Tourniquet use in hand surgery - Is it time to re-inflate the evidence?

Knowledge, attitudes, and practices of orthopedic operating room personnel regarding the use of pneumatic tourniquets

INTRODUCTION

Pneumatic tourniquets (PTs) play a crucial role in hemostasis during orthopedic surgery. This study aimed to investigate the current knowledge, attitudes, and practices (KAP) of orthopedic operating room personnel concerning the use of PTs.

METHODS

This cross-sectional study was conducted from Jul. 2023 to Aug. 2023. An online questionnaire was used to collect demographic information and KAP score data of the orthopedic operating room personnel from Hangzhou Regional Hospitals.

RESULTS

A total of 336 participants included orthopedic physicians (37.8%), orthopedic nurses (31.5%), anesthesiologists (8.9%), operating room nurses (19.9%) and medical students (1.8%). The median knowledge score was 28.5 (24, 32), with a maximum score of 38; the median attitude score was 31 (28, 35), of a maximum of 35; the median practice score was 41 (36, 44), of a maximum of 45. Correlation analysis showed links between knowledge and attitude (r = 0.388, p<0.001), knowledge and practice (r = 0.401, p<0.001), and attitude and practice (r = 0.485, p<0.001). Multivariate logistic regression analysis confirmed that female gender (OR = 0.294, 95% CI: 0.167-0.520; p<0.001), working in a specialized hospital (OR = 0.420, 95% CI: 0.219-0.803; p = 0.009), and occupation as a surgical anesthesiologist (OR = 3.358, 95% CI: 1.466-7.694; p = 0.004) were associated with better knowledge scores. A higher educational degree (OR = 0.237, 95% CI: 0.093-0.608; p = 0.003) was associated with better practice scores. No previous training was associated with lower knowledge (OR = 0.312, 95% CI: 0.187-0.520; p<0.001) and practice (OR = 0.325, 95% CI: 0.203-0.521; p<0.001) scores.

CONCLUSION

Orthopedic personnel in this study had acceptable knowledge, attitude, and practice concerning the use of PTs; additional training and guidance might enhance proficiency.

Principles of management of hand fractures

The optimal management of hand fractures requires a multidisciplinary approach. Initial assessment should include a thorough medical history and clinical examination, followed by appropriate radiological imaging. These are crucial in determining the appropriate management. Following joint stabilisation to allow fractures to unite, early mobilisation is needed to maximise the functional restoration of the hand. In this review, the principles of operative and non-operative management of these injuries are discussed.

Hyperbaric oxygen therapy does not alleviate tourniquet-induced acute ischemia-reperfusion injury in mouse skeletal muscles

During tourniquet application, blood flow is restricted to a limb to stop excessive limb hemorrhage in a trauma setting and to create a bloodless operating field in the surgical setting. During tourniquet-related ischemia, aerobic respiration stops, and ATP is depleted, and during subsequent reperfusion, there is an increase in reactive oxygen species (ROS) production and other endogenous substances, which leads to acute ischemia-reperfusion (IR) injuries, including tissue necrosis and skeletal muscle contractile dysfunction. Hyperbaric oxygen (HBO) therapy can increase the arterial oxygen tension in the tissues of patients with general hypoxia/anoxia, including carbon monoxide poisoning, circulatory arrest, and cerebral and myocardial ischemia. Here, we studied the protective effects of HBO pretreatment with 100% oxygen at 2.5 ATA against tourniquet/IR injury in mice. After one hour of HBO therapy with 100% oxygen at 2.5 ATA was administered to C57/BL6 mice, a rubber band was placed at the hip joint of the unilateral hindlimb to induce 3 h of ischemia and then released for 48 h of reperfusion. We analyzed gastrocnemius muscle morphology and contractile function and measured the levels of ATP and ROS accumulation in the muscles. HBO pretreatment did not improve tourniquet/IR-injured gastrocnemius muscle morphology and muscle contraction. Tourniquet/IR mice with HBO pretreatment showed no increase in ATP levels in IR tissues, but they did have a decreased amount of ROS accumulation in the muscles, compared to IR mice with no HBO pretreatment. These data suggest that one hour of HBO pretreatment with 100% oxygen at 2.5 ATA increases the antioxidant response to lower ROS accumulation but does not increase ATP levels in IR muscles and improve tourniquet/IR-injured muscle morphology and contractile function.