Systematic review of prehospital tourniquet use in civilian limb trauma An evaluation of combat application tourniquets on training military personnel: changes in application times and success rates in three successive phases Intravenous and Topical Tranexamic Acid Alone Are Superior to Tourniquet Use for Primary Total Knee Arthroplasty: A Prospective, Randomized Controlled Trial The efficacy of tourniquet release in blood conservation after total knee arthroplasty. Wide awake technique versus local anesthesia with tourniquet application for minor orthopedic hand surgery: a prospective clinical trial. Use of a pneumatic tourniquet in total knee arthroplasty increases the risk of distal deep vein thrombosis: A prospective, randomized study. The effect of a thigh tourniquet on the incidence of deep venous thrombosis after operations on the fore part of the foot. Clinical effects of applying a tourniquet in total knee arthroplasty on blood loss. Epinephrine-augmented Hypotensive Epidural Anesthesia Replaces Tourniquet Use in Total Knee Replacement The limited use of a tourniquet during total knee arthroplasty: a randomized controlled trial. Surgical/tourniquet pain accelerates blood coagulability but not fibrinolysis. The effects of a pneumatic tourniquet on blood loss in total knee arthroplasty. The influence of tourniquet use and timing of its release on blood loss in total knee arthroplasty. [Effect of tourniquet use on blood loss in total knee arthroplasty]. A randomized double-blind clinical trial of tourniquet application strategies for total knee arthroplasty Faster recovery without the use of a tourniquet in total knee arthroplasty Tourniquet-induced wound hypoxia after total knee replacement.
BACKGROUND Military enthusiasm for limb tourniquet use in combat casualty care has result ed 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 data base was search ed 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 data base report was included but analyzed separately ( 2,048 cases ) . All were retrospective cohort studies without prospect i ve 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 st and ardized data collection specific to limb trauma and tourniquet use can serve to improve the trauma community 's underst and ing of the safety and effectiveness of tourniquet use in civilian trauma setting s. LEVEL OF EVIDENCE Systematic review , level IV Introduction Haemorrhage from the injured extremity is a significant cause of preventable death in military setting s. This study evaluated the effect of training on the efficacy of the combat application tourniquet ( CAT ) and to define st and ards for military personnel . Method Participants from a training tank battalion were r and omised . Data collected included age , body mass index , mean arterial pressure , h and dominance , femoral artery diameter and skin thickness . The study involved  tourniquet application times ( AT ) and application success rates in basic , after-training and eyes-closed phases . Doppler ultrasound was used to identify the presence or absence of popliteal , radial and ulnar artery pulses . Results A total of 102 trainees participated . In the after-training phase , the left and right upper extremity ATs were 35±13.1 s , and 34.8±13.5 s and the right and left lower extremity ATs were 20.6±6.0 s and 20.5±5.5 s , respectively . The overall tourniquet success rates in three successive study phases were 69.6 % , 82.4 % and 91.2 % , respectively . A negative significant relationship was found between extremity circumference and tourniquet success . Discussion The results show that the efficacy of CAT application  increases with training . Further studies are required to investigate the reasons underlying application failures . This single group prospect i ve r and omised study involves level of evidence 4 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 r and omized 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 One hundred consecutive primary total knee arthroplasties performed by a single surgeon were prospect ively r and omized into two groups to study the effect of tourniquet release for hemostasis on postoperative blood loss and transfusion requirements . The two groups were comparable . Variables such as antiinflammatory drug use ; anesthetic ; soft-tissue release ; and component fixation were analyzed . There was no significant difference between the groups in terms of perioperative blood loss , decrease in hemoglobin or hematocrit level , transfusion need , or incidence of wound or thromboembolic complications . Tourniquet release for hemostasis is not an effective means of limiting postoperative blood loss or reducing transfusion need after primary total knee arthroplasty BACKGROUND