1
|
Ruterana P, Abitbol A, Castel LC, Gregory T. WALANT technique versus locoregional anesthesia in the surgical management of metacarpal and phalangeal fractures: Lessons from the Covid-19 crisis. HAND SURGERY & REHABILITATION 2021; 41:220-225. [PMID: 34923166 PMCID: PMC8675121 DOI: 10.1016/j.hansur.2021.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 11/21/2021] [Accepted: 12/03/2021] [Indexed: 10/27/2022]
Abstract
Wide Awake Local Anesthesia No Tourniquet (WALANT) is an anesthetic method which uses a local injection of anesthetic and epinephrine, avoiding use of a tourniquet. During the COVID-19 pandemic, human and logistic resources had to be reorganized, and WALANT ensured resilience in our department to maintain access to surgical care. The objective of the present study was to compare hand function recovery 3 months after surgery for unstable metacarpal or phalangeal fracture under regional anesthesia versus WALANT. From November 2020 to May 2021, 36 patients presenting a metacarpal or phalangeal fracture requiring surgical treatment were included in a single-center study in a university hospital center. Nineteen patients underwent surgery under locoregional anesthesia with tourniquet, and 17 under WALANT. The main endpoint was functional recovery at 3 months on QuickDASH score. Need for complementary anesthesia, surgery duration, analgesic consumption, reintervention rate, and patient satisfaction were also assessed. There was no significant difference between groups in functional recovery at 3 months or on the secondary endpoints. In the COVID-19 context, WALANT proved to be a safe and effective method in hand fracture surgery, ensuring access to surgical care. It should be included in surgical training to optimize day-to-day surgical care and face future crises.
Collapse
Affiliation(s)
- P Ruterana
- Service de Chirurgie Orthopédique, Hôpital Avicenne - Université Sorbonne Paris Nord, 125 Rue de Stalingrad, 93000 Bobigny, France; Université de Paris, 45 Rue des Saints-Pères, 75006 Paris, France.
| | - A Abitbol
- Service de Chirurgie Orthopédique, Hôpital Avicenne - Université Sorbonne Paris Nord, 125 Rue de Stalingrad, 93000 Bobigny, France; Université de Paris, 45 Rue des Saints-Pères, 75006 Paris, France
| | - L-C Castel
- Service de Chirurgie Orthopédique, Hôpital Avicenne - Université Sorbonne Paris Nord, 125 Rue de Stalingrad, 93000 Bobigny, France; Université de Paris, 45 Rue des Saints-Pères, 75006 Paris, France
| | - T Gregory
- Service de Chirurgie Orthopédique, Hôpital Avicenne - Université Sorbonne Paris Nord, 125 Rue de Stalingrad, 93000 Bobigny, France; MOVEO Institute, University Paris Seine-Saint-Denis, 11 Rue de Cambrai, Immeuble 028, 75019 Paris, France
| |
Collapse
|
2
|
Evaluating Clinical Outcomes for Determining the Optimal Delay to Skin Incision under WALANT: A Prospective Series of 34 Patients from a Low-Resource Tertiary Setting. Adv Orthop 2020; 2020:9351354. [PMID: 32953181 PMCID: PMC7481922 DOI: 10.1155/2020/9351354] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/25/2020] [Accepted: 06/30/2020] [Indexed: 11/18/2022] Open
Abstract
Background Additional studies on clinical outcomes to determine the optimal time delay from injection of local anesthesia to skin incision for WALANT surgeries are needed. The authors aimed to propose the optimal time delay from local injection to skin incision for WALANT surgeries of the hand and wrist by analyzing intraoperative blood loss, postoperative pain scores, and complication rates. Methods Thirty-four patients were consecutively recruited and allocated by either 7-min or 30-min delay for skin incision from local injection of epinephrine with lidocaine. Intraoperative bleeding and postoperative pain scores were analyzed between both groups by Mann–Whitney U-test, while complication rates were compared using Fisher's exact test. Results The present study did not find significant differences in mean intraoperative blood loss (8 ± 5.8 mL vs. 5 ± 2.2 mL, p=0.074), complication rates (18% vs. 0%, p=0.227), and mean pain scores (1.2 ± 0.5 vs. 1.4 ± 0.5, p=0.307) between the 7-min and 30-min groups. Conclusion The authors conclude that a waiting time of 7 min from the injection of local anesthesia is sufficient to achieve comparable clinical outcomes for minor hand and wrist surgeries under WALANT.
