Tourniquet Release Research Articles

Effectiveness of Lignocaine Tramadol Hydrochloride Combination in Bier’s Block on Post-Operative Analgesia

Background: Bier’s block has been most commonly used for hand and wrist surgery. Though it reduces the potential complication of general anaesthesia, significant post-operative pain is very common just after tourniquet release. Many adjuvants have been used so far with local anaesthetic to produce a dense block and to provide adequate post–operative analgesia. Of them, Tramadol Hydrochloride was used very successfully as it has got less potential side effects. This study was done to see the effect of Tramadol Hydrochloride in Bier’s block for post-operative analgesia after tourniquet release. Methods: This study was carried out in the Department of Anaesthesiology, Bangladesh Medical College Hospital, Dhaka, during the period of July ’2011 to march ’2012. A total sixty patients aged 20-60 years of ASA-1 and ASA-2 undergoing hand and wrist surgery of less than 40-minute duration were enrolled for the study. The effectiveness of combination of Lignocaine and Tramadol Hydrochloride as an anaesthetic solution in Bier’s block was assessed in terms of reduction of tourniquet pain, quality of anaesthesia, the time of first analgesic demand, and the amount of total analgesic needed in post-operative 24-hours period. Patients in control group (Gr-L) received 40 ml of 0.5% Lignocaine and patients in trial group (Gr-LT) received 38 ml of Lignocaine with 2ml (100mg) of Tramadol Hydrochloride as an anaesthetic solution. Patients were observed post-operatively for 24 hours. Pain was assessed in terms of VAS. Results: Tourniquet pain was significantly less in Gr-LT (p<0.000). Post-operative analgesia was also significantly prolonged in Gr-LT (109.61±12.32 min) than in Gr-L (75.8±9.30 min). The number of total analgesic demand in post-operative 24 hours period was also significantly reduced in Gr-LT (P<0.000).Conclusion: The Lignocaine and Tramadol Hydrochloride mixture in Bier’s block provides adequate post-operative analgesia and causes less analgesic demand in post-operative period.

The Effect of Intravenous Tranexamic Acid on Perioperative Blood Loss, Transfusion Requirements, Verticalization, and Ambulation in Total Knee Arthroplasty: A Randomized Double-Blind Study.

Background and Objectives: Total knee arthroplasty (TKA) is sometimes associated with significant perioperative bleeding. The aim of this study was to determine the efficacy of tranexamic acid (TXA) in reducing perioperative blood loss in patients undergoing primary TKA. The secondary objectives were to assess the efficacy of TXA in reducing the need for blood transfusion in these patients and to determine its effect on verticalization and ambulation after TKA. Materials and Methods: This study included 96 patients who were randomly assigned to two groups, each containing 48 patients. The study group received intravenous TXA at two time points: immediately after the induction with doses of 15 mg/kg and 10 mg/kg 15 min before the release of the pneumatic tourniquet. The control group received an equivalent volume of 0.9% saline solution via the same route. Results: TXA markedly reduced (Z = -6.512, p < 0.001) the total perioperative blood loss from 892.56 ± 324.46 mL, median 800 mL, interquartile range (IQR) 530 mL in the control group, to 411.96 ± 172.74 mL, median 375 mL, IQR 200 mL, in the TXA group. In the TXA group, only 5 (10.4%) patients received a transfusion, while in the control group, 22 (45.83%) received it (χ2 = 15.536, p = 0.001). Patients in the study group stood (χ2 = 21.162, p < 0.001) and ambulated earlier postoperatively, compared to the control group (χ2 = 26.274, p < 0.001). Patients who received TXA had a better overall postoperative functional recovery. There was a statistically significant difference in all the above results. Conclusions: TXA is an effective drug for reducing the incidence of perioperative bleeding, decreasing transfusion rates, and indirectly improving postoperative functional recovery in patients undergoing primary TKA.

Assessment of Ultrasonographic Measurement of Inferior Vena Cava Collapsibility Index in the Prediction of Hypotension Associated with Tourniquet Release in Total Knee Replacement Surgeries under Spinal Anesthesia

