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John F Kragh - One of the best experts on this subject based on the ideXlab platform.
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assessment of groin application of junctional Tourniquets in a manikin model
Prehospital and Disaster Medicine, 2016Co-Authors: John F Kragh, James K Aden, Jeffrey A Bailey, Andrew P Cap, Matthew P Lunati, Chetan Kharod, Cord W Cunningham, Zsolt T Stockinger, Jacob Chen, Leopoldo C CancioAbstract:Introduction To aid in preparation of military medic trainers for a possible new curriculum in teaching junctional tourniquet use, the investigators studied the time to control hemorrhage and blood volume lost in order to provide evidence for ease of use. Hypothesis Models of junctional tourniquet could perform differentially by blood loss, time to hemostasis, and user preference. Methods In a laboratory experiment, 30 users controlled simulated hemorrhage from a manikin (Combat Ready Clamp [CRoC] Trainer) with three iterations each of three junctional Tourniquets. There were 270 tests which included hemorrhage control (yes/no), time to hemostasis, and blood volume lost. Users also subjectively ranked tourniquet performance. Models included CRoC, Junctional Emergency Treatment Tool (JETT), and SAM Junctional Tourniquet (SJT). Time to hemostasis and total blood loss were log-transformed and analyzed using a mixed model analysis of variance (ANOVA) with the users represented as random effects and the tourniquet model used as the treatment effect. Preference scores were analyzed with ANOVA, and Tukey’s honest significant difference test was used for all post-hoc pairwise comparisons. Results All tourniquet uses were 100% effective for hemorrhage control. For blood loss, CRoC and SJT performed best with least blood loss and were significantly better than JETT; in pairwise comparison, CRoC-JETT ( P P = .0085) were statistically significant in their mean difference, while CRoC-SJT ( P = .35) was not. For time to hemostasis in pairwise comparison, the CRoC had a significantly shorter time compared to JETT and SJT ( P P = .0087). In responding to the directive, “Rank the performance of the models from best to worst,” users did not prefer junctional tourniquet models differently ( P > .5, all models). Conclusion The CRoC and SJT performed best in having least blood loss, CRoC performed best in having least time to hemostasis, and users did not differ in preference of model. Models of junctional tourniquet performed differentially by blood loss and time to hemostasis. Kragh JF Jr , Lunati MP , Kharod CU , Cunningham CW , Bailey JA , Stockinger ZT , Cap AP , Chen J , Aden JK 3d , Cancio LC . Assessment of Groin Application of Junctional Tourniquets in a Manikin Model . Prehosp Disaster Med . 2016 ; 31 ( 4 ): 358 – 363 .
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Extended (16-Hour) Tourniquet Application After Combat Wounds: A Case Report and Review of the Current Literature
2016Co-Authors: John F Kragh, David G Baer, Thomas J WaltersAbstract:Summary: We present a case of emergency tourniquet use of unusually long duration. The patient was wounded during combat operations, and the subsequent battle and evacuation caused a sig-nificant delay in surgical treatment of his wounds. Emergency tour-niquets can be lifesaving, but are not benign interventions. In general, the extent of tourniquet injury increases with increasing time of application. Despite having a tourniquet in place for 16 hours, the limb was salvaged and significant functional recovery was accom-plished. We conducted a search of the published literature including the Medline database, and present a review of the relevant articles concerning emergency tourniquet use, tourniquet injury, and miti-gating treatments. Given the widespread use of Tourniquets in ongoing military operations, it seems likely that Tourniquets will transition to civilian use. Thus it is important for physicians to understand tour-niquet injury and appreciate that even extended tourniquet applicatio
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which improvised tourniquet windlasses work well and which ones won t