Collapse
|
3
|
Sasor SE, Cook JA, Duquette SP, Lucich EA, Cohen AC, Wooden WA, Tholpady SS, Chu MW. Tourniquet Use in Wide-Awake Carpal Tunnel Release. Hand (N Y) 2020; 15:59-63. [PMID: 30003819 PMCID: PMC6966303 DOI: 10.1177/1558944718787853] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
Collapse
Affiliation(s)
- Sarah E. Sasor
- Indiana University, Indianapolis,
USA,Sarah E. Sasor, Division of Plastic Surgery,
Department of Surgery, Indiana University, 545 Barnhill Drive, EH 232,
Indianapolis, IN 46202, USA.
| | | | | | | | - Adam C. Cohen
- Richard L. Roudebush VA Medical Center,
Indianapolis, IN, USA
| | - William A. Wooden
- Indiana University, Indianapolis,
USA,Richard L. Roudebush VA Medical Center,
Indianapolis, IN, USA
| | - Sunil S. Tholpady
- Indiana University, Indianapolis,
USA,Richard L. Roudebush VA Medical Center,
Indianapolis, IN, USA
| | | |
Collapse
|
4
|
Lees DA, Penny JB, Baker P. A single blind randomised controlled trial of the impact on patient-reported pain of arm elevation versus exsanguination prior to tourniquet inflation. Bone Joint J 2016; 98-B:519-25. [PMID: 27037435 DOI: 10.1302/0301-620x.98b4.36014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 10/02/2015] [Indexed: 11/05/2022]
Abstract
AIMS The aim of this study was to compare the pain caused by the application of a tourniquet after exsanguination of the upper limb with that occurring after simple elevation. PATIENTS AND METHODS We used 26 healthy volunteers (52 arms), each of whom acted as their own matched control. The primary outcome measure was the total pain experienced by each volunteer while the tourniquet was inflated for 20 minutes. This was calculated as the area under the pain curve for each individual subject. Secondary outcomes were pain at each time point; the total pain experienced during the recovery phase; the ability to tolerate the tourniquet and the time for full recovery after deflation of the tourniquet. RESULTS There was a significant difference in the area under the pain curves in favour of exsanguination (mean difference 8.4; 95% confidence interval (CI) 3.0 to 13.7, p = 0.004). There was no difference between the dominant and non-dominant arms (mean difference -0.2; 95% CI -23.2 to 22.8, p = 0.99). The area under both recovery curves were similar (mean difference 0.7; 95% CI -6.0 to 4.6, p = 0.78). There was no statistical difference in recovery time, the actual mean difference being 30 seconds longer in the elevation group (p = 0.06). CONCLUSION Many orthopaedic and plastic surgery procedures are done under local anaesthetic or regional block where a bloodless field and a motionless patient are essential. Optimising patient comfort during surgery with the tourniquet inflated is thus a priority. This study is useful in that it compares two common methods of preparation of the upper limb prior to tourniquet inflation and which have not previously been compared in this context. Following on the results of this study, we can confidently conclude that exsanguinating the upper limb before inflating a tourniquet is more comfortable than simply elevating the arm for patients undergoing a procedure under local or regional block, both during the procedure and in the recovery phase. TAKE HOME MESSAGE Exsanguination rather than elevation is recommended in order to minimise patient discomfort and optimise the surgical field.
