CHANGES IN HÆMOSTATIC SYSTEM AFTER APPLICATION OF A TOURNIQUET

doi:10.1016/S0140-6736(77)92276-0

The Lancet

Volume 309, Issue 8019, 7 May 1977, Pages 970-972

https://doi.org/10.1016/S0140-6736(77)92276-0 Get rights and content

Abstract

In 35 patients undergoing routine orthopædic operations in which occlusive tourniquets were used there was a pronounced rise in fibrinolytic activity in the systemic circulation which lasted for at least 15 minutes after the release of the tourniquet; this response was seen after operations on both arms and legs. In contrast there was no increase in fibrinolytic activity in the systemic circulation associated with venous occlusion. Neither the application of a tourniquet nor venous occlusion resulted in changes in factors v or VIII, fibrinogen, or platelet-count. The application of a completely occlusive tourniquet might be a simple form of prophylaxis against deep-vein thrombosis and would avoid the disadvantages of using heparin.

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Cited by (93)

Treatment and contemporary outcomes associated with adjunct tourniquet use during phlebectomy of complex, voluminous truncular varicosities
2022, Journal of Vascular Surgery: Venous and Lymphatic Disorders
Phlebectomy of large voluminous varicose veins comes with a risk of substantial blood loss. The purpose of the present study was to investigate the outcomes associated with the use of an adjunct tourniquet during varicose vein surgery of complex and large truncular varicosities.
The prospectively collected registry data included anatomic and outcomes details for patients who presented with complex and large truncular varicosities with a CEAP clinical class of C2, or higher (indicating more serious venous disease) from December 2014 to December 2021. Of all patients, those treated with an adjunct tourniquet for large complex varicosities (largest diameter varicosity ≥1 cm by visual inspection) were selected for analysis. The venous clinical severity scores (VCSSs) and patient-reported outcomes (PROs) were obtained. Additional parameters, including operative time, tourniquet time, and blood loss, were obtained retrospectively via a review of the medical records. Univariate descriptive statistics of the demographic and procedural data were performed pre- and postoperatively, with comparisons performed using the Student two-tailed t test.
The data from 19 patients (22 limbs; 7 women and 12 men) were analyzed. Of the 22 limbs, 11 (50%) had advanced venous disease of C4 or higher preoperatively. A review of the preoperative duplex ultrasound scans confirmed the presence of large varicosities (average, 1.0 ± 0.54 cm; n = 18). All the limbs were treated using radiofrequency ablation of axial reflux and phlebectomy (a combination of powered and stab) under tourniquet control (82%) or phlebectomy under tourniquet control alone (18%). The average tourniquet time was 40 ± 12 minutes, with a median blood loss of 50 mL (interquartile range, 30-100 mL). The average follow-up was 332 ± 422 days after 19 procedures for 16 patients (2 patients moved out of state during the immediate postoperative period and 1 patient was lost to follow-up). Of the patients who completed >3 months of follow-up, 14 limbs experienced improvement in the CEAP class, 5 limbs had no change, and 3 were limbs of patients who moved or were lost to follow-up. The VCSSs significantly improved (8.8 ± 2.8 vs 3.9 ± 1.9; P < .0001). The PROs also improved significantly (16.1 ± 5.0 vs 2.2 ± 2.3; P < .0001).
Tourniquet use in the treatment of varicosities has only been described in the setting of high ligation and stripping. Our data suggest that in the modern era of minimally invasive endovenous treatment of axial reflux and phlebectomy, adjunct tourniquet use during the treatment of large complex varicosities can result in significant improvements in the VCSSs and PROs, with minimal blood loss.
Tourniquet and tranexamic acid use in total knee arthroplasty
2020, Arthroplasty Today
There is no consensus on how tourniquet and tranexamic acid (TXA) use in total knee arthroplasty (TKA) affect blood transfusion rates and total blood loss. We compared outcome measures and transfusion rates after TKA, with and without the use of tourniquet and TXA.
A retrospective study of 477 consecutive patients undergoing primary TKA between 2008 and 2013 was performed. There were 243 in the tourniquet-assisted (TA) and 234 in the tourniquet-unassisted (TU) group. Operative times, hemoglobin levels, blood transfusion rates, complications, and length of stay were assessed. Subanalysis was performed on those patients receiving and not receiving TXA within the TU group.
Mean operative duration was 66.4 minutes in the TA group and 87.5 minutes in the TU group (P < .0001). Mean postoperative drop in hemoglobin was greater in TU group (3.1 g/dL vs 2.8 g/dL, P = .002). The transfusion rate was 9.5% in TA compared with 11.5% in TU patients (P = .46) with comparable mean units transfused (2.6 vs 2.2, P = .30). There was no difference in wound infection (P = .82) and total complication rates (P = .27) between groups. Those patients given TXA had a lower hemoglobin drop (2.6 g/dL vs 3.3 g/dL, P = .04) with similar transfusion (13.3% vs 11%, P = .61) and complication (P = .95) rates.