Wilderness & Environmental Medicine, 2015Co-Authors: John F Kragh, James K Aden, Michael A Dubick, Timothy E Wallum, David G BaerAbstract:Objective Improvised Tourniquets in first aid are recommended when no scientifically designed tourniquet is available. Windlasses for mechanical advantage can be a stick or pencil and can be used singly or multiply in tightening a tourniquet band, but currently there is an absence of empiric knowledge of how well such windlasses work. The purpose of the present study was to determine the performance of improvised Tourniquets in their use by the type and number of windlasses to improve tourniquet practice. Methods A simulated Leg Tourniquet Trainer was used as a manikin thigh to test the effectiveness of improvised Tourniquets of a band-and-windlass design. Two users made 20 tests each with 3 types of windlasses. Tests started with 1 representative of a given type (eg, 1 pencil), then continued with increasing numbers of each windlass type until the user reached 100% effectiveness as determined by cessation of simulated blood flow. Windlass types included chopsticks, pencils, and craft sticks. Results Effectiveness percentages in stopping bleeding were associated inversely with breakage percentages. Pulse stoppage percentages were associated inversely with breakage. The windlass turn numbers, time to stop bleeding, the number of windlasses, and the under-tourniquet pressure were associated inversely with breakage. The windlass type was associated with breakage; at 2 windlasses, only chopsticks were without breakage. Of those windlass types that broke, 20.7% were chopsticks, 26.1% were pencils, and 53.2% were craft sticks. Conclusions A pair of chopsticks as an improvised tourniquet windlass worked better than pencils or craft sticks.
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performance of junctional Tourniquets in normal human volunteers
Prehospital Emergency Care, 2015Co-Authors: John F Kragh, Thomas J Walters, James K Aden, Russ S Kotwal, Bijan S Kheirabadi, Robert T Gerhardt, Andrew P Cap, Robert A Delorenzo, Heather F Pidcoke, Leopoldo C CancioAbstract:AbstractBackground. Inguinal bleeding is a common and preventable cause of death on the battlefield. Four FDA-cleared junctional Tourniquets (Combat Ready Clamp [CRoC], Abdominal Aortic and Junctional Tourniquet [AAJT], Junctional Emergency Treatment Tool [JETT], and SAM Junctional Tourniquet [SJT]) were assessed in a laboratory on volunteers in order to describe differential performance of models. Objective. To examine safety and effectiveness of junctional Tourniquets in order to inform the discussions of device selection for possible fielding to military units. Methods. The experiment measured safety and effectiveness parameters over timed, repeated applications. Lower extremity pulses were measured in 10 volunteers before and after junctional tourniquet application aimed at stopping the distal pulse assessed by Doppler auscultation. Safety was determined as the absence of adverse events during the time of application. Results. The CRoC, SJT, and JETT were most effective; their effectiveness did not di...
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transfusion for shock in us military war casualties with and without tourniquet use
Annals of Emergency Medicine, 2015Co-Authors: John F Kragh, Thomas J Walters, David G Baer, Jason J Nam, Keith A Berry, Vincent J Mase, James K Aden, Michael A Dubick, Charles E WadeAbstract:Study objective We assess whether emergency tourniquet use for transfused war casualties admitted to military hospitals is associated with survival. Methods A retrospective review of trauma registry data was made of US casualties in Afghanistan and Iraq. Patients with major limb trauma, transfusion, and tourniquet use were compared with similar patients who did not receive tourniquet use. A propensity-matching analysis was performed by stratifying for injury type and severity by tourniquet-use status. Additionally, direct comparison without propensity matching was made between tourniquet use and no-tourniquet use groups. Results There were 720 casualties in the tourniquet use and 693 in the no-tourniquet use groups. Of the 1,413 casualties, 66% (928) also had nonextremity injury. Casualties with tourniquet use had worse signs of hemorrhagic shock (admission base deficit, admission hemoglobin, admission pulse, and transfusion units required) than those without. Survival rates were similar between the 2 groups (1% difference; 95% confidence interval −2.5% to 4.2%), but casualties who received Tourniquets had worse shock and received more blood products. In propensity-matched casualties, survival rates were not different (2% difference; 95% confidence interval −6.7% to 2.7%) between the 2 groups. Conclusion Tourniquet use was associated with worse shock and more transfusion requirements among hospital-admitted casualties, yet those who received Tourniquets had survival rates similar to those of comparable, transfused casualties who did not receive Tourniquets.