Collapse
Affiliation(s)
- D A Lees
- Northern Deanery Trauma and Orthopaedic Training Scheme, Newcastle, NE15 8NY, UK
| | - J B Penny
- Northern Deanery Trauma and Orthopaedic Training Scheme, Newcastle, NE15 8NY, UK
| | - P Baker
- University of Durham, Marton Road, Middlesbrough, TS4 3BW, UK
| |
Collapse
|
5
|
Cousins GR, Gill SL, Tinning CG, Johnson SM, Rickhuss PK. Arm versus forearm tourniquet for carpal tunnel decompression - Which is better? A randomized controlled trial. J Hand Surg Eur Vol 2015; 40:961-5. [PMID: 25588664 DOI: 10.1177/1753193414565322] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Accepted: 11/29/2014] [Indexed: 02/03/2023]
Abstract
UNLABELLED Tourniquet pain is a common source of complaint for patients undergoing carpal tunnel decompression and practice varies as to the tourniquet position used. There is little evidence to suggest benefit of one position over another. Our aim was to compare patient and surgeon experience of forearm and arm tourniquets. Following a power calculation, 100 patients undergoing open carpal tunnel decompression under local anaesthetic were randomized to either an arm or a forearm tourniquet. Measurements of blood pressure, heart rate and pain were taken at 2.5 min intervals. The operating surgeon also provided a visual analogue scale rating for the extent of bloodless field achieved and for any obstruction caused by the tourniquet. There was no statistically significant inter-group difference in patient pain or physiological response, tourniquet time, bloodless field or length of procedure. The degree of obstruction caused by the tourniquet was significantly higher in the forearm group. LEVEL OF EVIDENCE I. Prospective Randomized Controlled Trial.
Collapse
Affiliation(s)
- G R Cousins
- Department of Orthopaedics and Trauma, Ninewells Hospital, Dundee, UK
| | - S L Gill
- Department of Orthopaedics and Trauma, Ninewells Hospital, Dundee, UK
| | - C G Tinning
- Department of Orthopaedics and Trauma, Ninewells Hospital, Dundee, UK
| | - S M Johnson
- Department of Orthopaedics and Trauma, Ninewells Hospital, Dundee, UK
| | - P K Rickhuss
- Department of Orthopaedics and Trauma, Ninewells Hospital, Dundee, UK
| |
Collapse
|
6
|
Pereira A, Hendriks S, Facca S, Bodin F, Gay A, Liverneaux P. Evaluation of a new tourniquet for hand surgery: Comparison of 76 carpal tunnel syndrome cases operated using a Hemaclear® Model-F tourniquet versus a pneumatic tourniquet. ACTA ACUST UNITED AC 2015; 34:73-8. [DOI: 10.1016/j.main.2015.01.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Revised: 01/03/2015] [Accepted: 01/09/2015] [Indexed: 11/27/2022]
|
7
|
Saied A, Ayatollahi Mousavi A, Arabnejad F, Ahmadzadeh Heshmati A. Tourniquet in surgery of the limbs: a review of history, types and complications. IRANIAN RED CRESCENT MEDICAL JOURNAL 2015; 17:e9588. [PMID: 25793122 PMCID: PMC4353220 DOI: 10.5812/ircmj.9588] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Revised: 11/04/2013] [Accepted: 11/12/2014] [Indexed: 11/17/2022]
Abstract
CONTEXT A tourniquet is a device that is used frequently in most orthopaedic surgeries but this routine device can lead to serious complications so we decided to review and declare it for safe instruction and use. EVIDENCE ACQUISITION We searched the word "tourniquet" in PubMed and Google and reviewed all full text English articles and abstracts of non-English articles. In addition, we read all the reference pages of articles to find the new references. RESULTS The use of tourniquet in orthopedic surgery can lead to serious but rare complications that can be prevented by its correct knowledge and use. CONCLUSIONS At present, there is not enough evidence to discontinue the routine uses of tourniquets.