TU TKA had a greater operative duration and postoperative drop in hemoglobin than TA TKA. However, transfusion rates were similar between groups. TXA use reduced the operative decrease in hemoglobin with no effect on complication or transfusion rates.
Level III, retrospective cohort study.
Hidden blood loss and the influential factors after intramedullary nail fixation of extra-articular tibial fractures - a retrospective cohort study
2020, Injury
Citation Excerpt :
We considered that surgical duration had an independent influence on HBL might be related to the users of a tourniquet during the surgery. Using the tourniquet would promote hyperactivity of the fibrinolytic system after surgery [24]; Releasing the tourniquet would caused tissue ischemia-reperfusion injury, contributing to the release of reactive oxygen species postoperatively [25], which would enhance acute red blood cell injury [26–28]. These reasons will result in an increase in the amount of HBL.
There were few reports in the literature about the hidden blood loss (HBL) after intramedullary nail (IMN) fixation for extra-articular tibial fractures. Our purpose was to evaluate the amount of hidden blood loss after intramedullary nail fixation for extra-articular tibial fractures, meanwhile, identified the influential factors causing HBL.
From January 2015 to December 2017, 122 consecutive extra-articular tibial fracture patients fixed with IMN and 96 met all inclusion criteria for the chosen analysis. Preoperative hematocrit (Hct) levels on admission and postoperative Hct levels on the third day after surgery to calculate the amount of HBL.
The mean HBL was 473.29 ± 102.75 ml after IMN fixation of extra-articular tibial fractures, the multiple regression analysis showed gender, surgical duration, and the diameter of the medullary cavity at the narrowest part of the tibia had an independent influence on HBL.
A significant amount of postoperative HBL has occurred after IMN fixation of extra-articular tibial fractures. Surgeons should be aware that more HBL can be developed in patients who have male sex, small medullary cavity, and long-time surgical duration. HBL deserves attention to ensure patients’ safety in the perioperative period of IMN fixation for extra-articular tibial fractures.
Efficacy and safety of multiple boluses of oral versus intravenous tranexamic acid at reducing blood loss after primary total knee arthroplasty without a tourniquet: A prospective randomized clinical trial
2018, Thrombosis Research
Citation Excerpt :
Our previous studies indicated that multiple boluses of IV TXA further inhibit the inflammatory and fibrinolytic responses after TKA [11,18], while this study found that oral and IV TXA may have equivalent effects in inhibiting the inflammatory and fibrinolytic responses. The application of a tourniquet may enhance hyperfibrinolysis, leading to increased blood loss [5,24]. Huang et al. found that patients treated with multiple doses of IV and topical TXA without a tourniquet had less hidden blood loss, less postoperative knee pain, and lower levels of inflammatory biomarkers than those treated with a tourniquet [25].
The aim of this study was to examine whether the administration of multiple boluses of oral or intravenous tranexamic acid (TXA) postoperatively were equivalent at reducing blood loss and the inflammatory and fibrinolytic responses in primary total knee arthroplasty (TKA) without a tourniquet.
In this prospective, double-blinded, randomized trial, patients undergoing primary THA were randomized into either an oral or intravenous TXA group. All patients received 1 dose of 20 mg/kg intravenous TXA 5–10 min before skin incision. Patients in the oral TXA group then received 3 doses of 2 g oral TXA at 4, 10, and 16 h postoperatively, while patients in the intravenous TXA group received 3 doses of 1 g intravenous TXA at 6, 12, and 18 h after surgery.
There was no significant difference in the hemoglobin (Hb) or hematocrit (Hct) drop on postoperative day 1 (14.7 ± 10.5 vs 14.4 ± 9.6 g/L, p = 0.869; 0.042 ± 0.032 vs 0.040 ± 0.028, p = 0.781) and 3 (22.6 ± 10.6 vs 20.5 ± 9.7 g/L, p = 0.300; 0.059 ± 0.031 vs 0.054 ± 0.031, p = 0.332). No patients needed an allogeneic blood transfusion. The mean total blood loss, hidden blood loss, length of hospital stay, the level of inflammatory and fibrinolytic markers on the first and third postoperative days, and the incidence of complications were not significantly different between the two groups (p > 0.05).
There was no difference in Hb and Hct drop, blood loss, inflammatory and fibrinolytic responses in primary TKA without a tourniquet between those who received multiple boluses of oral or intravenous TXA after surgery in current scheme.
Comparative study of topical vs. intravenous tranexamic acid regarding blood loss in total knee arthroplasty
2017, Revista Brasileira de Ortopedia
Comparar o uso de ácido tranexâmico (AT) tópico e intravenoso na artroplastia total de joelho com relação à perda de sangue e necessidade de transfusão.