Abstract This was a Prospective, observational study conducted on 60 patients with Total Knee Replacement (TKR); to characterize the collapsibility index of the IVC as a potential screening tool to identify patients who are candidate for hypotensive events after tourniquet release in TKR in an otherwise hemodynamically stable population. We found that; the mean age of all patients was (57 ± 5.6) years. Regarding gender of the patients, (58.3%) of patients were females; while (41.7%) were males. Regarding basic clinical data; the mean BMI of all patients was (25.7 ± 2.5); with (60%) of patients had DM, and (56.7%) had HTN. Regarding ASA class, (3.3%) had class I, (73.3%) had class II, and (23.3%) had class III. Regarding Baseline hemodynamic data; the average MAP was (104.6 ± 6) mmHg, the average RR was (10.5 ± 1.3) breath/min, and the average HR was (74.75 ± 7) beat/min. Regarding Data before tourniquet release; the average MAP was (102.3 ± 7.5) mmHg, the average RR was (10.7 ± 1.2) breath/min, and the average HR was (75.3 ± 6.5) beat/min, with average IVC-CI of (48.4 ± 7.7). Regarding Data 15-m after tourniquet release; the average MAP was (93.1 ± 9.3) mmHg, the average RR was (10.7 ± 1.4) breath/min, and the average HR was (76.45 ± 6.6) beat/min, with average IVC-CI of (51 ± 8.4). Regarding final outcome, (11.7%) of patients suffered Hypotension (PTRH). The 60 TKR patients were classified according to outcomes into 2 independent groups: group A IVCCI &amp;gt;55,5% (12 patients) and group B IVCCI &amp;lt;55,5% (48 patients). Regarding comparative study between the 2 groups as regards demographic data; no statistically significant differences were found except for ASA physical status of patients where group A had patients in ASA I class and most of its patients are ASA II while group B had no patients in ASA I class and a quarter of its patients were ASA III. Regarding comparative study between the 2 groups as regards hemodynamic and ultrasonographic data; no statistically different results were noted between groups in baseline readings. Results recorded before tourniquet release showed that IVC during inspiration reading was statistically lower while IVC collapsibility index was statistically higher in Group A when compared with group B . Results recorded 15 min after tourniquet release showed that IVC during inspiration reading was statistically lower while IVC collapsibility index was statistically higher in Group A when compared with group B, the IVC-CI before tourniquet release was not correlated with percent reduction in systolic blood pressure after tourniquet release in both groups with high (Group A) or low IVC-CI (Group B). Comparing patients who developed hypotension versus patients who did not, the 60 TKR patients were classified into hypotensive (7 patients) and normotensive (53 patients) groups. No statistically significant differences were found between hypotensive versus normotensive patients concerning demographic data and data recorded before tourniquet release. Baseline data showed significantly higher respiratory rate in hypotensive patients. Data recorded 15 min after tourniquet release showed statistically lower SBP, DBP and MAP, significantly higher HR and significantly lower IVC during inspiration and expiration in patients who developed hypotension. We studied different factors that may be included before tourniquet release that may predict the degree of PTRH by using ROC-curve analysis. IVC-CI before tourniquet release and BMI failed to be predictive factors for the occurrence of PTRH, while respiratory and heart rates before tourniquet release significantly predict the occurrence of PTRH. Performing multiple regression analysis using forward method showed that the increase in RR had an independent effect on increasing the probability of PTRH occurrence; with significant statistical difference (p &amp;lt; 0.039). Conclusion IVC-CI before tourniquet release is not a predictor for PTRH in patients undergoing TKR under spinal anesthesia.

Comparison of the effects of axillary brachial plexus block, inhalation anesthesia, and total intravenous anesthesia on tourniquet-induced ischemia-reperfusion injury in upper extremity surgery.

Post-ischemia reperfusion can lead to oxidative stress and an increase in oxidative markers. Employing preventive strategies and antioxidant agents may help mitigate ischemia-reperfusion injury (IRI). The use of a tourniquet in extremity surgery has been associated with IRI. This study aims to investigate the impact of three different approaches- brachial plexus block, total intravenous anesthesia (TIVA), and inhalation anesthesia-on IRI during upper extremity surgery using a tourniquet. Patients aged 18 to 45 with American Society of Anesthesiologists (ASA) I-II scores were randomly assigned to one of three groups: Group A received an axillary block with bupivacaine; Group I underwent inhalation anesthesia with sevoflurane; and Group T received TIVA with propofol and remifentanil infusion. Blood samples were collected to measure glucose, lactate, total anti-oxidant status (TAS), total oxidant status (TOS), and ischemia-modified albumin (IMA) levels at various time points: before anesthesia (t1), 1 minute before tourniquet release (t2), 20 minutes after tourniquet release (t3), and 4 hours after tourniquet release (t4). In Group I, lactate levels at t3, and glucose levels at t2 and t3, were higher compared to the other groups. Group A exhibited lower IMA levels at t2, t3, and t4 than the other groups. Additionally, Group I had lower IMA levels at t2, t3, and t4 compared to Group T. TAS levels were higher in Group I at t2, t3, and t4 compared to the other groups. TOS levels at t2 and t3 were lower in Group A than in Group I. Axillary anesthesia results in a sympathetic block, promoting better perfusion of the upper extremity. This study demonstrated lower levels of oxidative stress markers with axillary plexus block. Therefore, these results suggest that the axillary block has the potential to mitigate IRI.

Role of tourniquet release timing on blood loss and functional outcomes in total knee arthroplasty: Insights from a low- and middle-income country.