Collapse
Affiliation(s)
- Alireza Saied
- Department of Orthopedics, Kerman Neuroscience Research Center, Kerman University of Medical Sciences, Kerman, IR Iran
| | - Alia Ayatollahi Mousavi
- Department of Neuroscience, Kerman Neuroscience Research Center, Kerman University of Medical Sciences, Kerman, IR Iran
| | - Fateme Arabnejad
- School of Medicine, Kerman University of Medical Sciences, Kerman, IR Iran
| | | |
Collapse
|
8
|
Lim E, Shukla L, Barker A, Trotter DJ. Randomized blinded control trial into tourniquet tolerance in awake volunteers. ANZ J Surg 2014; 85:636-8. [PMID: 24517440 DOI: 10.1111/ans.12532] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND The ability to tolerate a tourniquet is often the limiting factor to elective and emergent procedures of the upper limb performed under local anaesthesia. This study aims to demonstrate that upper limb tourniquets are more predictably and better tolerated when inflated to 200 mmHg than to the traditional inflation pressure of 250 mmHg in awake, unsedated subjects. METHODS Forty healthy volunteers were randomized to have a tourniquet applied at either 200 or 250 mmHg for 20 min. Vital signs and pain scores were measured pre-test, at intervals throughout the time the tourniquet was inflated and post-deflation until the parameters normalized. Grip strength was measured pre-test, immediately post-deflation of the tourniquet and every 2 min until return of normal strength. RESULTS All subjects were able to tolerate a tourniquet inflated for the allocated 20 min irrespective of the inflation pressure; however, there was a statistically significant lower average pain score in the group where the tourniquet was inflated to 200 mmHg compared with 250 mmHg. There was a quicker return of normal grip strength, although this was not shown to be statistically significant. CONCLUSIONS Tourniquets inflated to 200 mmHg are better tolerated in awake, unsedated subjects that would allow predictably short procedures of the hand, wrist and forearm to be performed under local anaesthesia. It represents a pilot study prior to a further clinical study investigating the efficacy of tourniquets inflated to a lower pressure in maintaining an effective bloodless field.
Collapse
Affiliation(s)
- Eugene Lim
- Department of Plastic and Reconstructive Surgery, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Lipi Shukla
- Department of Plastic and Reconstructive Surgery, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Anthony Barker
- Department of Plastic and Reconstructive Surgery, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Dean J Trotter
- Department of Plastic and Reconstructive Surgery, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| |
Collapse
|
9
|
Chiao F, Chen J, Lesser J, Resta-Flarer F, Bennett H. Single-cuff forearm tourniquet in intravenous regional anaesthesia results in less pain and fewer sedation requirements than upper arm tourniquet † †Post-Graduate Assembly in Anesthesiology 2011—awarded second place in the Current Research by New Investigators competition. Br J Anaesth 2013; 111:271-5. [DOI: 10.1093/bja/aet032] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
10
|
Bidwai ASC, Benjamin-Laing HE, Shaw DA, Iqbal S, Jones WA, Brown DJ. Patient satisfaction with tourniquet application and local anaesthesia infiltration in carpal tunnel decompression and the relationship with overall satisfaction. J Plast Surg Hand Surg 2013; 47:481-3. [PMID: 23596990 DOI: 10.3109/2000656x.2013.787935] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
This was a prospective study designed to determine what effect poor tolerance to tourniquet application and local anaesthesia infiltration in open carpal tunnel decompression has on overall patient satisfaction with the surgical procedure. Fifty patients were recruited into the study. Visual analogue scores (VAS) were recorded postoperatively for pain related to tourniquet application, local anaesthesia infiltration and the surgical procedure overall. In terms of the procedure, poor tolerance to the tourniquet and local anaesthetic showed no significant relationship to the overall patient satisfaction (Student t-test). The factors, which are related to satisfaction with carpal tunnel decompression, are discussed.