Most minor h and operations can be performed with local anesthesia and tourniquet . Some literature supports this concept based on the believe that the " patient can tolerate it " . Nowadays , the wide-awake technique with epinephrine- contained lidocaine is safe . This technique does not need a tourniquet because epinephrine provides local vasoconstriction . OBJECTIVE The present study was design ed to compare patients ' comfort and effectiveness of local anesthesia as well as bleeding at the surgical site between wide-awake anesthesia and local lidocaine with tourniquet application . MATERIAL AND METHOD Prospect i ve Clinical Trial was performed in 60 patients who received outpatient surgery for common h and problems at Maharaj Nakorn Chiang Mai Hospital . With r and omization , 30 patients were in wide-awake group , who received adrenaline-contained lidocaine as a local anesthetic agent , with tourniquet wrapping but with no pressure applied ( group 1 ) . The other 30 patients were in the conventional group that received lidocaine ( no adrenaline ) and a 250-mmHg tourniquet application ( group 2 ) . Operations were performed with st and ard methods . Visual analog scores , surgical field bleeding , amount of bleeding , any complications within 4 weeks were recorded . RESULTS There are no significant differences between the two groups in terms of patient profiles ( sex , age and diseases ) , injected site pain and surgeon 's opinion of surgical site bleeding . Tourniquet 's pain and the amount of blood loss in the conventional group were significantly higher than the wide-awake group . CONCLUSION Wide-awake technique ( no tourniquet applied ) offers better comfort for patients and less total blood loss while providing effective anesthesia and patient safety as with the conventional technique BACKGROUND There has been controversy regarding the incidence of deep vein thrombosis ( DVT ) after total knee arthroplasty ( TKA ) with or without the use of a tourniquet . The aim of this r and omized , prospect i ve study was to clarify the effects of tourniquet use on DVT in TKA . METHODS The subjects were 109 patients scheduled to undergo TKA from April 2008 to March 2009 before the establishment of the American Association of Orthopedic Surgeons ( AAOS ) practice guidelines . They were r and omized into two groups : 51 patients in the tourniquet group ( group T ) and 52 patients in the control group without a tourniquet ( group C ) . We investigated the thrombotic presence using ultrasonography one week after surgery and compared both groups . RESULTS There was no difference in the rate of proximal DVTs ( P=0.63 ) . However , the risk of distal DVT was significantly higher in group T than in group C ( 52.9 % vs. 23.1 % ; P=0.002 ) . CONCLUSIONS Use of the tourniquet in TKA increased the risk of distal DVT We performed a prospect i ve r and omized clinical study to determine whether use of a thigh tourniquet influences the incidence of deep venous thrombosis . The lower limbs of patients who were scheduled for elective surgery on the fore part of the foot were r and omized and assigned to one of three treatment categories : Group I , no tourniquet ; Group II , exsanguination by an Esmarch b and age before tourniquet application ; and Group III , exsanguination by elevation of the extremity prior to application of a tourniquet . The 117 limbs of seventy-one patients included in this study were evaluated preoperatively and twenty-four and seventy-two hours postoperatively with 125I-labeled fibrinogen , and preoperatively and seventy-two hours postoperatively with  Doppler ultrasound studies and phleborheography .  The findings in all of the Doppler ultrasound studies and all of the phleborheograms were normal . Two of the 125I-fibrinogen studies were positive , but subsequent contrast venography revealed that these were false-positive findings . We therefore concluded that the use of a thigh tourniquet does not increase the risk of deep venous thrombosis in patients who have had an operation on the fore part of the foot BACKGROUND Tourniquets used during total knee arthroplasty may lead to many complications . The aim of this study was to determine perioperative blood loss and its clinical relevance in total knee replacement surgery after applying a tourniquet . METHODS From June 2009 to October 2009 , 60 consecutive patients who underwent routine total knee arthroplasty were r and omly divided into two groups and were treated with or without a tourniquet ( 30 patients /group ) . There were no significant differences in patient baseline characteristics between the two groups . We compared the two groups of patients in terms of intra- and postoperative bleeding , invisible or visible