To identify the effect of releasing a tourniquet before versus after wound closure in total knee arthroplasty (TKA) on blood loss, functional outcomeand postoperative complications. A prospective cohort study was conducted including 53 patients from May 2023 to September 2023. All patients underwent unilateral TKA and were divided into two groups based on surgeon preference of deflating tourniquet, Group A consisted of patients in whom the tourniquet was deflated before wound closure for haemostasis and Group B consisted of patients in which tourniquet was deflated after wound closure and compressive dressing. Blood loss was evaluated via intraoperative blood loss (the number of soaked sponges/gauzes, blood in a suction bottle, total output in a suction bottle-irrigation used)and on-field blood lossand calculated blood loss (Using Gross and Meunier's formula). The Functional outcome was evaluated using Knee injury and osteoarthritis score-42 questions. Early postoperative complications and differences in the requirement of blood transfusions were also assessed. There was a significant difference in intraoperative blood loss between the two groups. The median intraoperative blood loss was 135 mL(interquartile range [IQR]: 90-149) in Group A and 56.2 mL (IQR: 45-68) in Group B (p value: 0.001). However, no difference was found between the groups in calculated blood loss using Gross and Meunier's formula. The median calculated blood loss was 439 mL (IQR: 450-813) in Group A and 508 mL (IQR:226-671) in group B (pvalue: 0.981). There was no significant difference between the groups in blood transfusion requirements or functional outcomes. Based on our results, we conclude that the intraoperative blood loss in TKA is significantly different between the groups but only represents a fraction of true blood loss (23%). The timing of releasing the tourniquet does not affect functional outcomes, blood transfusionand postoperative morbidity; hence, any time can be opted as per surgeon preference. Level II,prospective comparative study.

Relationship between median nerve vascularization before tourniquet release and the Boston Carpal Tunnel Questionnaire: a cohort study.

The results of this study suggest that a decreased vascularization of the median nerve after releasing the carpal tunnel predicts an inferior clinical improvement assessed by the Boston Carpal Tunnel Questionnaire.

Impact of intraosseous regional administration of tranexamic acid in total knee arthroplasty on perioperative blood loss: a protocol for a randomised controlled trial

IntroductionTotal knee arthroplasty (TKA) is a common surgical intervention to treat joint diseases. However, TKA is associated with significant blood loss. Tranexamic acid (TXA) has been used to reduce perioperative...

Regional versus systemic dexmedetomidine as an adjuvant to lidocaine for intravenous regional anaesthesia in healthy volunteers: a randomized crossover study

Background Dexmedetomidine enhances the quality and duration of lidocaine intravenous regional anaesthesia (IVRA). However, the two administration routes have not been directly compared regarding effects on tourniquet tolerance time with lidocaine IVRA. Additionally, it remains unclear whether the prolonged tourniquet tolerance stems from the direct peripheral action of dexmedetomidine or indirect systemic analgesic effects. Methods We conducted forearm IVRA in 12 healthy volunteers using a crossover design on two separate study days. One day, the systemic dexmedetomidine group received an intravenous infusion of 0.5 μg/kg dexmedetomidine (20 mL) in one arm, followed by 0.5% lidocaine (25 mL) forearm IVRA in the contralateral arm. On the other day, the regional dexmedetomidine group received an intravenous 0.9% saline infusion (20 mL) in one arm, followed by combined 0.5% lidocaine (25 mL) and 0.5 μg/kg dexmedetomidine forearm IVRA in the opposite arm. After a two-week washout period, participants crossed over to receive the alternate treatment. The primary outcome was tourniquet tolerance time, from initiating IVRA until the patient-reported tourniquet pain numerical rating scale exceeded three. Results The tourniquet tolerance time was longer with regional versus systemic dexmedetomidine (36.9 ± 7.6 min vs 23.3 ± 6.2 min, respectively), with a 13.6 min mean difference (95% CI: 10.8 to 16.4 min, p < 0.001). Regional dexmedetomidine also hastened sensory onset and extended sensory recovery compared to systemic administration. Delayed sedation after tourniquet release occurred in 5 of 12 subjects receiving regional dexmedetomidine. Conclusion The addition of regional dexmedetomidine to lidocaine prolonged tourniquet tolerance time in forearm IVRA to a greater extent compared to systemic dexmedetomidine in healthy volunteers. Trial registration Chinese Clinical Trial Registry, ChiCTR2300067978.

Rethinking limb tourniquet conversion in the prehospital environment.

