Ortopedide turnike kullanımı: İstanbul’daki ortopedistler ve uzmanlık öğrencileri arasında tanımlayıcı anket çalışması

Yıl 2014, Cilt: 48 Sayı: 5, 483 - 490, 12.11.2014

Merter Yalcinkaya Sami Sukucu Sinan Erdogan Yavuz S. Kabukcuoglu

https://doi.org/10.3944/AOTT.2014.14.0068

Öz

Amaç: Bu çalışmanın amacı, Türkiye’deki ortopedist ve uzmanlık öğrencilerinin turnike kullanımındaki eğilimlerini ve bu eğilimlerin dayandığı bilgilerin doğruluğunu yüz yüze uygulanmış bir anket ile araştırmak ve anket sonuçlarını yorumlamaktı.

Çalışma planı: On iki sorudan oluşan anket, Türkiye’de bulunan ve ortopedi ameliyatlarına aktif olarak katılan ortopedist ve uzmanlık öğrencilerine yüz yüze uygulandı. Ankette hekimlerin kişisel bilgileri, tercih ettikleri manşon basınçları (MB) ile turnike şişirme süreleri (TŞS) ve bu tercihlerin dayandığı bilgilerin kaynağı sorgulandı. Alınan yanıtlar istatistiksel olarak analiz edildi.

Bulgular: Ankete 211 ortopedist ve uzmanlık öğrencisi katıldı. Üst ekstremitede (ÜE) tercih edilen ortalama MB ve TŞS, sırasıyla, 247.1 mmHg ve 108.6 dakika iken, alt ekstremitede (AE) bu değerler, yine sırasıyla, 345.02 mmHg ile 122.4 dakika idi. Alt ekstremitede tercih edilen basınç miktarı ile meslekte çalışma süresi arasında istatistiksel olarak anlamlı düzeyde bir korelasyon saptandı; meslekte çalışma süresi arttıkça tercih edilen basınç miktarı da artıyordu (r=0.144, p=0.04). Üst ekstremite ve AE için, ankete katılanların sırasıyla %95.7 ile %84.8’i turnikeyi en fazla 120 dakika boyunca kullanmayı tercih etmişlerdi.

Çıkarımlar: Ortopedist ve uzmanlık öğrencilerinin tercih ettikleri MB’nin literatür bilgisi ile uyumlu olmadığı ve bilimsel önerilerin üstündeki MB’nin sıklıkla tercih edildiği saptandı. Çalışmanın sonuçları güncel turnike kullanımının gözden geçirilmesi konusunda uyarıcı niteliktedir. Turnike kullanımı konusunda deneyime dayalı uygulamaların ve kişisel öğretilerin yerini kanıta dayalı uygulamalar almalıdır.

Anahtar Kelimeler

Anket; kılavuz; ortopedik ameliyat; turnike.

Tourniquet use in orthopedic surgery: a descriptive survey study among Turkish orthopedic surgeons and residents in Istanbul

Öz

Objective: The aim of this study was to investigate and interpret the trends in tourniquet use and the accuracy of knowledge among Turkish orthopedic physicians through face-to-face survey.

Methods: Turkish orthopedic physicians actively practicing operative orthopedics were questioned in a 12 question face-to-face survey. Personal information of physicians, preferred cuff pressure (CP) and tourniquet inflation time (TIT) and the source of the information for these preferences were questioned. Answers gathered were analyzed statistically.

Results: The survey was completed by 211 orthopedic physicians. Mean preferred CP and TIT was 247.1 mmHg and 108.6 minutes, respectively, in the upper limb (UL) and 345.02 mmHg and 122.4 minutes, respectively, in the lower limb (LL). A statistically significant correlation was found between the amount of pressure preferred in the LL and the years of practice; longer the years in practice, higher the amount of pressure preferred (r=0.144, p=0.04). Tourniquets were used for a maximum period of 120 minutes for the UL by 95.7% of participants and for the LL by 84.8%.

Conclusion: The amount of CP used by the orthopedic physicians surveyed is inconsistent with the literature with frequent use of CP higher than those scientifically recommended. The outcomes of the survey should be cautionary for orthopedic physicians to review the current utilization and replace personal teachings and experience-based methods with evidence-based best practices for tourniquet application.