Thomas J Walters - One of the best experts on this subject based on the ideXlab platform.
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Extended (16-Hour) Tourniquet Application After Combat Wounds: A Case Report and Review of the Current Literature
2016Co-Authors: John F Kragh, David G Baer, Thomas J WaltersAbstract:Summary: We present a case of emergency tourniquet use of unusually long duration. The patient was wounded during combat operations, and the subsequent battle and evacuation caused a sig-nificant delay in surgical treatment of his wounds. Emergency tour-niquets can be lifesaving, but are not benign interventions. In general, the extent of tourniquet injury increases with increasing time of application. Despite having a tourniquet in place for 16 hours, the limb was salvaged and significant functional recovery was accom-plished. We conducted a search of the published literature including the Medline database, and present a review of the relevant articles concerning emergency tourniquet use, tourniquet injury, and miti-gating treatments. Given the widespread use of Tourniquets in ongoing military operations, it seems likely that Tourniquets will transition to civilian use. Thus it is important for physicians to understand tour-niquet injury and appreciate that even extended tourniquet applicatio
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performance of junctional Tourniquets in normal human volunteers
Prehospital Emergency Care, 2015Co-Authors: John F Kragh, Thomas J Walters, James K Aden, Russ S Kotwal, Bijan S Kheirabadi, Robert T Gerhardt, Andrew P Cap, Robert A Delorenzo, Heather F Pidcoke, Leopoldo C CancioAbstract:AbstractBackground. Inguinal bleeding is a common and preventable cause of death on the battlefield. Four FDA-cleared junctional Tourniquets (Combat Ready Clamp [CRoC], Abdominal Aortic and Junctional Tourniquet [AAJT], Junctional Emergency Treatment Tool [JETT], and SAM Junctional Tourniquet [SJT]) were assessed in a laboratory on volunteers in order to describe differential performance of models. Objective. To examine safety and effectiveness of junctional Tourniquets in order to inform the discussions of device selection for possible fielding to military units. Methods. The experiment measured safety and effectiveness parameters over timed, repeated applications. Lower extremity pulses were measured in 10 volunteers before and after junctional tourniquet application aimed at stopping the distal pulse assessed by Doppler auscultation. Safety was determined as the absence of adverse events during the time of application. Results. The CRoC, SJT, and JETT were most effective; their effectiveness did not di...
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transfusion for shock in us military war casualties with and without tourniquet use
Annals of Emergency Medicine, 2015Co-Authors: John F Kragh, Thomas J Walters, David G Baer, Jason J Nam, Keith A Berry, Vincent J Mase, James K Aden, Michael A Dubick, Charles E WadeAbstract:Study objective We assess whether emergency tourniquet use for transfused war casualties admitted to military hospitals is associated with survival. Methods A retrospective review of trauma registry data was made of US casualties in Afghanistan and Iraq. Patients with major limb trauma, transfusion, and tourniquet use were compared with similar patients who did not receive tourniquet use. A propensity-matching analysis was performed by stratifying for injury type and severity by tourniquet-use status. Additionally, direct comparison without propensity matching was made between tourniquet use and no-tourniquet use groups. Results There were 720 casualties in the tourniquet use and 693 in the no-tourniquet use groups. Of the 1,413 casualties, 66% (928) also had nonextremity injury. Casualties with tourniquet use had worse signs of hemorrhagic shock (admission base deficit, admission hemoglobin, admission pulse, and transfusion units required) than those without. Survival rates were similar between the 2 groups (1% difference; 95% confidence interval −2.5% to 4.2%), but casualties who received Tourniquets had worse shock and received more blood products. In propensity-matched casualties, survival rates were not different (2% difference; 95% confidence interval −6.7% to 2.7%) between the 2 groups. Conclusion Tourniquet use was associated with worse shock and more transfusion requirements among hospital-admitted casualties, yet those who received Tourniquets had survival rates similar to those of comparable, transfused casualties who did not receive Tourniquets.