Limb tourniquets are among the most effective lifesaving interventions after severe injury. Tourniquets used for less than two hours have proven safe, even when in hindsight the tourniquet was determined not to have been necessary. However, tourniquets used for longer than 2 hours may result in severe ischemic changes, fasciotomy rhabdomyolysis, renal failure, amputation and death.Given their frequent use after even minor limb injury (>50%), as soon as safely feasible all limb tourniquets must be reassessed. They may be transitioned to a hemostatic dressing with tourniquet release, (tourniquet conversion, TC), or moved to just above the injury site (tourniquet replacement, TR). Their near ubiquitous application by medical and non-medical personnel has resulted in significant discussion regarding who should perform TC/TR if arrival at a forward medical location is delayed. In the ongoing war in Ukraine, the first near peer large scale combat operation in 80 years, prolonged evacuation times are common and have highlighted the need for early TC/TR prior to hospital arrival. Similar concerns exist in the austere rural and wilderness civilian setting where prolonged tourniquet application is common, given the long distances to a trauma center.This article describes proposed changes in tourniquet use and how the anticipated duration of tourniquet application dictates increased training requirements. Increased emphasis on who needs a tourniquet and then TC/TR is necessary to maximize benefit while minimizing potential harm.Level of Evidence and Study Type: N/A.

Blood-conserving and therapeutic efficacy of intravenous tranexamic acid at different time points after primary total knee arthroplasty with tourniquet application: a randomised controlled trial

BackgroundThe use of a tourniquet in combination with tranexamic acid (TXA) not only ensures clear vision, reduces intraoperative blood loss and shortens operative time but also improves cement-bone inter-digitation in total knee arthroplasty (TKA). However, there is no proof whether the blood flow blocking effect of tourniquet affects the antifibrinolytic effect of TXA, and the optimal timing of TXA administration is still unclear. Therefore, this study aims to investigate the effect of the first dose of TXA administered intravenously before tourniquet compression and release in TKA on perioperative blood loss and therapeutic efficacy in patients.MethodsIn this double-blind trial, 90 patients undergoing primary TKA were randomised into 2 groups: Group A, patients received intravenous TXA 10 min before tourniquet compression (20 mg/kg) and 3, 6 and 24 h later (10 mg/kg), and Group B, patients were treated the same as those in Group A but received intravenous TXA before tourniquet release. The primary outcomes were changes in blood loss, haemoglobin and haematocrit. Secondary outcomes included operation and tourniquet times, blood transfusion rate, subcutaneous petechiae and circumferential changes in the operated limb, visual analogue scale (VAS) score, hospital for special surgery (HSS) score, length of stay (LOS) postoperatively, complications and patient satisfaction.ResultsNo statistically significant difference was found between the 2 groups with regard to age, sex, weight, body mass index (BMI), Kellgren-Lawrence class, preoperative blood volume, preoperative laboratory values, operation and tourniquet times, transfusion rate, knee circumference, preoperative HSS, or VAS score (P:n.s.). There was no significant difference in intraoperative blood loss (IBL) (52.7 ml vs. 63.4 ml, P = 0.07), hidden blood loss (HBL) (91.4 ml vs. 119.9, P = 0.4) or total blood loss (TBL) (144.1 ml vs. 183.3 ml, P = 0.72) between Groups A and B. Haemoglobin, haematocrit and red blood cell count (RBC) dropped to a low point on postoperative day 3 and then rebounded, returning to normal levels on day 21, and the trend of change between the 2 groups was not statistically significant (P:n.s.). There was no significant difference in subcutaneous ecchymosis incidence, knee swelling rate, HSS score, VAS score, LOS postoperatively, complication rate or patient satisfaction (P:n.s.).ConclusionTXA was administered intravenously prior to tourniquet compression could effectively reduce blood loss in patients who had undergone total knee arthroplasty. However, there was no significant difference in knee swelling rate, subcutaneous bruising and petechiae incidence, knee function, complication rate or satisfaction between patients who TXA was given intravenously before tourniquet compression and release in primary TKA.

Is Intraoperative Bleeding Control Useful After Tourniquet Release in Arthroscopic Anterior Cruciate Ligament Reconstruction?

Background Arthroscopic anterior cruciate ligament (ACL) reconstruction is a common orthopedic surgery, and rehabilitation is very important to achieve successful postoperative results. Postoperative hemarthrosis causes pain and limitation of movement, which prolongs the rehabilitation period. For these reasons, various strategies are used to reduce hemarthrosis in patients undergoing ACL reconstruction. This study aimed to evaluate the effect of bleeding control after releasing the tourniquet in ACL reconstruction surgery on the amount of hemarthrosis and pain in the postoperative period. Methodology A total of 60 patients who underwent arthroscopic single-bundle ACL reconstruction were enrolled in this prospective randomized control study. Bleeding control with the radiofrequency (RF) probe after releasing the tourniquet was done at the end of the arthroscopic ACL reconstruction in 30 patients (coagulation group) while bleeding control was not done for the other 30 patients (control group). Both groups were compared in terms of the degree of hemarthrosis using the Coupens and Yates classification in the early postoperative period and the degree of pain using the Visual Analog Scale (VAS) score and postoperative complications. Results In both groups, isolated ACL reconstruction was performed in 10 patients, additional partial meniscectomy in three patients, and additional arthroscopic meniscus repair in 17 patients. There was no statistically significant difference between the coagulation and control groups in terms of VAS (p > 0.05) and the degree of hemarthrosis (p > 0.05). Although the duration of tourniquet application was similar in both groups (p = 0.78), the duration of anesthesia was significantly longer in the coagulation group (p = 0.001). There was no significant difference between the groups in terms of postoperative complications. Conclusions Bleeding control with the RF probe after tourniquet release does not yield superior outcomes. More research with larger populations is needed to confirm these findings.