Anahtar Kelimeler

Guideline, orthopedic surgery, survey, tourniquet

Kaynakça

• Fitzgibbons PG, Digiovanni C, Hares S, Akelman E. Safe tourniquet use: a review of the evidence. J Am Acad Orthop Surg 2012;20:310-9.
• Noordin S, McEwen JA, Kragh JF Jr, Eisen A, Masri BA. Surgical tourniquets in orthopaedics. J Bone Joint Surg Am 2009;91:2958-67.
• Kam PC, Kavanagh R, Yoong FF. The arterial tourniquet: pathophysiological consequences and anaesthetic implications. Anaesthesia 2001;56:534-45.
• Cox C, Yao J. Tourniquet usage in upper extremity surgery. J Hand Surg Am 2010;35:1360-1.
• Sharma JP, Salhotra R. Tourniquets in orthopedic surgery. Indian J Orthop 2012;46:377-83.
• Younger AS, Kalla TP, McEwen JA, Inkpen K. Survey of tourniquet use in orthopaedic foot and ankle surgery. Foot Ankle Int 2005;26:208-17.
• Konrad G, Markmiller M, Lenich A, Mayr E, Rüter A. Tourniquets may increase postoperative swelling and pain after internal fixation of ankle fractures. Clin Orthop Relat Res 2005;433:189-94.
• Kornbluth ID, Freedman MK, Sher L, Frederick RW. Femoral, saphenous nerve palsy after tourniquet use: a case report. Arch Phys Med Rehabil 2003;84:909-11.
• Hirota K, Hashimoto H, Kabara S, Tsubo T, Sato Y, Ishihara H, et al. The relationship between pneumatic tourniquet time and the amount of pulmonary emboli in patients undergoing knee arthroscopic surgeries. Anesth Analg 2001;93:776-80.
• Omeroğlu H, Uçaner A, Tabak AY, Güney O, Biçimoğlu A, Günel U. The effect of using a tourniquet on the intensity of postoperative pain in forearm fractures. A randomized study in 32 surgically treated patients. Int Orthop 1998;22:369-73.
• Yang JH, Lim H, Yoon JR, Jeong HI. Tourniquet associated chemical burn. Indian J Orthop 2012;46:356-9.
• Pedowitz RA. Tourniquet-induced neuromuscular injury. A recent review of rabbit and clinical experiments. Acta Orthop Scand Suppl 1991;245:1-33.
• Ducic I, Chang S, Dellon AL. Use of the tourniquet in reconstructive surgery in patients with previous ipsilateral lower extremity revascularization: is it safe? A survey. J Reconstr Microsurg 2006;22(3):183-9.
• Reid HS, Camp RA, Jacob WH. Tourniquet hemostasis. A clinical study. Clin Orthop Relat Res 1983;177:230-4.
• Pedowitz RA, Gershuni DH, Botte MJ, Kuiper S, Rydevik BL, Hargens AR. The use of lower tourniquet inflation pressures in extremity surgery facilitated by curved and wide tourniquets and an integrated cuff inflation system. Clin Orthop Relat Res 1993;287:237-44.
• Tredwell SJ, Wilmink M, Inkpen K, McEwen JA. Pediatric tourniquets: analysis of cuff and limb interface, current practice, and guidelines for use. J Pediatr Orthop 2001;21:671-6.
• Levy O, David Y, Heim M, Eldar I, Chetrit A, Engel J. Minimal tourniquet pressure to maintain arterial closure in upper limb surgery. J Hand Surg Br 1993;18:204-6.
• Aorn Recommended Practices Committee. Recommended practices for the use of the pneumatic tourniquet in the perioperative practice setting. Aorn J 2007;86:640-655.
• Tejwani NC, Immerman I, Achan P, Egol KA, McLaurin T. Tourniquet cuff pressure: The gulf between science and practice. J Trauma 2006;61:1415-8.
• Kutty S, McElwain JP. Padding under tourniquets in tourniquet controlled surgery: Bruner’s ten rules revisited. Injury 2002;33:75.
• Tuncali B, Karci A, Bacakoglu AK, Tuncali BE, Ekin A. Controlled hypotension and minimal inflation pressure: a new approach for pneumatic tourniquet application in upper limb surgery. Anesth Analg 2003;97:1529-32.
• Tuncali B, Karci A, Tuncali BE, Mavioglu O, Ozkan M, Bacakoglu AK, et al. A new method for estimating arterial occlusion pressure in optimizing pneumatic tourniquet inflation pressure. Anesth Analg 2006;102:1752-7.
• Kalla TP, Younger A, McEwen JA, Inkpen K. Survey of tourniquet use in podiatric surgery. J Foot Ankle Surg 2003;42:68-76. 24- Selecting The Method of Data Collection. In: Czaja R, Blair J, editors. Designing surveys. A Guide to Decisions and Procedures. 2nd ed. California: Pine Forge Press, Sage Publications; 2005. p. 33-58.
• Van Roekel HE, Thurston AJ. Tourniquet pressure: the effect of limb circumference and systolic blood pressure. J Hand Surg Br 1985;10:142-4.
• Abdel-Salam A, Eyres KS. Effects of tourniquet during total knee arthroplasty. A prospective randomised study. J Bone Joint Surg Br 1995;77:250-3.
• Salam AA, Eyres KS, Cleary J, el-Sayed HH. The use of a tourniquet when plating tibial fractures. J Bone Joint Surg Br 1991;73:86-7.
• Maffulli N, