquet injury, and mitigating treatments. Given the widespread use of tourniquets in ongoing military operations, it seems likely that tourniquets will transition to civilian use. Thus it is important for physicians to understand tourniquet injury and appreciate that even extended tourniquet application times does not necessarily doom the affected limb.

BACKGROUND: Angular deformities of the knee are not rare in Nigeria, and are a usual cause of serious concern for parents. METHOD: In this prospective study, 96 angular deformities of the knee in patients aged 4-20 years were treated by corrective osteotomy and cast application. Half of this operations were done with thigh tourniquet and half without. All the patients included in the study had hemoglobin levels of 11.5g/dl and above. AIM: The aim of the study was to estimate the difference in blood loss between the two groups. RESULTS: There was signifant reduction in hemoglobin levels in both groups postoperatively P CONCLUSION: It is suggested that the use of tourniquet may not significantly reduce blood loss during such operations. Its use may not be necessary in all corrective osteotomies. KEY WORD: Tourniquet use, Blood loss corrective osteotemy. Nigerian Journal of Orthopaedics and Trauma Vol.3(2) 2004: 134-138

INTRODUÇÃO: A dosagem de cálcio ionizado, em nosso meio, tem se tornado freqüente em substituição à de cálcio total, com vantagens, por ser a fração fisiologicamente ativa e pelo desenvolvimento de metodologia robusta e com relação custo/benefício adequada. Seu uso implica a necessidade de definição de intervalos de referência. OBJETIVO: Estimar o intervalo de referência para o cálcio ionizado sérico e avaliar interferências do tempo de permanência do torniquete e do resfriamento da amostra. MATERIAL E MÉTODO: Para a estimativa do intervalo de referência, foram incluídos os resultados de 11.320 dosagens consecutivas de cálcio ionizado realizadas de janeiro de 2000 a novembro de 2002; para avaliar o efeito da refrigeração foram realizadas 16 coletas em duplicata, sendo que um dos tubos foi colocado em banho de gelo imediatamente após a coleta e o outro foi mantido à temperatura ambiente; para avaliar o efeito do tempo de garroteamento, em seis voluntários foi realizada a coleta em um dos braços imediatamente após a aplicação do torniquete e, no outro braço, após 3 minutos de garroteamento. O sangue foi colhido em tubos sem ar, contendo gel separador, e centrifugado em até 30 minutos após a coleta. Todas as dosagens foram realizadas em até 4 horas após a centrifugação por eletrodo íon-seletivo. RESULTADOS: Considerando-se os 95% centrais dos dados, os limites inferior e superior foram 1,11mmol/l (intervalo de confiança de 90%: 1,1 a 1,11mmol/l) e 1,4mmol/l (intervalo de confiança de 90%: 1,39 a 1,41mmol/l), respectivamente. Não foram detectadas diferenças significativas nos resultados das amostras com e sem refrigeração e entre as amostras coletadas com menos de um minuto e com três minutos de garroteamento. INTRODUCTION: The ionized serum calcium determination has become frequent replacing the total calcium with advantages: it is the physiologically active fraction, and the availability of robust methodology with favorable cost/benefice ratio. The use of this methodology implies in reference interval estimation. OBJECTIVE: To estimate the reference interval for serum ionized calcium, and to evaluate interferences in tourniquet time application, and interferences in sample refrigeration before analysis. MATERIAL AND METHOD: to estimate the reference interval we included the results of 11,320 consecutive calcium ionized determinations accomplished from January 2000 to November 2002; in order to evaluate the effect of sample refrigeration, 16 samples were collected in duplicate, so that one tube was placed in ice bath and the other was maintained in room temperature. To evaluate the effect of tourniquet application time, we collected blood samples from one arm of 6 normal subjects, immediately after, and from the other arm, after 3 minutes of the tourniquet application. The blood was collected in evacuated tubes with gel separator and centrifuged up to 30 minutes after collection. All determinations were performed up to 4 hours after the centrifugation by ion-selective electrode. RESULTS: regarding to the central 95% data distribution, the inferior and superior limits were, respectively, 1.11 (confidence interval of 90%: 1.1 to 1.11) and 1.4mmol/l (confidence interval of 90%: 1.39 to 1.41). No significant differences were detected between results with and without refrigeration and between samples with less than 1 and after 3 minutes of tourniquet application. Universidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina Centro de Medicina Diagnóstica Universidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina Hospital do Rim UNIFESP, EPM, Hospital do Rim SciELO

The purpose of this study was to assess the influences of surgical approaches and tourniquet application on the lateral retinacular tension (LRT). Single-setting bilateral total knee arthroplasty was performed in 10 patients, and the medial parapatellar and midvastus approaches were randomly performed on each knee using tourniquet application. The LRT was measured using the buckle transducer before and after each approach. Next, the tourniquet was deflated and the measurement was repeated. After the parapatellar approach, LRT was significantly decreased. Conversely, no significant change was seen after the midvastus approach with the tourniquet inflated. However, in the midvastus approach, LRT was significantly decreased after tourniquet deflation. We concluded that both the parapatellar and midvastus approaches influence patellar tracking and LRT.