Diz Replasmanı Ameliyatı Altındaki Hastalarda Bacağın İskemi/Reperfüzyonu Sırasında Tiyol-Disülfit Dengesi Üzerine Spinal ve Genel Anestezinin Etkisi

Objective: Surgical trauma causes serious neuroendocrine and cytokine activity. In addition, the free oxygen radicals formed because of the ischemia/reperfusion injury resulting from applying and releasing the tourniquet (TQ) cause oxidative stress. Thiol and disulfide are among the new oxidative stress parameters used reliably in recent years. The aim of this study was to compare thiol-disulfide balance in general and spinal anesthesia, which are frequently used in total knee replacement (TKR) surgery. Methods: Fifty six patients aged 60-74 years scheduled to undergo TKR were randomly allocated to the general anesthesia (n=26) and spinal anesthesia (n=30) groups. The tourniquet (TQ) was applied for the TKR procedure after collecting a preanesthetic blood sample (T1). Blood samples were also collected at 5 minutes (T2) and 40 minutes (T3) after TQ release and at postoperative 24 hours (T4) to analyze native thiol, total thiol, disulfide, disulfide/native thiol ratio, disulfide/total thiol ratio, and native thiol/total thiol ratio. All patients had intravenous patient-controlled analgesia during the postoperative period. Mean arterial pressure, TQ times, and Visual Analogue Scale (VAS) scores were recorded. Decrease in thiol and increase in disulfide in the thiol-disulfide balance were recorded as oxidative stress indicators. Results: There was no difference between the groups in terms of VAS and analgesic consumption at the end of 24 hours. The general anesthesia group had higher native thiol, total thiol, and native thiol/total thiol ratio and lower disulfide, disulfide/native thiol ratio, and disulfide/total thiol ratio at all time points compared to the spinal anesthesia group. Conclusion: Assessment in terms of thiol-disulfide balance suggests that general anesthesia had a favorable effect on oxidative stress. Keywords: General anesthesia, oxidative stress, spinal anesthesia, thiol-disulfide, tourniquet time, visual analogue scale

Protective effect of dexmedetomidine on Tourniquet induced lung injury in patients undergoing total knee arthroplasty: A randomized trial

Objective To investigate whether dexmedetomidine (Dex) can reduce the severity of tourniquet-induced lung injury. Methods 36 patients undergoing total knee arthroplasty with a tourniquet were randomly assigned to the control (ischemia/reperfusion [I/R]) group and Dex group. Patients in the Dex group received a loading dose of Dex (0.8 μg/kg over 10 min intravenously) followed by continuous infusion of Dex (0.5 μg/kg/h intravenously) until the end of the surgery. The I/R group received an equal amount of 0.9% saline instead of Dex. The serum concentrations of tumor necrosis factor-α (TNF-α), Clara cell protein (CC-16), soluble receptor for advanced glycation end products (sRAGE), and brain-derived neurotrophic factor (BDNF) were measured and arterial blood gas analysis was performed before anesthesia and 30 min, 6 h, and 24 h after tourniquet release. Results In the I/R group, compared with baseline, the TNF-α, CC-16, and sRAGE concentrations were higher ( p &lt; 0.05) and the BDNF concentration was lower ( p &lt; 0.05) at most time points. In the Dex group, the TNF-α, CC-16, and sRAGE concentrations were lower than those in the I/R group ( p &lt; 0.05), whereas the concentration of BDNF was higher ( p &lt; 0.05). In the arterial blood gas analysis, the Dex group showed a significantly higher partial pressure of oxygen and arterial/alveolar oxygen tension ratio ( p &lt; 0.05) and a significantly lower alveolar/arterial oxygen tension difference than the I/R group ( p &lt; 0.05). Conclusion Dex administration partly inhibits the release of proinflammatory cytokines, affording protection against tourniquet-induced lung injury.

Enhanced recovery after surgery (ERAS) protocol in geriatric patients underwent unicompartmental knee arthroplasty: A retrospective cohort study.

