Esmarch Bandage Research Articles

Why Do Bier Blocks Work for Hand Surgery … Most of the Time?

surgical procedures because it provides anesthesia for short procedures and a bloodless field under tourniquet control. It is a safe and cost-effective alternative to general anesthesia, with patients who undergo IVRA leaving the hospital one hour sooner and having less postoperative nausea than those undergoing general anesthesia. 2,3 The success of IVRA for hand surgery is contingent on careful patient selection, maintenance of a bloodless field, and tolerance of the tourniquet. We will discuss why Bier blocks work well for hand surgery, and review some of the recent literature on technical modifications to improve intraoperative hemostasis and tourniquet tolerance. TRADITIONAL METHOD OF IVRA Traditionally, IVRA is performed by first applying a single or double lumen tourniquet to the proximal arm. For surgery less than 20 minutes duration, a single lumen tourniquet is usually chosen, whereas for surgery up to 60 minutes, a double lumen tourniquet provides a more extended period before tourniquet pain occurs. A 20- or 22-gauge cannula is inserted preoperatively into a vein on the dorsum of the hand. The extremity is then elevated and exsanguinated using an Esmarch bandage. Incomplete exsanguination can reduce the quality of anesthesia and hemostasis within the surgical field. The proximal lumen of the tourniquet is then inflated. Local anesthetic (LA) is then injected slowly. A dose of 3 mg/kg 0.5% lidocaine is used frequently. Rapid infusion can exceed the tourniquet pressure and LA may enter the systemic circulation. Surgical-level anesthesia is commonly reached within 5 to 10 minutes. The tourniquet’s proximal lumen remains inflated until the patient becomes uncomfortable. The distal lumen, which is over an anesthetized area, is then inflated, followed by release of the proximal lumen. Gradual release of the distal lumen at the end of the procedure is recommended to prevent systemic LA toxicity for procedures lasting less than 20 minutes. 4

Open reduction of medial epicondyle fractures: operative tips for technical ease.

In the pediatric population, medial humeral epicondylar fractures account for nearly 12% of all elbow fractures. There is ongoing debate about the surgical management of medial epicondyle fracture cases. Our technique in the operative management of medial epicondyle fractures uses the external application of an Esmarch bandage, as well as provisional fixation with needle rather than K-wire fixation. This technique decreases the need for soft-tissue release and, therefore, theoretically, maintains soft-tissue vascularity of the small fracture fragments. Moreover, it preserves the soft-tissue tension medially. It involves the use of a bandage that is universally available in orthopedic operating rooms, including those in developing nations. It is easy to apply by either the principal or assisting surgeon. With practice, it cuts down operative time and can help substitute for an assistant. This relatively simple operative technique makes for a more seamless operative process, improved reduction, and key preservation of soft-tissue vascularity.

Differential Increases in Blood Flow Velocity in the Middle Cerebral Artery after Tourniquet Deflation during Sevoflurane, Isoflurane or Propofol Anaesthesia

The purpose of this study was to examine the comparative effects of sevoflurane, isoflurane or propofol on cerebral blood flow velocity after tourniquet deflation during orthopaedic surgery. Thirty patients undergoing elective orthopaedic surgery were randomly divided into sevoflurane, isoflurane and propofol groups. Anaesthesia was maintained with sevoflurane, isoflurane or propofol infusion in 33% oxygen and 67% nitrous oxide, in whatever concentrations were necessary to keep bispectral index values between 45 and 50. Ventilatory rate or tidal volume was adjusted to target PaCO2 of 35 mmHg. A 2.0 MHz transcranial Doppler probe was attached to the patient's head at the temporal window and mean blood flow velocity in the middle cerebral artery was continuously measured. The extremity was exsanguinated with an Esmarch bandage and the pneumatic tourniquet was inflated to a pressure of 450 mmHg. Arterial blood pressure, heart rate, velocity in the middle cerebral artery and arterial blood gas analysis were measured every minute for 10 minutes after release of the tourniquet in all three groups. Velocity in the middle cerebral artery in the three groups increased for five minutes after tourniquet deflation. Because of the different cerebrovascular effects of the three agents, the degree of increase in flow velocity in the isoflurane group was greater than in the other two groups, the change in flow velocity in the propofol group being the lowest (at three minutes after deflation 40 +/- 7%, 32 +/- 6% and 28 +/- 10% in the isoflurane, sevoflurane and propofol groups respectively, P < 0.05).