bleeding , and total blood loss . RESULTS None of the patients showed poor wound healing , lower extremity deep venous thrombosis or other complications . The amount of blood loss during surgery was lower in the tourniquet group than in the control group ( P < 0.01 ) . However , postoperative visible bleeding ( P < 0.05 ) and occult bleeding ( P < 0.05 ) were significantly greater in the tourniquet group than in the control group . There was no significant difference in the total amount of blood loss between the two groups ( P > 0.05 ) . CONCLUSIONS Tourniquet can reduce bleeding during total knee replacement surgery , but is associated with greater visible and invisible blood loss Tourniquets commonly are used during total knee arthroplasties to reduce intraoperative blood loss , despite their various side effects . The goal of this study was to determine whether tourniquet use could be avoided using epinephrine-augmented hypotensive epidural anesthesia during a total knee arthroplasty without negative effects on perioperative hemoglobin values .  One hundred patients having total knee arthroplasties were included in a prospect i ve , observer-blinded , controlled , and r and omized study . Forty-nine patients received epinephrine-augmented hypotensive epidural anesthesia without use of a tourniquet ( Group A ) , and 51 patients received normotensive epidural anesthesia with use of a tourniquet ( Group B ) . Hemoglobin was evaluated and is reported preoperatively , immediately and 6 hours postoperatively , and on Days 1 , 2 , 3 , 5 , and 6 in absolute and relative values . Data were not collected for Day 4 . Greater absolute and relative postoperative hemoglobin values were observed in Group A immediately postoperative , on Day 5 , and on Day 6 . In patients who did not have transfusions , the mean relative hemoglobin values were greater in Group A at all times evaluated ( except on Day 1 ) . Epinephrine-augmented hypotensive epidural anesthesia is an effective method to avoid the use of a tourniquet during total knee arthroplasty without the negative effects on perioperative hemoglobin values . Level of Evidence : Therapeutic study , Level I-1a ( r and omized controlled trial , significant difference ) . See the Guidelines for Authors for a complete description of levels of evidence BACKGROUND Total knee arthroplasty ( TKA ) is commonly performed using a tourniquet . However , some studies have reported that several complications were associated with the use of a tourniquet in TKA . In this study we investigate whether the limited use of a tourniquet in TKA would reduce complications and facilitate postoperative recovery . METHODS Sixty patients were r and omly divided into two groups ( 30 cases/group ) : group A using the tourniquet throughout the surgical procedure , and group B using the tourniquet starting from the cementation to the completion of the procedure .  Operation time , total measured blood loss , and incidence of complications were all recorded . RESULTS There was no significant difference in operation time , total measured blood loss , and hemoglobin concentration between the two groups . Incidence of postoperative complications in group B was significantly decreased in comparison to that in group A. The limb circumference at 10 cm above the superior patellar pole or below the inferior patellar pole and the pain score in group B were significantly decreased compared with that in group A at any time point . Range of motion in group B was significantly increased at three and 5 days postoperatively in comparison to that in group A. CONCLUSIONS The limited use of a tourniquet in TKA provides the benefit of decreased limb swelling and knee joint pain while not compromising the operation time or blood loss and recovery . LEVEL OF EVIDENCE Level I ( Therapeutic ) . TRIAL REGISTRATION NUMBER NCT02102581 Tissue damage during surgery induces coagulation factors and activates platelets . Surgical pain may provoke release of catecholamines , leading to hypercoagulability . We have investigated the effect of surgical pain on blood coagulability and fibrinolysis in orthopaedic operations using tourniquets in 22 patients undergoing total knee replacement . Patients were allocated to one of two groups to receive extradural anaesthesia ( EA ; n = 11 ) or general anaesthesia ( GA ; n = 11 ) . The EA group received lumbar extradural block with lidocaine . The GA group received only general anaesthesia , maintained with 1.5 - 2.5 % sevoflurane and 66 % nitrous oxide in oxygen . Using a thrombelastogram technique , blood coagulability and fibrinolysis were measured . Mean maximum amplitude ( MA ) , which reflects coagulability , increased after tourniquet inflation ( 11 % ) in group