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battle casualty survival with emergency tourniquet use to stop limb bleeding
Journal of Emergency Medicine, 2011Co-Authors: John F Kragh, Thomas J Walters, David G Baer, Charles E Wade, Michelle L Littrel, John A Jones, John B HolcombAbstract:Abstract Background In a previous study conducted at a combat support hospital in Iraq, we reported the major lifesaving benefits of emergency Tourniquets to stop bleeding in major limb trauma. Morbidity associated with tourniquet use was minor. Study Objectives The objective of this study is to further analyze emergency tourniquet use in combat casualty care. Design and Setting This report is a continuation of our previous study of tourniquet use in casualties admitted to a combat support hospital (NCT00517166 at www.ClinicalTrials.gov). Methods After verifying comparable methodologies for the first study and the current study, we compared patient results for these two time periods and then pooled data to analyze outcomes with a larger sample size. Results The total study population was 499 (232 in the previous study and 267 in the current study). In all, 862 Tourniquets were applied on 651 limbs. Survival was 87% for both study periods. Morbidity rates for palsies at the level of the tourniquet were 1.7% for study 1 and 1.5% for study 2; major limb shortening was 0.4% for both. Survival was associated with prehospital application (89% vs. 78% hospital, p Conclusions This study shows consistent lifesaving benefits and low risk of emergency Tourniquets to stop bleeding in major limb trauma.
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the military emergency tourniquet program s lessons learned with devices and designs
Military Medicine, 2011Co-Authors: John F Kragh, Thomas J Walters, David G Baer, Charles E Wade, John B Holcomb, Michael A Dubick, Michelle L Oneill, Lorne H BlackbourneAbstract:ABSTRACTObjective: The purpose of this study is to report the device lessons learned from an emergency tourniquet program and, in particular, to emphasize analysis of discarded devices recovered after clinical use. Methods: Discarded tourniquet devices were analyzed after use in emergency care of war casualties to determine wear and tear patterns, effectiveness rates, and associations among device designs. Results: The 159 devices recovered comprised seven designs. Emergency & Military Tourniquet (92%) and Combat Application Tourniquet (79%) effectiveness rates were significantly different from each other and better than other Tourniquets (p < 0.002) as the most effective ambulance and field Tourniquets, respectively. Designs had specific pitfalls (e.g., sand-clogged ratchets) and strengths (the pneumatic design was least painful). Every device had wear, abrasions, or deformity about the band edges or bladder. User understanding of how devices work best helped attain better results. Some desirable traits ...
David G Baer - One of the best experts on this subject based on the ideXlab platform.
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Extended (16-Hour) Tourniquet Application After Combat Wounds: A Case Report and Review of the Current Literature
2016Co-Authors: John F Kragh, David G Baer, Thomas J WaltersAbstract:Summary: We present a case of emergency tourniquet use of unusually long duration. The patient was wounded during combat operations, and the subsequent battle and evacuation caused a sig-nificant delay in surgical treatment of his wounds. Emergency tour-niquets can be lifesaving, but are not benign interventions. In general, the extent of tourniquet injury increases with increasing time of application. Despite having a tourniquet in place for 16 hours, the limb was salvaged and significant functional recovery was accom-plished. We conducted a search of the published literature including the Medline database, and present a review of the relevant articles concerning emergency tourniquet use, tourniquet injury, and miti-gating treatments. Given the widespread use of Tourniquets in ongoing military operations, it seems likely that Tourniquets will transition to civilian use. Thus it is important for physicians to understand tour-niquet injury and appreciate that even extended tourniquet applicatio
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which improvised tourniquet windlasses work well and which ones won t