Tissue hemoglobin index: a non-invasive optical measure of total tissue hemoglobin

IntroductionThe tissue hemoglobin index (THI) is a hemoglobin signal strength metric provided on the InSpectra™ StO2 Tissue Oxygenation Monitor, Model 650. There is growing interest regarding the physiologic meaning of THI and whether a clinically useful correlation between THI and blood hemoglobin concentration exists. A series of in vitro and in vivo experiments was performed to evaluate whether THI has potential utility beyond its primary purpose of helping InSpectra™ device users optimally position a StO2 sensor over muscle tissue.MethodsThe THI and tissue hemoglobin oxygen saturation (StO2) were measured using the InSpectra™ StO2 Tissue Oxygenation Monitor, Model 650, with a 15 mm optical sensor. A THI normal reference range was established in the thenar eminence (hand) for 434 nonhospitalized human volunteers. In 30 subjects, the thenar THI was also evaluated during 5-minute arterial and venous blood flow occlusions, and with blood volume exsanguination in the hand induced with an Esmarch bandage. In addition, correlation of the THI to blood total hemoglobin concentration (Hbt) was studied in five pigs whose Hbt was isovolumetrically diluted from 13 to 4 g/dl systemically and 0.5 g/dl locally in the hind limb. The sensitivity and specificity of the THI to measure tissue hemoglobin concentration (THC) were characterized in vitro using isolated blood tissue phantoms.ResultsIn human thenar tissue, the average THI was 14.1 ± 1.6 (mean ± standard deviation). The THI extrapolated to 100% blood volume exsanguination was 3.7 ± 2.0 units presumably from myoglobin. On average, the THI increased 1.5 ± 1.0 units with venous occlusion and decreased 4.0 ± 2.0 units with arterial occlusion. In porcine hind limbs, the THI weakly correlated with Hbt (r2 = 0.26) while ΔTHI during venous occlusion had a stronger correlation (r2 = 0.62). In vitro tests indicated that THI strongly correlated (r2 > 0.99) to phantom THC and was insensitive to StO2 changes.ConclusionsSteady-state THI values do not reliably indicate Hbt. The THI is a reproducible quantitative index for THC, and THI trends can discriminate between arterial or venous blood flow occlusions. The THI magnitude permits the estimation of myoglobin's contribution to StO2.

Clinical Consequences of Different Exsanguination Methods in Hand Surgery. A Double-blind Randomised Study

A randomised trial was performed in 100 patients in order to evaluate the effectiveness of three commonly used methods of exsanguination (simple elevation, squeeze method and Esmarch bandage) in a clinical setting. The quality and quantity of the exsanguination was evaluated every 5 min by the surgeon and the amount of oozing was observed. Although there was no significant difference between squeezing the arm and Esmarch bandaging, both resulted in significantly better exsanguination than simple elevation. In 22 out of the 100 patients, a small amount of ooze was observed. The oozing was observed significantly more frequently in the patients exsanguinated by simple elevation.

Comparison of two different methods of limb exsanguination (Esmarch bandage and limb elevation) in intravenous regional anesthesia

Study Objective To compare the effect of the Esmarch bandage and limb elevation techniques in quality of painlessness of intravenous (IV) regional anesthesia. Design Double-blinded, controlled, randomized clinical trial. Setting Operating room of university hospital. Patients 70 ASA physical status І and П patients who were scheduled for repair of upper extremity soft-tissue injuries. Interventions Patients were randomized for exsanguination of their upper extremities either by Esmarch bandage (Esmarch group) or by limb elevation (elevation group) to 90° for about 5 minutes. Measurements Preoperative and intraoperative pain intensities were evaluated by verbal response scale. The intensity of pain and need for IV sedative and analgesic medications were compared in both groups by Fisher's exact and χ 2 tests. Main Results There was no significant statistical difference between the pain intensity data of two groups either before or after starting the surgery. The need for IV supplemental drugs for pain relief was similar in both groups. Conclusion The limb elevation technique, while producing less discomfort for patients, can be as effective as the Esmarch bandage in limb exsanguination during IV regional anesthesia.

