Effects of tourniquet use in paediatric lower leg surgery

Abstract

Background The purpose of this study is to evaluate the use of the tourniquet and its effect on post-operative pain in the paediatric population following lower leg procedures. Methods A retrospective study of paediatric patients (under the age of 18) undergoing inpatient orthopaedic procedure below the knee performed at a single academic institution between 1st December 2013 and 31st January 2019 was conducted. Primary outcome measures of total opioid consumption during hospital stay and pre-operative nerve block utilization were retrieved from the electronic medical record (EMR). Secondary outcome measures of blood loss, tourniquet time, procedure time and length of hospital stay were also retrieved. Student’s t-tests were used to assess statistical significance between two sample means. Results The final analysis included 204 paediatric procedures, 118 of which used a tourniquet and 86 of which did not. Paediatric patients with a tourniquet had significantly more opioid consumption post-operatively in the form of weight-based morphine equivalents/length of stay (p = 0.01) compared to those who had no tourniquet. This held true for males (p = 0.049) and females (p = 0.04) respectively. We did not see an increase in wound complications or return trips to the operating room in the tourniquet cohort. All procedures included an osseous component except one procedure in the non-tourniquet group. Conclusion Minimizing opioid consumption may be achieved by avoiding tourniquet use in paediatric patients with lower leg procedures. In non-anaemic paediatric patients, it is reasonably risk-free to perform these surgeries without the use of tourniquet to decrease opioid dependence in the post-­operative period. Level of evidence III

A systematic review of tourniquet use in paediatric orthopaedic surgery: can we extrapolate from adult guidelines?

“…This is an example of a tourniquet associated adverse event that is entirely preventable through the correct application of a shut-off. Similar to the evidence from the adult population ( 16 ), tourniquet use is associated with increased post-operative pain and analgesia ( 62 ), which can prolong hospital stay and interfere with rehabilitation.…”

“…Hanna et al included 204 children who underwent lower limb orthopaedic surgery. Tourniquet use was associated with increased pain levels and post-operative analgesia requirements ( 62 ). Mean tourniquet time was 75.9 min (range: 7–195), but tourniquet pressures were not reported.…”

“…Despite the primary goals for the intraoperative use of tourniquets being to improve visibility of the surgical field and decreased blood loss, no study directly assessed quality of the surgical field with and without the use of a tourniquet and only one study reported on the difference in blood loss ( 62 ) which was not clinically significant. The routine use of tourniquet in both elective and fracture fixation is not evidence based, in terms of benefits as well as potential complications.…”

Factors for Prolonged Pain and Restriction of Movement Following Hemiepiphysiodesis Plating for the Correction of Lower Limb Malalignment in the Frontal Plane: An Explorative Analysis

“…However, in the present study, patients tended to have a higher complication rate and pain after implantation of hemiepiphysiodesis plates at higher tourniquet pressures. Accordingly, Hanna et al [ 22 ] found a reduction of opioid consumption in the postoperative period by avoiding the use of tourniquet in pediatric patients with lower limb surgery. Another study from Kamath et al [ 23 ] found that the incidence of tourniquet pain was directly proportional to the duration of tourniquet use but not to the amplitude of tourniquet inflation pressure.…”