GA whereas MA in group EA did not change . After tourniquet deflation , MA values in both GA and EA groups increased significantly ( 10 % and 20 % , respectively ) ( P < 0.05 ) , and there was also a significant difference in MA between groups ( P < 0.05 ) . The fibrinolytic rate did not change in either group during tourniquet inflation , but increased significantly ( 160 % ) after tourniquet deflation . There was no significant difference in fibrinolytic rate between the groups . We conclude that the hypercoagulability seen in group GA could have been caused by surgical or tourniquet pain , or both , and that extradural anaesthesia is a useful technique to prevent hypercoagulability OBJECTIVE In lower-extremity surgery there are significant risks associated with the use of tourniquets . This prospect i ve study was done to assess to what extent these risks may be offset by the potential advantages of tourniquets , namely reductions in blood loss , length of hospital stay and complication rates . DESIGN A prospect i ve case study . SETTING A major urban hospital . PATIENTS Sixty-three consecutive patients scheduled for primary cemented total knee arthroplasty ( TKA ) were blindly r and omized into tourniqet ( n = 33 ) and non-tourniquet ( n = 30 ) groups . INTERVENTION TKA during which a pneumatic tourniquet was applied or not applied to control blood loss . MAIN OUTCOME MEASURES Perioperative blood loss , operating time , complication rates , hospital stay and transfusion needs . RESULTS Differences in the total measured blood loss , intraoperative blood loss and the Hemovac drainage blood loss between the 2 groups were not significantly different ( p > 0.25 ) . The calculated total blood loss was actually lower in the non-tourniquet group ( p = 0.02 ) . Between the groups there were no statistical differences in surgical time , length of hospital stay , transfusion requirements or rate of complications ( although there was a trend to more complications in the tourniquet group ( p = 0.06 ) ) . CONCLUSION The effectiveness of a pneumatic tourniquet to control blood loss in TKA is question able In surgical practice , hemostasis is used to minimize postoperative bleeding in total knee arthroplasty . We performed a prospect i ve r and omized study to determine the influence of tourniquet use and the timing of its release on amount of bleeding .  Eighty four patients ( 96 knees ) were scheduled for total knee arthroplasty and r and omly divided into three groups . Posterior cruciate retaining bicompartmental total knee prostheses  were used in all . In group I , no tourniquet was used . In group II , a tourniquet was used and was deflated for hemostasis once all components had been inserted . In group III , the tourniquet was deflated after wound closure and application of a compressive dressing .  Mean blood drainage , mean volume of blood transfusion , hemoglobin ( Hb ) and hematocrit ( Hct ) values and operative time were compared between the three groups . Mean blood drainage was 810 mL ( 300 - 1300 ) in groups I 720 mL ( 240 - 1200 ) in group II and 705 mL ( 250 - 1150 ) in group III ( p = 0.062 ) . The Hb and Hct values , tourniquet time ( for groups II and III ) and volume of blood transfusion were similar . The operative time was significantly longer for first group ( p = 0.012 ) . Using tourniquet and its intraoperative release with hemostasis , does not reduce blood loss in total knee arthroplasty , but using tourniquet reduces operation time significantly AIM To reduce blood loss in total knee arthroplasty various physical measures including the use of a tourniquet are recommended . The question of an early tourniquet release is still unsettled . PATIENTS AND METHOD To confirm our theory that blood loss and need of blood transfusions might be reduced while removing the tourniquet for meticulous hemostasis before wound closure we analysed 70 ( 41 male , 29 female ) consecutive patients with total knee arthroplasty for osteoarthritis performed by a single surgeon in a prospect ive-r and omized study between 1/1996 to 6/1998 . In group I the tourniquet was released before , in group II after wound closure . RESULTS We could n't find any significant differences in the estimated blood loss , the decrease of hemoglobin and hematocrit level , and the transfusion need . In Group II we observed two cases of deep vein thrombosis . This difference was not significant . CONCLUSION We conclude that tourniquet release for hemostasis is not an effective tool in reducing blood loss or transfusion need in total knee arthroplasty Purpose The optimal timing of pneumatic lower limb tourniquet application during primary elective total knee arthroplasty surgery ( TKA ) is a matter of debate . Most previous reports have failed to show significant differences between different tourniquet timings . The aim of the work was to determine how three strategies of lower limb pneumatic tourniquet application affect the outcome for TKA patients . Methods Forty-three patients who undergo TKA were r and omized into one of the three groups , and 36 of these patients completed the study . The tourniquet was inflated just before incision and deflated after the hardening of the cement for twelve patients ( Group 1 ) , it was inflated just before cement application and deflated after its hardening for another twelve patients ( Group 2 ) , and it was inflated before incision and deflated after the last suture of the skin for a further twelve patients ( Group 3 ) . Fit-to-discharge criteria and six methods for calculating estimated blood loss were used . Results The estimated blood loss in Group 1 was lower than in Group 2 , as determined by six methods of calculation ( p < 0.05 ) . Estimated blood loss in Group 3 was lower than in Group 2 , as determined by one method ( p = 0.050 ) . The mobilization performance in Group 1 was better than in Group 2 ( p = 0.023 ) and in Group 3 ( p = 0.033 ) . Group 1 was better fit to discharge than Group 3 ( p = 0.030 ) . Conclusions Inflation of an automatic pneumatic lower limb tourniquet before skin incision and its deflation after hardening of cement tends to give better outcomes in TKA patients during six postoperative days . The estimated blood loss was highest when the tourniquet was inflated just before cement application and deflated after its hardening . Level of evidence II Background and purpose — Tourniquet application is still a common practice in total knee arthroplasty ( TKA ) surgery despite being associated with several adverse effects . We evaluated the effects of tourniquet use on functional and clinical outcome and on knee range of motion ( ROM ) . Patients and methods — 70 patients who underwent TKA were r and omized  into a tourniquet group ( n = 35 ) and a non-tourniquet group ( n = 35 ) . All operations were performed by the same surgeon and follow-up was for 1 year . Primary outcomes were functional and clinical outcomes , as evaluated by KOOS and knee ROM . Secondary outcomes were intraoperative blood loss , surgical time and visibility , postoperative pain , analgesic consumption , and transfusion requirements . Results — Patients in the non-tourniquet group showed a better outcome in all KOOS subscores and better early knee ROM from surgery to week 8 . No difference was detected at the 6- and 12-month follow-ups . Postoperative pain and analgesic consumption were less when a tourniquet was not used . Surgical time and visibility were similar between groups . Intraoperative blood loss was greater when not using a tourniquet , but no postoperative transfusions were required . Interpretation— This study shows that TKA without the use of a tourniquet results in faster recovery in terms of better functional outcome and improved knee ROM . Furthermore , reduced pain and analgesic use were registered and no intraoperative difficulties were encountered We have investigated whether the thigh tourniquet used during total knee replacement ( TKR ) influenced the development of postoperative wound hypoxia and was a cause of delayed wound healing . We allocated r and omly 31 patients ( 31 TKRs ) to one of three groups : 1 ) no tourniquet ; 2 ) tourniquet inflated at low pressure ( about 225 mmHg ) ; and 3 ) tourniquet inflated to high pressure of about 350 mmHg .  Wound oxygenation was measured using transcutaneous oxygen electrodes . In the first week after surgery , patients with a tourniquet inflated to a high pressure had greater wound hypoxia than those with a low pressure . Those without a tourniquet also had wound hypoxia , but the degree and duration were less pronounced than in either of the groups with a tourniquet . Use of a tourniquet during TKR can increase postoperative wound hypoxia , especially when inflated to high pressures . Our findings may be relevant to wound healing and the development of wound infection
The 50 original articles included in this qualitative , systematic review revealed that the recommendations " Tourniquet " of the DGAI published in 2016 are mostly still up to date despite an inhomogeneous study situation .
INTRODUCTION The effectiveness of a  tourniquet  in the case of life-threatening hemorrhages of the extremities is well recognized and led to the recommendations on " Tourniquet " of the German Society of Anaesthesiology and Intensive Care ( DGAI ) in 2016 .
The aim of this systematic review was to re-evaluate the current medical literature in relation to the published DGAI recommendations .