Comparison of two indirect techniques for local delivery of a high dose of an antimicrobial in the distal portion of forelimbs of horses

To compare isolated limb retrograde venous injection (ILRVI) and isolated limb infusion (ILI) for delivery of amikacin to the synovial fluid of the distal interphalangeal and metacarpophalangeal joints and to evaluate the efficacy of use of an Esmarch tourniquet in standing horses. 6 healthy adult horses. Horses were randomly assigned in a crossover design. In ILRVI, the injection consisted of 1 g of amikacin diluted to a total volume of 60 mL administered during a 3-minute period. In ILI, the infusion consisted of 1 g of amikacin diluted to 40 mL administered during a 3-minute period followed by administration of boluses of diluent (82 mL total) to maintain vascular pressure. During ILI, the infusate and blood were circulated from the venous to the arterial circulation in 5-mL aliquots. Synovial fluid and serum samples were obtained to determine maximum amikacin concentrations and tourniquet leakage, respectively. Both techniques yielded synovial concentrations of amikacin > 10 times the minimum inhibitory concentration (MIC) for 90% of isolates (80 microg/mL) and > 10 times the MIC breakpoint (160 microg/mL) of amikacin-susceptible bacteria reported to cause septic arthritis in horses. These values were attained for both joints for both techniques. Esmarch tourniquets prevented detectable loss of amikacin to the systemic circulation for both techniques. Both techniques reliably achieved synovial fluid concentrations of amikacin consistent with concentration-dependent killing for bacteria commonly encountered in horses with septic arthritis. Esmarch tourniquets were effective for both delivery techniques in standing horses.

Effect of different cuff widths on the motor nerve conduction of the median nerve: an experimental study

BackgroundA bloodless operative field is considered mandatory for most surgical procedures on the upper and lower extremity. This is accomplished by using either an Esmarch bandage or a pneumatic tourniquet, but a number of complications are associated with both. Nerve palsy is one of the most frequently encountered complications of this procedure. Wider cuffs have been found to cause reduced risk of tourniquet induced injury to the underlying soft tissues than the narrower ones due to the fact that lower occlusion pressures are caused by the former. To address and investigate this question, conduction in the median nerve has been measured proximal to tourniquet as well as distal to the tourniquet. Parameters of nerve conduction measured are nerve conduction velocity, latency and amplitude.MethodsSphygmomanometer cuffs with widths 14 cm and 7 cm were applied to the upper extremities of 20 healthy, normotensive volunteers (9 males and 11 females with age ranging from 22 to 27). Systolic blood pressure was measured first and then the cuff was inflated to about 20–30 mm Hg above it and was kept inflated for 15 minutes. Recordings were done prior to, for the period of tourniquet inflation, and following release of the tourniquet.ResultsNerve conduction was found to be more severely affected by the 14 cm cuff than the 7 cm cuff.ConclusionWider cuffs resulted in more severe changes in the nerve. This brings us to the conclusion that though lower inflation pressures are required for the occlusion of the blood supply using wider cuffs, the nerve conduction is more severely affected by the wider ones. Both electrophysiological changes and occlusion pressure should be kept in mind while choosing the width of the cuff.

'The BloodStopper' - experiences with a novel portable hand-held orthopaedic limb tourniquet

Tourniquets are widely employed in orthopaedic practice to maintain a bloodless operative field during extremity surgery. In areas of the world where reliable pressurized air systems for tourniquet inflation are not available, and as an alternative to the traditional Esmarch bandage, we report on the successful and safe use of a novel hand-held, battery-operated limb tourniquet.

Combined Use of Low-dose Bupivacaine, Colloid Preload and Wrapping of the Legs for Preventing Hypotension in Spinal Anaesthesia for Caesarean Section

We tested the hypothesis that using a combination of methods would result in a greater reduction in the incidence of hypotension due to spinal anaesthesia in caesarean sections compared with using each method on its own. A total of 120 patients were randomly allocated to the following four treatment groups: 10 mg bupivacaine 0.5% intrathecally plus 500 ml Ringer lactate solution (group B); 4 mg bupivacaine 0.5% plus 25 mug fentanyl plus 500 ml Ringer lactate solution (group F); 4 mg bupivacaine 0.5% plus 25 mug fentanyl intrathecally plus 500 ml Gelofusine intravenously (group G); and 4 mg bupivacaine 0.5% plus 25 mug fentanyl intrathecally plus 500 ml Gelofusine intravenously plus tight wrapping of the lower extremities with an Esmarch bandage (group E). The Esmarch bandage was only loosely applied in groups B, F and G. Hypotension was detected in 100% of the patients in group B compared with 70.0%, 46.7% and 23.3% of those in groups F, G and E, respectively. Hypotension was thus reduced by using a combination of several methods.

Esmarch tourniquet in orthopaedic surgery

A bloodless field is important in many orthopaedic operations necessitating the use of a pneumatic tourniquet or Esmarch bandage. The outcome of the use of an Esmarch bandage for exsanguination and as a tourniquet in 112 consecutive patients who had elective orthopaedic operations on 131 limbs was evaluated. The setting was at Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria, from March 2003 to February 2005. The mean age of the patients was 25.7 + standard deviation years (range 1-70 years). The duration of tourniquet application ranged from 20 min to 2 h 35 min. Four limbs (3.1%) developed acute compartment syndrome; four (3.1%) had tourniquet paralysis with ulnar nerve involvement in three limbs. All limbs regained full neurological function following physiotherapy. There was wound infection in two limbs (1.5%). In spite of its drawbacks, the Esmarch bandage is still useful for exsanguination and as a tourniquet in orthopaedic surgery where there is no pneumatic tourniquet.

Endoscopic Abdominoplasty

We describe a technique for endoscopic abdominoplasty in which we used 3 incisions, following the triangulation principles. To maintain the subcutaneous cavity, CO2 was insufflated at 8 mm Hg, and Esmarch bandages were placed at the submammary fold in a circumferential way to prevent subcutaneous emphysema. The aponeurosis plication was done with interrupted "8" figure sutures, with extracorporeal knots tied up in a double fisherman knot. The rest of the technique is similar to those previously described. Seven patients were treated, with an average age of 35.7 years (range, 25-60), and the mean length of surgery was of 197.11 minutes (range, 129-240). After surgery, 2 patients had mild pulmonary hypoventilation treated only with oxygen through a nasal mask for 24 hours. There were other complications such as seromas, inadequate implantation of the navel, and superficial periumbilical necrosis. According to the patients' opinion, the esthetic results have been satisfactory so far.

Maintenance of Subcutaneous Cavities With CO2

Since mechanical retractors in endoscopic plastic surgery cause certain drawbacks, we developed a model in dogs, which, by insufflating CO2 into a subcutaneous cavity, we were able to maintain. We evaluated the magnitude of subcutaneous emphysema and absorption of CO2 by insufflating different pressures and the efficacy of external pressure on the skin with the purpose of limiting the subcutaneous emphysema. Sixteen dogs were divided in 3 groups, A, B, and C. We controlled the pulmonary function by using a volume-cycle ventilator. In all groups, we maintained a subcutaneous cavity by insufflating CO2. Groups A and C were insufflated at 15 mm Hg; group B, at 8 mm Hg. We placed circumferential Esmarch bandages on the thorax of groups B and C to delimit superiorly and inferiorly the surgical area. Arterial blood gas analyses (ABGA) were taken from the femoral artery 60 minutes after intubation, 60 minutes after Esmarch bandage was placed and at the end of the CO2 insufflation. Statistically, results were analyzed by Wilcoxon test. P < 0.05 was considered statistically significant. Group A showed extensive subcutaneous emphysema. Two dogs died. The systemic increase of the CO2 showed a median of 9.6 mm Hg (P < 0.05). In Group B, Esmarch bandages caused increase in CO2, with a median of 1.65 mm Hg (P < 0.028). None of these dogs showed subcutaneous emphysema during the insufflation after CO2 insufflation pressure augmented with a median of 3.7 mm Hg (P < 0.028). In Group C, chest restriction increased CO2 median of 6.1 mm Hg (P < 0.043), and subcutaneous emphysema shown was less extensive than group A. The CO2 increased after insufflation a median of 16 mm Hg (P < 0.043). Subcutaneous cavities can be maintained open with CO2 insufflation at 8 mm Hg, limiting perfectly the surgical area; as done with Esmarch bandages, it reduces CO2 absorption and makes this procedure safe.