Wilderness & Environmental Medicine, 2015Co-Authors: John F Kragh, James K Aden, Michael A Dubick, Timothy E Wallum, David G BaerAbstract:Objective Improvised Tourniquets in first aid are recommended when no scientifically designed tourniquet is available. Windlasses for mechanical advantage can be a stick or pencil and can be used singly or multiply in tightening a tourniquet band, but currently there is an absence of empiric knowledge of how well such windlasses work. The purpose of the present study was to determine the performance of improvised Tourniquets in their use by the type and number of windlasses to improve tourniquet practice. Methods A simulated Leg Tourniquet Trainer was used as a manikin thigh to test the effectiveness of improvised Tourniquets of a band-and-windlass design. Two users made 20 tests each with 3 types of windlasses. Tests started with 1 representative of a given type (eg, 1 pencil), then continued with increasing numbers of each windlass type until the user reached 100% effectiveness as determined by cessation of simulated blood flow. Windlass types included chopsticks, pencils, and craft sticks. Results Effectiveness percentages in stopping bleeding were associated inversely with breakage percentages. Pulse stoppage percentages were associated inversely with breakage. The windlass turn numbers, time to stop bleeding, the number of windlasses, and the under-tourniquet pressure were associated inversely with breakage. The windlass type was associated with breakage; at 2 windlasses, only chopsticks were without breakage. Of those windlass types that broke, 20.7% were chopsticks, 26.1% were pencils, and 53.2% were craft sticks. Conclusions A pair of chopsticks as an improvised tourniquet windlass worked better than pencils or craft sticks.
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transfusion for shock in us military war casualties with and without tourniquet use
Annals of Emergency Medicine, 2015Co-Authors: John F Kragh, Thomas J Walters, David G Baer, Jason J Nam, Keith A Berry, Vincent J Mase, James K Aden, Michael A Dubick, Charles E WadeAbstract:Study objective We assess whether emergency tourniquet use for transfused war casualties admitted to military hospitals is associated with survival. Methods A retrospective review of trauma registry data was made of US casualties in Afghanistan and Iraq. Patients with major limb trauma, transfusion, and tourniquet use were compared with similar patients who did not receive tourniquet use. A propensity-matching analysis was performed by stratifying for injury type and severity by tourniquet-use status. Additionally, direct comparison without propensity matching was made between tourniquet use and no-tourniquet use groups. Results There were 720 casualties in the tourniquet use and 693 in the no-tourniquet use groups. Of the 1,413 casualties, 66% (928) also had nonextremity injury. Casualties with tourniquet use had worse signs of hemorrhagic shock (admission base deficit, admission hemoglobin, admission pulse, and transfusion units required) than those without. Survival rates were similar between the 2 groups (1% difference; 95% confidence interval −2.5% to 4.2%), but casualties who received Tourniquets had worse shock and received more blood products. In propensity-matched casualties, survival rates were not different (2% difference; 95% confidence interval −6.7% to 2.7%) between the 2 groups. Conclusion Tourniquet use was associated with worse shock and more transfusion requirements among hospital-admitted casualties, yet those who received Tourniquets had survival rates similar to those of comparable, transfused casualties who did not receive Tourniquets.
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testing of junctional Tourniquets by military medics to control simulated groin hemorrhage
Journal of special operations medicine : a peer reviewed journal for SOF medical professionals, 2014Co-Authors: John F Kragh, David G Baer, James K Aden, Donald L Parsons, Russ S Kotwal, Bijan S Kheirabadi, Robert T Gerhardt, Michael A DubickAbstract:Abstract : Background: Junctional hemorrhage is a common cause of death on the battlefield, but there is no documented direct comparison for the use of junctional tourniquet models by US medics. The purpose of this testing is to assess military medic experience with the use of junctional Tourniquets in simulated out-of-hospital trauma care. Methods: Nine medics (seven men and two women) used four different junctional Tourniquets: Combat Ready Clamp (CRoC ; http://www.combatmedicalsystems .com), Abdominal Aortic and Junctional Tourniquet (AAJT ; http://www.compressionworks.net), Junctional Emergency Treatment Tool (JETT ; http://www.narescue .com), and SAM Junctional Tourniquet (SJT ; http:// www.sammedical.com/products). These medics also acted as simulated casualties. Effectiveness percentages, as measured by stopped distal pulse by Doppler auscultation, and time to effectiveness were recorded in two tests per tourniquet (72 total tests). Tourniquet users ranked their preference of model by answering the question: If you had to go to war today and you could only choose one, which tourniquet would you choose to bring? Results: All Tourniquets used were safe under the conditions of this study. Both the SJT and the CRoC had high effectiveness percentages; their rate difference was not statistically significant. The SJT and the CRoC had fast times to effectiveness; their time difference was not statistically significant. Users preferred the SJT and the CRoC; their ranked difference was not statistically significant. Conclusion: The SJT and the CRoC were equally effective and fast and were preferred by the participants.