The enhanced recovery after surgery (ERAS) pathway was formulated with the aim to reduce surgical stress response, alleviate pain and guarantee the best-fit experience of patients' perioperative period. However, the application of ERAS in geriatric patients who underwent unicompartmental knee arthroplasty (UKA) was relatively lacking. We hypothesize that UKA patients can benefit from the ERAS protocol. A total of 238 patients were recruited in this retrospective study from August 2018 to December 2021, and Oxford phase III UKA was applied to all patients. ERAS pathway included nutrition support, anesthesia mode, interoperative temperature, and blood pressure control, application of tranexamic acid, early initiation of oral intake and mobilization, and pain management. Demographic data, operation-relative variables, and postoperative complications were analyzed. Forgotten Joint Scores, Oxford Knee Score, Lysholm score, numerical rating scale, and knee range of motion were introduced to estimate the activity function and pain of surgical knee, and these variables were compared between the 2 groups. There were 117 patients in the ERAS group and 121 patients in the traditional group, respectively. The ERAS group had a shorter length of surgical incision and less intraoperative blood loss. Postoperative hemoglobin and albumin of patients in the ERAS group were better than those in the traditional group (P < .05), after 17.0 ± 10.8 months follow-up, the numerical rating scale, Lysholm, Oxford Knee Score, Forgotten Joint Scores, and knee range of motion of patients in the ERAS group were significantly better than the traditional group. The length of hospital stay for patients who underwent ERAS was 11.7 ± 3.8 days and the postoperative complication rate was lower for the ERAS group patients (P = .000 and 0.031). ERAS can reduce the length of hospital stay, and patients can achieve excellent postoperative knee function. The formulation and implementation of the ERAS protocol require good collaboration across multiple disciplines, as well as a deep understanding of the existing clinical evidence and the concept of the ERAS program.

Comparison of adjuvant therapy with midazolam, paracetamol, tramadol, or magnesium sulfate during intravenous regional anesthesia with ropivacaine: A randomized clinical trial.

Intravenous (IV) regional anesthesia is an easy, safe, reliable, and efficient option for inducing anesthesia during surgeries but with tourniquet-related pain. This study aimed to evaluate midazolam, paracetamol, tramadol, and magnesium sulfate administration as adjuvants with ropivacaine on pain relief and hemodynamic changes in IV regional anesthesia. A randomized, double-blind, placebo-controlled trial was conducted in subjects undergoing forearm surgery with IV regional anesthesia. The block randomization method was used to assign eligible participants to each of five study groups. Hemodynamic parameters were assessed before applying the tourniquet, at prespecified time points (5, 10, 15, and 20 min), then and every subsequent 10 min until surgery completion. A Visual Analog Scale was used to assess pain severity at baseline followed by every 15 min until completion of the surgery, and after tourniquet deflation every 30 min to 2 h, and at 6, 12, and 24 h postoperative. Data were analyzed using Chi-square and analysis of variance with repeated data testing. The shortest onset and the longest duration of sensory block were observed in the tramadol group and the shortest onset of motor block in the midazolam group (P < 0.001). Pain score was estimated to be significantly lower in the tramadol group at the time of tourniquet application and release, and 15 min to 12 h after tourniquet release (P < 0.05). In addition, the lowest dose of pethidine consumption was observed in the tramadol group (P < 0.001). Tramadol appeared to be able to effectively relieve pain, shorten the onset of sensory block, prolong the duration of sensory block, and achieve the lowest consumption of pethidine.

Assessment of Ultrasonographic Measurement of Inferior Vena Cava Collapsibility Index in The Prediction of Hypotension Associated with Tourniquet Release in Total Knee Replacement Surgeries under Spinal Anesthesia

Assessment of Ultrasonographic Measurement of Inferior Vena Cava Collapsibility Index in The Prediction of Hypotension Associated with Tourniquet Release in Total Knee Replacement Surgeries under Spinal Anesthesia

Role of Tranexamic Acid in Arthroscopic Osteocapsular Release of the Elbow for Degenerative Arthritis.