Collapse
Affiliation(s)
- Amit S C Bidwai
- Department of Trauma and Orthopaedic Surgery, Royal Liverpool and Broadgreen Hospitals , Prescot Street, Liverpool L7 8XP , UK
| | | | | | | | | | | |
Collapse
|
11
|
Smith OJ, Heasley R, Eastwood G, Royle SG. Comparison of pain perceived when using pneumatic or silicone ring tourniquets for local anaesthetic procedures in the upper limb. J Hand Surg Eur Vol 2012; 37:842-7. [PMID: 22719004 DOI: 10.1177/1753193412449116] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The aim of this study was to evaluate the level of pain felt when silicone ring and pneumatic tourniquets were applied to the upper arm and to determine which was more suitable for use in local anaesthetic procedures. Pain was measured using a visual analogue score pain scale on application and at 1, 5, and 10 minutes in 30 volunteers. Volunteers experienced significantly more pain on application and at 1 and 5 minutes with the silicone ring tourniquet. This difference in pain was most marked on application. Two volunteers could not tolerate application of the silicone ring tourniquet. We conclude that the silicone ring tourniquet would not be suitable for local anaesthetic procedures in the upper limb due to the severe pain experienced on application, which may reduce the patients' confidence and adversely affect their experience of the procedure. The pneumatic tourniquet is more suitable for local procedures.
Collapse
Affiliation(s)
- O J Smith
- Trauma and Orthopaedics Unit, Stockport NHS Foundation Trust, Stepping Hill Hospital, Stockport, UK.
| | | | | | | |
Collapse
|
12
|
Abstract
Tourniquets are compressive devices that occlude venous and arterial blood flow to limbs and are commonly used in upper limb surgery. With the potential risk of complications, there is some debate as to whether tourniquets should continue to be routinely used. In this review, we first look at the different designs, principles, and practical considerations associated with the use of tourniquets in the upper limb. The modern pneumatic tourniquet has many design features that enhance its safety profile. Current literature suggests that the risk of tourniquet-related complications can be significantly reduced by selecting cuff inflation pressures based on the limb occlusion pressure, and by a better understanding of the actual level of pressure within the soft tissue, and the effects of cuff width and contour. The evidence behind tourniquet time, placement, and limb exsanguination is also discussed as well as special considerations in patients with diabetes mellitus, hypertension, vascular calcification, sickle cell disease and obesity. We also provide an evidence-based review of the variety of local and systemic complications that may arise from the use of upper limb tourniquets including pain, leakage, and nerve, muscle, and skin injuries. The evidence in the literature suggests that upper limb tourniquets are beneficial in promoting optimum surgical conditions and modern tourniquet use is associated with a low rate of adverse events. With the improvement in knowledge and technology, the incidence of adverse events should continue to decrease. We recommend the use of tourniquets in upper limb surgery where no contraindications exist.
Collapse
Affiliation(s)
- Emeka Oragui
- Department of Trauma & Orthopaedics, West Middlesex University Hospital NHS Trust, London, TW7 6AF UK
| | - Antony Parsons
- Department of Anaesthetics, West Middlesex University Hospital NHS Trust, London, TW7 6AF UK
| | - Thomas White
- Department of Trauma & Orthopaedics, West Middlesex University Hospital NHS Trust, London, TW7 6AF UK
| | - Umile Giuseppe Longo
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo, 200, 00128 Trigoria, Rome, Italy
| | - Wasim Sardar Khan
- University College London Institute of Orthopaedics and Musculoskeletal Sciences, Royal National Orthopaedic Hospital, Stanmore, HA7 4LP UK
| |
Collapse
|
13
|
Bilateral forearm intravenous regional anesthesia with prilocaine for botulinum toxin treatment of palmar hyperhidrosis. J Am Acad Dermatol 2010; 63:466-74. [DOI: 10.1016/j.jaad.2009.10.034] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2008] [Revised: 10/07/2009] [Accepted: 10/22/2009] [Indexed: 11/18/2022]
|
14
|
Frank R, Cowan BJ, Lang S, Harrop AR, Magi E. Modification of the forearm tourniquet techniques of intravenous regional anaesthesia for operations on the distal forearm and hand. ACTA ACUST UNITED AC 2009; 43:102-8. [DOI: 10.1080/02844310802576420] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
15
|
Prodhomme G, Mouraux D, Dugailly PM, Chantelot C, Fontaine C, Schuind F. Tolerance of upper extremity pneumatic tourniquets and their effect on grip strength. J Hand Surg Eur Vol 2008; 33:266-71. [PMID: 18562355 DOI: 10.1177/1753193408087093] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
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.