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survey of trauma registry data on tourniquet use in pediatric war casualties
Pediatric Emergency Care, 2012Co-Authors: John F Kragh, David G Baer, Charles E Wade, James K Aden, Michael A Dubick, þ Arthur Cooper, Lorne H BlackbourneAbstract:OBJECTIVES Previously, we reported on the use of emergency Tourniquets to stop bleeding in war casualties, but virtually all the data were from adults. Because no pediatric-specific cohort of casualties receiving emergency Tourniquets existed, we aimed to fill knowledge gaps on the care and outcomes of this group by surveying data from a trauma registry to refine device designs and clinical training. METHODS A retrospective review of data from a trauma registry yielded an observational cohort of 88 pediatric casualties at US military hospitals in theater on whom Tourniquets were used from May 17, 2003, to December 25, 2009. RESULTS Of the 88 casualties in the study group, 72 were male and 16 were female patients. Ages averaged 11 years (median, 11 years; range, 4-17 years). There were 7 dead and 81 survivor outcomes for a trauma survival rate of 93%. Survivor and dead casualties were similar in all independent variables measured except hospital stay duration (median, 5 days and 1 day, respectively). Six casualties (7%) had neither extremity nor external injury in that they had no lesion indicating tourniquet use. CONCLUSIONS The survival rate of the present study's casualties is similar to that of 3 recent large nonpediatric-specific studies. Although current emergency Tourniquets were ostensibly designed for modern adult soldiers, tourniquet makers, perhaps unknowingly, produced Tourniquets that fit children. The rate of unindicated Tourniquets, 7%, implied that potential users need better diagnostic training. LEVELS OF EVIDENCE Level 4; case series, therapeutic study.
Muhamed M Farhanalanie - One of the best experts on this subject based on the ideXlab platform.
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tourniquet use in lower limb trauma and fracture surgery
Journal of Bone and Joint Surgery-british Volume, 2021Co-Authors: Muhamed M Farhanalanie, Alex Trompeter, Peter Wall, Matthew L CostaAbstract:The use of Tourniquets in lower limb trauma surgery to control bleeding and improve the surgical field is a long established practice. In this article, we review the evidence relating to harms and benefits of tourniquet use in lower limb fracture fixation surgery and report the results of a survey on current tourniquet practice among trauma surgeons in the UK.