Level of Evidence: V, Expert Opinion

Thigh pain following tourniquet application is a common patient complaint in the early postoperative period following total knee arthroplasty. Postoperative thigh pain was evaluated in 28 consecutive simultaneous bilateral total knee arthroplasty patients between April 1996 and October 1996. A prospective, double-blind, randomized clinical trial was performed. Tourniquet pressure of 350 mmHg was used on 1 thigh (thigh 1) and 100 mmHg plus systolic blood pressure on the other (thigh 2). A scale of pain (no pain, mild, moderate, or severe) was applied on the first, second, and third days, as well as 2 and 6 weeks after surgery. There were 16 men and 12 women with a mean age of 72 years (range, 55-85 years). The mean tourniquet time was similar in both groups (thigh 1 = 23 minutes, thigh 2 = 22 minutes). The mean tourniquet pressure in thigh 2 was 230 mmHg (range, 212-260 mmHg). There was a statistically significant difference in thigh pain on the first (P = .01), second (P = .01), and third (P = .001) postoperative days between both groups, with more thigh pain on the 350 mmHg side. At 6 weeks after surgery, the difference in thigh pain was gone. For total knee arthroplasty, using the tourniquet at a pressure of 100 mmHg above the systolic blood pressure is recommended. This is adequate to provide a bloodless field and will result in a less unpleasant postoperative period.

Background Many clinicians believe that prolonged tourniquet application lowers the serum bicarbonate concentration in samples drawn from that limb, but this effect has never been examined prospectively. Objective To test the effect of prolonged tourniquet application before phlebotomy on serum bicarbonate concentration in healthy adults. Methods We drew blood samples from 27 healthy adult volunteers without a tourniquet and again 1, 3, and 5 minutes after applying a blood pressure cuff and inflating it to the mean arterial pressure. Results The mean bicarbonate concentration was 27.3 +/- 2.26 mmol/L (standard deviation) at baseline, 27.7 +/- 2.39 mmol/L at 1 minute, 27.7 +/- 2.05 mmol/L at 3 minutes, and 27.7 +/- 1.96 mmol/L at 5 minutes. The mean change in bicarbonate concentration from baseline was -0.04 +/- 1.02 mmol/L at 1 minute, 0.44 +/- 1.05 mmol/L at 3 minutes, and 0.44 +/- 1.31 mmol/L at 5 minutes. The mean lactate concentration was 1.1 +/- 0.28 mmol/L at baseline, 1.3 +/- 0.65 mmol/L at 1 minute, 1.2 +/- 0.52 mmol/L at 3 minutes, and 1.2 +/- 0.36 mmol/L at 5 minutes. The mean change in lactate concentration from baseline was 0.15 +/- 0.67 mmol/L at 1 minute, 0.11 +/- 0.11 mmol/L at 3 minutes, and 0.12 +/- 0.37 mmol/L at 5 minutes. Conclusions Prolonged tourniquet application before phlebotomy does not lower the serum bicarbonate concentration in healthy adults.

This chapter deals with the control of infection, including aspects of clinical pathology and the nurse’s role in communicating with the hospital pathology laboratory.

The hemodynamic and metabolic effects of unilateral tourniquet use were assessed in 30 children. Intraoperative hyperthermia, tachycardia, endtidal CO2, and lactic acid concentration were measured before and after tourniquet inflation. Maximum changes in temperature and pulse rate occurred in patients who had tourniquet application time lasting greater than 75 min. Lactate and endtidal CO2 levels were also significantly increased in the same group of patients.

We report a case of tibial nerve palsy after pneumatic tourniquet application for 40 minutes with a tourniquet pressure of 300 mmHg. A 45 years old woman with morbid obesity and diabetes mellitus was underwent partial lateral meniscectomy of left knee. Even 3 months after the event, nerve palsy was not completely recovered. The case underscores the necessity of being aware of the potential for complications associated with tourniquets, despite following recommended guidelines of tourniquet time and pressure. Especially, in the patients with metabolic diseases such as diabetes mellites or obesity, safe duration of tourniquet application may be shortened.

Background: Core temperature changes during tourniquet inflation and deflation have been reported. The aim of this study is to investigate the extent of core temperature changes during inflation and deflation, depending on tourniquet time. Methods: Esophageal temperature in sixty patients who undergoing knee arthroscopy with tourniquet longer than 1 h (group L, n = 30) and less than 1 h (group S, n = 30) were measured before inflation, 30 and 60 min after inflation, just before deflation, and 1 min interval for 10 min after deflation. Results: Tourniquet time in L and S group was 109 ± 20 min and 46 ± 10.7 min, respectively. Compared to baseline value of 35.7 ± 0.07℃, significant increase of 0.14 ± 0.02℃, 0.25 ± 0.03℃, 0.4 ± 0.05℃ were observed at 30, 60 min after inflation, and just before deflation, respectively in group L, and the increase of 0.11 ± 0.03℃ and 0.18 ± 0.03℃ at 30 min after inflation and just before deflation, respectively in group S. Temperatures from 2 to 10 min after deflation were significantly lower than value of just before deflation in each group (P＜0.05). At 10 min after deflation, 0.76 ± 0.13℃ in group L and 0.4 ± 0.04℃ in group S were lower than values of just before deflation in each group (P＜0.05). Temperature at 10 min after deflation was significantly different between the groups (P＜0.05). Conclusions: Extent of core temperature decrease after tourniquet deflation was dependent on the duration of tourniquet application. (Korean J Anesthesiol 2007; 53: 453~7)

Local hypothermia was studied as a method to safely prolong tourniquet time for reconstructive procedures of the upper extremity. An ice blanket constructed of flannel cloth and cold gel packs was applied to the limb for 45 minutes preoperatively. Seventy-eight patients were evaluated for complications resulting from hypothermia and prolonged tourniquet application. The duration of continuous tourniquet ischemia averaged two hours and 25 minutes. Intraoperative muscle temperature recordings indicated that the iced limbs were an average of 12.9 degrees cooler than noniced limbs before tourniquet inflation. Electron microscopic studies of biopsied muscle showed no evidence of ischemic changes. There were no postoperative complications associated with prolonged tourniquet inflation or the hypothermia blanket technique. Local hypothermia appears to be a safe and effective method of decreasing the adverse effects of tourniquet ischemia and allowing continuous tourniquet inflation time to extend safely beyond the customary two-hour limit.