Foram randomizados 90 pacientes para receber AT por via intravenosa (20 mg/kg em 100 mL de solução salina; grupo IV), tópico (1,5 g em 50 mL de solução salina, antes de soltar o torniquete; grupo tópico) ou solução salina intravenosa (100 mL com anestesia; grupo controle). O volume de sangue drenado em 48 horas, a quantidade de sangue transfundido e as concentrações sérias de hemoglobina e hematócrito foram avaliados antes e depois da cirurgia.
Os grupos eram semelhantes quanto a sexo, idade, lateralidade e concentrações pré‐operatórias de hemoglobina e hematócrito (p > 0,2). A concentração de hemoglobina diminuiu em todos os grupos quando as avaliações pré‐operatória e em 48 horas foram comparadas: o grupo controle teve redução média de 3,8 mg/dL, enquanto o grupo IV teve diminuição de 3,0 e o grupo tópico, de 3,2 (p = 0,019). A diferença entre os grupos controle e IV foi confirmada pelo teste de Bonferroni (p = 0,020). A diferença entre os grupos controle e tópico não foi significativa (p = 0,130), apesar de haver uma menor diminuição da hemoglobina no grupo tópico; a comparação entre os grupos IV e tópico também não foi significativa (p = 1,000).
O uso de AT tópico e IV reduziu as perdas sanguíneas e a necessidade de transfusão na artroplastia total do joelho. O uso tópico mostrou resultado semelhante ao uso IV em relação à necessidade de transfusão sanguínea, porém sem os possíveis efeitos colaterais da administração IV.
To compare topical vs. intravenous tranexamic acid (TA) in total knee arthroplasty regarding blood loss and transfusion.
Ninety patients were randomized to receive TA intravenously (20 mg/kg in 100 mL of saline; IV group), topically (1.5 g in 50 mL of saline, sprayed over the operated site, before release of the tourniquet; topical group), or intravenous saline (100 mL with anesthesia; control group). The volume of drained blood in 48 h, the amount of transfused blood, and the serum levels of hemoglobin and hematocrit before and after surgery were evaluated.
The groups were similar for sex, age, weight, laterality, and preoperative hemoglobin and hematocrit levels (p > 0.2). The hemoglobin level dropped in all groups when comparing the preoperative and the 48‐hour evaluations: the control group decreased 3.8 mg/dL on average, while the IV group had a decrease of 3.0, and the topical group, of 3.2 (p = 0.019). The difference between the control and IV groups was confirmed by Bonferroni test (p = 0.020). The difference between the control group and the topical group was not significant (p = 0.130), although there was less reduction in hemoglobin in the topical group; the comparison between the IV group and the topical group was also not significant (p = 1.000).
Using tranexamic acid topic and an IV decreased blood loss and the need for transfusion in total knee arthroplasty. Topical application showed results similar to using an IV regarding the need for blood transfusion, but without the possible side effects of IV administration.
Combined Administration of IV and Topical Tranexamic Acid is Not Superior to Either Individually in Primary Navigated TKA
2017, Journal of Arthroplasty
Citation Excerpt :
Further TXA group did not have any advantage in terms of functional recovery over control group. Surgical trauma after arthroplasty results in a hyperfibrinolytic state [8,19]. This is further augmented by increased fibrinolysis following tourniquet release [20,21].
In this study, we tried to assess if combined method (intravenous [IV] and topical) of tranexamic acid (TXA) administration, which has been shown to be superior in conventional arthroplasty, has similar effect in navigational arthroplasty compared to administration of drug either individually.
In present randomized control trial, 200 patients were randomly divided in one of the 4 groups using computer-generated tables—control, IV, intraarticular, and combined. We studied evident loss through drain, total loss based on Gross method and hemoglobin balance method, hidden losses, hemoglobin and hematocrit drop, functional scores, and all possible complications related to TXA.
Evident loss in combined group was 535.55 mL, not significantly less than IV (585 mL, P = .15) and intraarticular group (514 mL, P = .74). However, these were significantly less than control group (696 mL, P = .000). Functional scores and recovery rates were, however, comparable in all 4 groups. No patients in any group developed symptomatic deep vein thrombosis.
Tranexamic use decreases blood loss in navigation-assisted arthroplasty, however, less than that observed for conventional arthroplasty in literature. Further, combined group has no added advantage over other methods of drug administration. We believe that additional amount of TXA administered in combined regimen may not be clinically useful. Further TXA group did not have any advantage in terms of functional recovery over control group.

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CHANGES IN HÆMOSTATIC SYSTEM AFTER APPLICATION OF A TOURNIQUET

Abstract

Injury

Lancet

Lancet

Lancet

J. Bone Jt Surg.

Br. med. J.