A novel elastic exsanguination tourniquet as an alternative to the pneumatic cuff in pediatric orthopedic limb surgery

We describe our experience with a novel surgical exsanguination tourniquet (S-MART; OHK Medical Devices, Haifa, Israel) in clinical pediatric orthopedics. We evaluated the surgical exsanguination tourniquet's properties and clinical use in 51 patients and compared our observations with our long-standing experience with the Esmarch bandage, pneumatic tourniquet and sterile stockinet. Using the surgical exsanguination tourniquet, we found superior exsanguination quality, quick application and the ability to place the occlusion ring closer to the surgical field. No side effects or ischemic complications were observed. After removal, the skin under the ring was intact in all cases. We conclude that the surgical exsanguination tourniquet is safe and valuable in our practice.

Use of glycyrrhizin in prevention of tissue damage caused by ischemia-reperfusion in rabbit hind limbs

BackgroundGlycyrrhizin, an agent that can bind to selectins and inhibit their ability to bind neutrophils, was found to be effective in preventing tissue edema caused by ischemiareperfusion in a rabbit model. MethodsComplete ischemia was produced by applying a tight Esmarch tourniquet to the hind limbs of 24 Japanese white rabbits. Immediately before and 1h after release of the tourniquet, 12 animals were given glycyrrhizin intravenously; 12 controls received saline. ResultsThe mean relative increase in the circumference of the shins before and after ischemia-reperfusion with or without glycyrrhizin treatment was 4.6%±2.4% and 9.6%±4.2%, respectively, indicating that tissue edema caused by the ischemia-reperfusion was significantly attenuated by glycyrrhizin. Histological studies of cross sections of the anterior tibial muscle 24h after reperfusion showed a significant reduction in the incidence of necrotic muscle fibers in the glycyrrhizin-treated animals compared with the controls that did not receive glycyrrhizin. The mRNA levels of P- and Eselectin 24h after reperfusion were significantly higher in the ischemic anterior tibial muscle than in the nonischemic normal muscle. After 24h of reperfusion, the mean activity of myeloperoxidase, a neutrophil-specific enzyme, in the anterior tibial muscles of the group given glycyrrhizin (0.0022±0.0013 absorbance units) was lower than that of the untreated group (0.027±0.026 absorbance units). ConclusionsThese data suggest that glycyrrhizin treatment is effective in suppressing the acute inflammatory reaction or edema following ischemia-reperfusion and might be potentially useful in clinical practice for preventing ischemiareperfusion injuries to the extremities.

Esmarch's Bandage

Over the centuries, surgeons have battled with the problem of blood loss in trauma and surgery. In major limb surgery, amputation for example, the assistant would apply digital pressure over the artery or a tourniquet would be used – a pad over the arterial pressure point would be bound down with a bandage, tape or rope tied around the limb. However, this had a tendency to slip and the limb could not be exsanguinated efficiently.

Pneumatische Tourniquet-Blutstromunterbrechung in der distalen Bypasschirurgie

The femoral-popliteal or distal bypass requires as a rule exact isolation and dissection of the arteriosclerotic and calcified artery. The tourniquet is an effective substitute for vascular occlusion especially in case of seriously calcified vessels. As opposed to the Esmarch bandage, the sterile Löfquist-bandage has a lot of advantages. Starting the bypass operation as usual procedure the Löfquist-bandage can be used for interruption of circulation just before opening the vessels. Positive experiences in varicose vein surgery induced us to perform this tourniquet procedure in distal bypass surgery by using the special Löfquist-bandage. Meanwhile we operated on 74 patients between 1999 and 2003. We treated 29 patients with primary distal bypass reconstruction and 45 patients who suffered from bypass occlusion. In addition to bypass thrombectomy, these patients underwent PTA, reconstructions of the distal anastomosis and bypass prolongations. The advantages were both a short clamping time and an economic dissection of the vessels. The complications were haematomas, re-occlusion, wound infections and major amputations in only few patients. Operative complications with the bandage were not observed. Indications, important technical details and the results are critically discussed.