Collapse
Affiliation(s)
- G Prodhomme
- Department of Traumatology and Orthopaedics, Hospital Erasme, Brussels, Belgium.
| | | | | | | | | | | |
Collapse
|
16
|
Comparing the effectiveness of modified forearm and conventional minidose intravenous regional anesthesia for reduction of distal forearm fractures in children. J Pediatr Orthop 2008; 28:410-6. [PMID: 18520275 DOI: 10.1097/bpo.0b013e31816d7235] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Minidose intravenous regional anesthesia (IVRA) and modified forearm IVRA have been used for closed reduction of forearm fractures and for hand surgery in children. METHODS Children (5-17 years old) with forearm fractures presenting to a pediatric emergency department were enrolled in a randomized controlled trial to test if modified forearm and minidose IVRA together would provide improved analgesia with reduced risk of anesthetic toxicity compared with conventional minidose IVRA. Pain was assessed using a visual analog scale (FACES) and an objective pain scale (OPS) score at baseline and at critical times. Spearman rank correlation and repeated-measures analysis of variance were used to compare interobserver pain measures and detect differences between the groups over time. RESULTS Among the 62 patients in the study, no significant differences were observed between groups in objective measures of blood pressure, oxygen saturation, and heart rate at baseline, 5 minutes after IVRA, during surgical reduction, and 15 minutes after reduction. Nurses reported patients experienced a reduction in pain of 2.5 (SD, 3.1) on FACES and 2.3 (SD, 3.1) on OPS at 5 minutes after sedation (P < 0.001 for both). From time of reduction to 15 minutes after the procedure, FACES score declined 1.7 (SD, 3.4) (P = 0.001), and OPS declined 2.1 (SD, 3.6) (P = 0.002). No significant differences were found between experimental arms. CONCLUSION The modified forearm minidose IVRA procedure is an acceptable alternative for the relief of pain that usually accompanies the manipulation and reduction of forearm fractures but does not appear to provide additional pain relief compared with conventional minidose IVRA. LEVEL OF EVIDENCE Level I, therapeutic study.
Collapse
|
17
|
Karalezli N, Ogun CO, Ogun TC, Yildirim S, Tuncay I. Wrist Tourniquet: The Most Patient-Friendly Way of Bloodless Hand Surgery. ACTA ACUST UNITED AC 2007; 62:750-4. [PMID: 17414359 DOI: 10.1097/01.ta.0000249076.11239.96] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The literature is scarce on wrist tourniquets. In this study, three well-established locations of tourniquet setting including upper arm, proximal forearm, and wrist were compared on the same limb using both clinical as well as biochemical variables in paramedical volunteers. METHODS Twenty unmedicated, healthy, paramedical, right-hand dominant volunteers participated in the study. The left upper arms were used for monitoring. Blood pressures and heart rates were monitored and recorded before (baseline) and immediately after the application of the tourniquet, every 5 minutes, and at the time the patient requested deflation. An intravenous cannula (22 G) was placed on the right hand to obtain samples, which were taken at baseline and immediately after deflation of the tourniquet to evaluate the levels of pO2, pCO2, O2 saturation, pH, bicarbonate, blood sugar, lactate, hematocrit, and electrolytes. The tourniquets were applied to the right upper arm, forearm, and wrist of each subject with 5-day intervals between each trial. Subjective discomfort and tourniquet pain levels were recorded. For each trial, tourniquet tolerance and details of discomfort were recorded. Statistical analysis was performed as appropriate. RESULTS Twenty volunteers aged 