Effects of Digital Tourniquet Ischemia: A Single Center Study

Surgical Pearl: Simple Techniques for Achieving Hemostasis on Digital Lesions

The fingers are highly vascular sites which bleeds profusely during procedure. Penrose drain and gasket are not readily available in the clinic. For this problem, we advocated the use of hand gloves and cotton gauze to achieve haemostasis at the site of finger.

Use of local anesthetics with an epinephrine additive on fingers and penis - dogma and reality

Epinephrine supplements in local anesthetics are regularly used for surgery in areas with terminal vessels. According to the pharmaceutical guidelines, the use of epinephrine as an additive to local anesthetics is contraindicated for these areas. This review provides an overview of the current scientific data as well as new clinical developments in various fields. It also reviews the current legal situation. A literature research was carried out to survey the current status of relevant data. Written inquiries to several German institutions (Institute for Quality and Efficiency in Health Care, National Association of Statutory Health Insurance Physicians, Center for Clinical Studies Tübingen, Federal Institute for Drugs and Medical Devices) were made to determine the legal situation. No evidence was found in the literature for a causal relationship between the use of epinephrine as a vasoconstrictor and necrosis of the finger or penis. Studies and reviews show that the use of local anesthetics with epinephrine on the fingers or penis is a safe procedure with many clinical and economic advantages. In routine clinical practice, the WALANT method (Wide Awake Local Anesthesia No Tourniquet) as well as the increasing incidence of skin tumors in acral areas has led to a tendency towards increasing use. However, its use is still legally contraindicated, and the pharmaceutical companies show no interest in supporting a drug study. Further clinical trials - regardless of the strength of the evidence - would not change the current legal contraindication.

Successful Treatment of Digital Ischemia Following a Carbon Dioxide Laser and Tourniquet for a Digital Procedure With Adjuvant Low-Level Laser Therapy

A digital tourniquet with/without epinephrine is commonly used in local anesthetics when operating on digits. However, such a complication as digital ischemia could occur following tourniquet application. We reported an elderly patient with atherosclerotic risk factors and she subsequently underwent a digital tourniquet, partial nail plate removal, and a carbon dioxide laser treatment for subungual wart with digital gangrene development. The successful treatment consisted of wound-dressing, medication, and adjuvant low-level light therapy (LLLT) to enhance the wound healing process, thereby resulting in almost complete recovery of skin color and function of the digit in 3 months. In conclusion, the digital tourniquet should be cautiously applied, especially in elderly patients with atherothrombosis, under minimal pressure and appropriate length of time. Moreover, LLLT could be an effective adjuvant treatment to prevent the vascular complications of the digit.

Painless local pressure application to test microvascular reactivity to ischemia

BACKGROUND

Forearm cutaneous blood flux (CBF) measurement with post-occlusive reactive hyperemia (PORH) is uncomfortable and may not be devoid of risks. We aimed to investigate post-compression reactive hyperemia (PCRH) with a custom-made indenter that was designed to be easily used routinely by inexperienced observers.

METHODS

Medical students evaluated PCRH with 1- to 4-min pressure applications of 16 to 34 kPa and PORH with 3-min forearm cuff occlusion using laser speckle contrast imaging in 15 healthy volunteers. Participants were asked to quantify their discomfort with a visual analogue scale (VAS) of 10 cm. Total ischemia (ISCH) was quantified by the product of CBF during ischemia and ischemia duration (min). We subtracted the CBF changes in the skin from a reference ipsilateral (PCRH) or contralateral (PORH) non-stimulated area.

RESULTS

The average VAS was 1.0 for PCRH vs. 6.0 for PORH (p < 0.001). A strong linear relationship between ISCH and peak PCRH (r² = 0.915, p < 0.001) was noted. Peak PORH values (63.9 laser perfusion units (LPU)) were significantly lower than all values of the 3-min PCRH (72.6 LPU), including the one obtained with 16 kPa.

CONCLUSION

Inexperienced observers could test microvascular reactivity with PCRH without inducing the discomfort that is typically experienced with PORH. Further, PCRH elicits a higher peak response to ischemia compared with PORH. This extremely simple method could influence a broad spectrum of routine cutaneous microcirculation investigations, especially when a painful approach is particularly inadequate or if the patient is fragile.

CLINICAL TRIAL REGISTRATION

NCT02861924.

The iTClamp in the management of prehospital haemorrhage

INTRODUCTION

Bleeding remains a leading cause of death in trauma patients. The iTClamp is a temporary wound closure device designed to control external bleeding within seconds of injury. We describe our experience using this device on 10 patients in the prehospital environment.

METHODS

We have implemented the iTClamp for prehospital use through our physician-staffed helicopter emergency medical service (HEMS). Indications were massive bleeding that could not be controlled with an ordinary compressive bandage or a haemostatic bandage.

RESULTS

Ten patients were treated with the iTClamp. Seven patients had a severe head injury due to various traumas, one patient had a neck injury from a disk cutter, one patient had an open chest wound and one patient had an open femur fracture. After applying the iTClamp, bleeding was controlled in 90% of these patients (n=9), with complete cessation reported in 60% (n=6), partial cessation with adequate control reported in 30% (n=3); in one patient, the bleeding could not be controlled with the iTClamp alone. It took an average of 10s to apply the iTClamp, and the average usage satisfaction score was 7.7.

CONCLUSION

We conclude that the iTClamp is a safe, fast and useful tool for stopping or controlling external blood loss in our series of prehospital patients. Further studies of the iTClamp are needed to determine which patients might benefit from this device.

its about the journey!

The aim of this article is to discuss: the importance of effective communication, the importance of maintaining confidentiality and equality for all individuals, the importance of maintaining a secure, safe and hygienic environment within the operating department, the principles of maintaining sterility and controlling infection, and the resulting hazards if these are not maintained. A paediatric patient was followed through her perioperative journey to find out if routinely, at the author's trust, the values of the NHS constitution--the six Cs--are being upheld.