BackgroundMinimizing intra-articular bleeding and swelling is crucial in preventing the development of stiffness around the elbow. Tranexamic acid (TXA) has been shown to be an effective adjunct in reducing perioperative bleeding after surgery.Purpose:To determine the effect of intravenous (IV) TXA on postoperative drain tube output in arthroscopic osteocapsular release of the elbow for primary degenerative arthritis.Study Design:Cohort study; Level of evidence, 3.Methods:The authors performed a retrospective cohort study of 83 consecutive patients with primary degenerative elbow arthritis who underwent an arthroscopic osteocapsular release between 2015 and 2018. They organized patients into a no-TXA group (control) and a group that was given 1.0 g of IV TXA before tourniquet release. The primary outcome measure was drain tube output, and secondary outcome measures included postoperative day 1 pain levels on a visual analog scale and early range of motion at 8 weeks. Differences between groups were analyzed using 1-way analysis of variance, the Mann-Whitney U test, or the Fisher exact test.Results:There were 43 patients in the no-TXA group and 40 patients in the TXA group. Administration of IV TXA resulted in a 51% decrease in mean intra-articular bleeding for the TXA group, as measured via drain tube output (88.8 ± 80.5 mL [no-TXA] vs 43.4 ± 52.4 mL [TXA]; P = .0016). In both groups, there were significant increases in elbow arc of motion when compared with preoperative measurements. There were no between-group differences in early range of motion (129.7° ± 12.4° [no-TXA] vs 131.7° ± 9.2° [TXA]; P = .549) or postoperative pain (1.9 ± 2.2 [no-TXA] vs 1.5 ± 1.7 [TXA]; P = .89).Conclusion:In this study, IV TXA significantly reduced postoperative intra-articular bleeding in patients who underwent arthroscopic osteocapsular release of the elbow for primary degenerative arthritis. However, there were no differences in postoperative range of motion or pain between patients who received TXA and controls.

ADDITION OF DEXMEDETOMIDINETO LIGNOCAINE FOR INTRAVENOUS REGIONAL ANESTHESIA IN UPPER EXTREMITY ORTHOPAEDIC SURGERIES

Objective: The objective of this study was to determine the duration of onset and regression time of sensory and motor blocks, the quality of anesthesia, and post-operative analgesia by the addition of dexmedetomidine to local anesthetic solution in intravenous regional anesthesia (IVRA) in upper extremity orthopedic surgeries. Methods: This is a prospective, randomized, and double blind clinical trial. Ninety American Society of Anaesthesiologists Grade I and II patients of either gender between 18 and 60 years of age scheduled for elective upper extremity orthopedic surgeries lasting for &lt;90 min were included in the study. Patients were randomly allocated to two Groups A and B of 45 each. Group A received 3 mg/kg preservative free lignocaine alone and Group B received 3 mg/kg preservative free lignocaine with dexmedetomidine, 0.5 μg/kg in IVRA. Result: Onset time of sensory blockade in Group A and B was 5.6±0.93 min and 3.9±0.63 min, respectively. Onset time of motor blockade in Group A and Group B was 15.01±4.53 min and 10.74±3.64 min, respectively. The difference in onset time of sensory and motor blockade between the two groups was statistically significant (p&lt;0.05). Sensory blockade recovery time after release of tourniquet was 6.9±0.53 min in Group A and 29.21±5.23 min in Group B. Motor blockade recovery time was 4.35±0.76 min for Group A and 12.32±7.23 min for Group B. The difference in sensory and motor blockade recovery time between the two groups was statistically significant (p&lt;0.05). Conclusion: Dexmedetomidine on addition to lignocaine for IVRA provided rapid onset of sensory and motor blockade, prolonged duration of sensory and motor blockade, and reduced tourniquet pain.

Intra‐individual variability in processed EEG (bispectral index monitor) under general anesthesia predicts postoperative cognitive change after total knee arthroplasty

AbstractBackgroundPrevious research shows 1) clock drawing performance slows for older adults after total knee arthroplasty (TKA; Hizel et al., 2018), and 2) brain‐behavioral associations with intra‐individual variability on an EEG‐derived index during TKA (Hernaiz et al., 2019). The current study expanded upon these findings by examining how preoperative cognition and intraoperative responses to anesthesia may predict postoperative clock drawing performance. We hypothesized greater intraoperative intra‐individual BIS variability would explain a significant portion of variance in four primary latency measures to command and copy condition at 3‐weeks following surgery.MethodThe final prospectively recruited IRB consented participant sample included 54 non‐demented patients age 60+ receiving TKA under general anesthesia. Consistent with Hernaiz et al., (2019), derived 2‐channel EEG variability was studied from tourniquet inflation to tourniquet release, thereby establishing a consistent period of examination. Intra‐individual variability was calculated as the squared deviation from the mean BIS value over the duration of measurement. Clock drawing to command and copy was recorded with digital pen technology and scored with semiautomatic rater‐guided software (Souillard‐Mandar et al., 2016). Outcome latency variables of interest: 1) total completion time in seconds (TCT), 2) time prior to setting the first hand in seconds (pre‐first hand latency; PFHL), 3) seconds after drawing the clock face to next pen stroke (post‐clock face latency; PCFL).ResultAt 3‐weeks, participants took, on average, six seconds longer to complete the drawing compared to baseline performance, and two seconds longer to set the first clock hand. Correcting for baseline performance, separate hierarchical regressions showed intra‐individual EEG‐derived variability explained an additional 4.3% of variance in postoperative command TCT (F(2,51)=28.301, p&lt;.038, R2=.536, ∆R2=.043), such that those with greater intraoperative BIS variability took longer to complete the drawing to command.ConclusionIn non‐demented older adults undergoing TKA, higher intra‐individual BIS variability significantly contributed to total clock drawing time during the command condition. Command total completion time is sensitive to numerous cognitive domains including processing speed, language, working memory, and declarative memory (Dion et al., 2020). Fluctuations during general anesthesia as recorded on an EEG‐derived index may help explain postoperative slowing during clock drawing at 3‐weeks post‐surgery.