20 to 44 years were included. For each trial, in the first 10 minutes after inflation of the tourniquet, the heart rate and systolic blood pressure were increased compared with baseline values. Diastolic blood pressure was elevated immediately after inflation and remained so until deflation in each trial. Diastolic blood pressure values were higher in the upper-arm tourniquet group compared with wrist. Then pH, pO2, and O2 saturation values were decreased and pCO2 and lactate levels were increased compared with baseline values in each trial. Blood sugar was decreased significantly in the arm group. The decrease in pH, pO2, O2 saturation, and blood sugar in the upper arm group was significantly higher compared with wrist and forearm groups. The lactate value was higher in the upper arm group compared with wrist. Visual analog scale and numerical rating scores were lower in the wrist group compared with others at all times. The longest tourniquet tolerance was in the wrist group. In the wrist group, curling was observed in all subjects but the fingers could easily be extended. CONCLUSION The wrist tourniquet is the most comfortable technique of bloodless surgery for procedures limited to the hand region.
Collapse
Affiliation(s)
- Nazim Karalezli
- Department of Orthopedics and Traumatology, Selçuk University Meram School of Medicine, Turkey
| | | | | | | | | |
Collapse
|
18
|
Delgado-Martinez AD, Marchal JM, Blanco F, Molina M, Palma A. Distal forearm tourniquet for hand surgery. INTERNATIONAL ORTHOPAEDICS 2004; 28:267-9. [PMID: 15480658 PMCID: PMC3456980 DOI: 10.1007/s00264-004-0582-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2004] [Accepted: 06/08/2004] [Indexed: 11/30/2022]
Abstract
To evaluate the usefulness of the tourniquet placed at the distal forearm, 30 patients were operated with the tourniquet set at the distal forearm using nerve-block anaesthesia. Pain during surgery, flexion of the fingers, bloodless field, and general complications during surgery and 18 months thereafter were recorded. The mean time of ischemia was 19.6+/-7.5 (10-50) min. A bloodless field was achieved in all cases, and pain during operation was low. Flexion of the fingers were found in most cases but was reducible and not annoying for the surgeon. There were no serious complications during surgery or at follow-up. The tourniquet placed at the distal forearm is painless, safe, and useful in hand surgery.
Collapse
Affiliation(s)
- Alberto D Delgado-Martinez
- Hospital Universitario Neurotraumatológico, Complejo Hospitalario de Jaén, Universidad de Jaén, Ed. B-3, 23071 Jaen, Spain.
| | | | | | | | | |
Collapse
|
19
|
|
20
|
Maury AC, Roy WS. A prospective, randomized, controlled trial of forearm versus upper arm tourniquet tolerance. JOURNAL OF HAND SURGERY (EDINBURGH, SCOTLAND) 2002; 27:359-60. [PMID: 12162977 DOI: 10.1054/jhsb.2002.0787] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
This prospective, randomized, controlled trial studied the duration of upper and forearm tourniquet tolerance in 24 fit, healthy volunteers. Upper arm and forearm tourniquets were applied to either arm and inflated simultaneously. The time to request for deflation was recorded for each tourniquet. The mean tolerance for the upper arm tourniquet was 18 (range 10-26) min and for the forearm tourniquet was 25 (range 12-52) min. Under the conditions of this study, forearm tourniquets were tolerated for a mean of 7 min longer than upper arm tourniquets. The increase in tourniquet time afforded by a forearm tourniquet is clinically important in hand surgery performed under local anaesthetic.
Collapse
Affiliation(s)
- A C Maury
- Royal Glamorgan Hospital, Ynysmaerdy, Llantrisant, CF72 8XR, Mid Glamorgan, Wales, UK.
| | | |
Collapse
|