The role of Esmarch bandage and percutaneous cannulated cancellous screws in tibial condylar fracture

Background : Proximal tibial fractures involving the condyles are often a matter of debate with regards to surgical management. The purpose of this study was to evaluate the efficacy of using closed reduction with an eschmarch bandage, gentle hammering, and use of percutaneous cannulated cancellous screws for fixation and buttressing the fracture, as a treatment modality for specific tibial condyle fractures. Methods : We evaluated 90 closed upper end tibia fractures, Schatzker types I, III, and IV, treated with closed reduction using an esmarch bandage and minimally invasive percutaneus fixation with cannulated cancellous screws. Results : We achieved excellent results in 33.3% of the cases, good result in 50%, a fair result in 13.3 %, and a poor result in 3.3 % cases. Conclusion : This minimally invasive modality of treatment of upper end tibia fractures gives satisfactory results. The use of esmarch bandage and gentle hammering to help achieve acceptable reduction has the advantage of being relatively simple and easily reproducible, without the use of any expensive extra medical equipment. The percutaneous fixation with cancellous screws has minimal morbidity. Thus, this is a good modality of treatment of tibial condlyle fractures of Schatzker types I, III and IV.

Experimental experience with a temporary intraluminal heparin-bonded polyurethane arterial shunt.

After vascular injury, intraluminal arterial shunting may be employed if definitive surgery must be delayed. This paper describes use of a heparin-bonded polyurethane shunt to restore distal circulation after ligation of the femoral artery in sheep. In studies to determine tissue viability for 12 h after insertion into the femoral artery, five of seven shunts remained patent. In another series of experiments to study tissue viability after limb ischaemia, the femoral artery was ligated and a tight Esmarch bandage applied to the limb for 6 h before shunt insertion. The shunt remained patent for 12 h in five of six cases. Nearly all shunt failures occurred shortly after placement and were attributable to intimal damage arising from difficulties during insertion.

Assessing the site of recurrence in patients with secondary hyperparathyroidism by a simplified Casanova autograftectomy test.

Patients with recurrent secondary hyperparathyroidism (rSHPT) following total parathyroidectomy and autotransplantation were prospectively studied by a modified Casanova test to discriminate between the graft-bearing arm and the neck as the site of the recurrence. The test measures intact parathyroid hormone (PTH) in blood obtained from the non-graft-bearing arm before an ischemic period and from the arm bearing the parathyroid graft during an ischemic period caused by an Esmarch bandage. The aim of this study was to evaluate the time course of PTH levels during the test and to establish an abbreviated procedure. A series of 30 patients with rSHPT who were admitted for reoperative surgery between 1994 and 2002 were studied. Systemic PTH levels were determined prior to suprasystolic exclusion of the graft-bearing arm as well as 2, 4, 6, 8, 10, 20, and 30 minutes during it and at 10 minutes afterward. Results were interpreted with a simple algorithm that suggested graft-dependent recurrence (GDR) whenever PTH levels dropped by more than 50% and neck-dominated recurrence (NDR) whenever the PTH levels dropped to less than 20%. Patients were operated on accordingly. Biochemical normalization of calcium and PTH was defined as success. Altogether, 15 patients had GDR and were cured after graft explantation. All of these patients were identified within 4 minutes of starting the test. Another 12 patients had NDR and were cured by excising overlooked or supernumerary glands. PTH levels were indeterminate in three patients (10%). Clinically, NDR is likely in all of these cases, but the test results were firmly established with 100% accuracy 8 minutes after the start of the test procedure. This abbreviated form of the Casanova test is advantageous for accurately determining the site of recurrence in the presence of rSHPT. It is less time-consuming, satisfactory in an ambulatory setting, equally effective, and less invasive than the original Casanova procedure.