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the risks associated with tourniquet use in lower limb trauma surgery a systematic review and meta analysis
European Journal of Orthopaedic Surgery and Traumatology, 2021Co-Authors: Muhamed M Farhanalanie, Alex Trompeter, Fatema Dhaif, Martin Underwood, Joyce Yeung, Nicholas R Parsons, Andrew Metcalfe, Peter WallAbstract:Tourniquet use in lower limb fracture surgery may reduce intra-operative bleeding, improve surgical field of view and reduce length of procedure. However, Tourniquets may result in pain and the production of harmful metabolites cause complications or affect functional outcomes. This systematic review aimed to compare outcomes following lower limb fracture surgery performed with or without tourniquet. We searched databases for RCTs comparing lower limb fracture surgery performed with versus without tourniquet reporting on outcomes pain, physical function, health-related quality of life, complications, cognitive function, blood loss, length of stay, length of procedure, swelling, time to union, surgical field of view, volume of anaesthetic agent, biochemical markers of inflammation and injury, and electrolyte and acid–base balance. Random-effects meta-analysis was performed. PROSPERO ID CRD42020209310. Six RCTs enabled inclusion of 552 procedures. Pooled analysis demonstrated that tourniquet use reduced length of procedure by 6 minutes (95% CI −10.12 to −1.87; p < 0.010). We were unable to exclude increased harms from tourniquet use. Pooled analysis showed post-operative pain score was higher in tourniquet group by 12.88 on 100-point scale (95% CI −1.25–27.02; p = 0.070). Risk differences for wound infection, deep venous thrombosis and re-operation were 0.06 (95% CI −0.00–0.12; p = 0.070), 0.05 (95% CI −0.02–0.11; p = 0.150) and 0.03 (95% CI -0.03–0.09; p = 0.340). Tourniquet use was associated with a reduced length of procedure. It is possible that Tourniquets also increase incidence of important complications, but the data are too sparse to draw firm conclusions. Methodological weaknesses of the included RCTs prevent any solid conclusions being drawn for outcomes investigated. Further studies are required to address these limitations.
Peter Wall - One of the best experts on this subject based on the ideXlab platform.
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tourniquet use in lower limb trauma and fracture surgery
Journal of Bone and Joint Surgery-british Volume, 2021Co-Authors: Muhamed M Farhanalanie, Alex Trompeter, Peter Wall, Matthew L CostaAbstract:The use of Tourniquets in lower limb trauma surgery to control bleeding and improve the surgical field is a long established practice. In this article, we review the evidence relating to harms and benefits of tourniquet use in lower limb fracture fixation surgery and report the results of a survey on current tourniquet practice among trauma surgeons in the UK.
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the risks associated with tourniquet use in lower limb trauma surgery a systematic review and meta analysis
European Journal of Orthopaedic Surgery and Traumatology, 2021Co-Authors: Muhamed M Farhanalanie, Alex Trompeter, Fatema Dhaif, Martin Underwood, Joyce Yeung, Nicholas R Parsons, Andrew Metcalfe, Peter WallAbstract:Tourniquet use in lower limb fracture surgery may reduce intra-operative bleeding, improve surgical field of view and reduce length of procedure. However, Tourniquets may result in pain and the production of harmful metabolites cause complications or affect functional outcomes. This systematic review aimed to compare outcomes following lower limb fracture surgery performed with or without tourniquet. We searched databases for RCTs comparing lower limb fracture surgery performed with versus without tourniquet reporting on outcomes pain, physical function, health-related quality of life, complications, cognitive function, blood loss, length of stay, length of procedure, swelling, time to union, surgical field of view, volume of anaesthetic agent, biochemical markers of inflammation and injury, and electrolyte and acid–base balance. Random-effects meta-analysis was performed. PROSPERO ID CRD42020209310. Six RCTs enabled inclusion of 552 procedures. Pooled analysis demonstrated that tourniquet use reduced length of procedure by 6 minutes (95% CI −10.12 to −1.87; p < 0.010). We were unable to exclude increased harms from tourniquet use. Pooled analysis showed post-operative pain score was higher in tourniquet group by 12.88 on 100-point scale (95% CI −1.25–27.02; p = 0.070). Risk differences for wound infection, deep venous thrombosis and re-operation were 0.06 (95% CI −0.00–0.12; p = 0.070), 0.05 (95% CI −0.02–0.11; p = 0.150) and 0.03 (95% CI -0.03–0.09; p = 0.340). Tourniquet use was associated with a reduced length of procedure. It is possible that Tourniquets also increase incidence of important complications, but the data are too sparse to draw firm conclusions. Methodological weaknesses of the included RCTs prevent any solid conclusions being drawn for outcomes investigated. Further studies are required to address these limitations.