No Difference in Blood Loss and Risk of Transfusion Between Patients Treated with One or Two Doses of Intravenous Tranexamic Acid After Simultaneous Bilateral TKA.

Tranexamic acid (TXA) is often used to prevent excessive blood loss during bilateral TKA. Although it diminishes blood loss, TXA may have a potentially elevated thrombogenic risk with extra, unnecessary doses of TXA in this high-risk population. To date, the most efficacious dosing protocol in this setting has not yet been ascertained. We compared one versus two doses of intravenous TXA in the setting of same-day bilateral TKA in terms of (1) perioperative blood loss that occurred during the hospital stay, (2) transfusion usage during the hospital stay, and (3) major complications occurring within 30 days of surgery. Between August 2013 and October 2016, 309 patients underwent simultaneous bilateral TKA performed by one of five attending surgeons. During that time, indications for same-day bilateral TKA included bilateral knee pathology in which each knee was independently indicated for TKA and the patient preferred bilateral simultaneous TKAs versus staged bilateral surgeries. Patients who had cardiac disease or an American Society for Anesthesiologists physical classification score of greater than 2 were not generally indicated for bilateral simultaneous TKAs. After preoperative clearance from the primary physician and/or specialists as necessary, the decision for bilateral TKA was at the judgment of the operating surgeons. Input from anesthesia occurred at the time of the surgery as the procedure was performed in a sequential fashion allowing for the surgery to be restrained to a single limb if anesthesia identified concerns at the completion of the first TKA. The current retrospective, comparative series compared generally sequential groups in terms of TXA usage. Between August 2013 and July 2015, we used two TXA doses. Patients received 1 g of intravenous TXA as a bolus immediately after the last tourniquet release and were given a 1-g intravenous bolus 6 hours after the initial dose. A total of 167 patients were treated with this approach, of whom 96% (161) are fully analyzed here. Between August 2015 and October 2016, our approach changed to a single TXA dose. The dosing regimen change occurred as a group decision for change of practice and occurred mid-year to coincide with the fellowship year cycle. Patients received a 1-g bolus of intravenous TXA immediately after the final tourniquet release. A total of 105 patients were treated with this approach, of whom 89% (93) are fully analyzed here. An additional 37 patients were excluded because they did not receive any TXA because of a medical contraindication such as history of venous thromboembolism, history of thrombotic stroke, cardiac stent in the past 2 years, atrial fibrillation, or long-term anticoagulation therapy. We compared patients who received one versus two doses in terms of blood loss, transfusion usage, and 30-day major complications. The mean age was 65 years for patients receiving one dose and 67 years for patients receiving two doses (p = 0.17). The one-dose group comprised 67% (62 of 93) women and the two-dose group comprised 61% (98 of 161) women (p = 0.36). Blood loss was defined as change in the hemoglobin level (the last recorded value before discharge subtracted from the preoperative value). During the study period, the decision to transfuse was based on a hemoglobin level less than 8.0 g/dL or at higher levels for symptomatic patients, patients with cardiac disease, or at the discretion of the attending surgeon. We defined complications as major medical events that included cerebrovascular accidents, myocardial infarction, deep vein thrombosis, and pulmonary embolism. With the numbers available, there was no difference in blood loss between patients treated with one and those treated with two doses of TXA (mean hemoglobin decrease -3.5 ± 1.2 g/dL versus -3.5 ± 1.0 g/dL, respectively; mean difference 0.03 g/dL [95% CI -0.2 to 0.3 g/dL]; p = 0.80). No patient in either group received a transfusion. There was no difference in the proportion of patients in either group who experienced a cerebrovascular accident (0% [0 of 93] versus 1% [1 of 161]; p > 0.99), deep vein thrombosis (1% [1 of 93] versus 0% [0 of 161]; p = 0.37), or pulmonary embolism (1% [1 of 93] versus 1% [1 of 161]; p > 0.99). No patient in either the one-dose or two-dose TXA groups experienced a myocardial infarction. The findings of this study suggest that a single dose of intravenous TXA may be adequate to control excessive blood loss and reduce blood transfusion in simultaneous bilateral TKA. Despite its short half-life, TXA still appears to be effective in this demanding procedure without requiring prolonged plasma concentrations obtained from multiple doses. Additional high-quality studies are still needed to determine the most appropriate dosing regimen. Level III, therapeutic study.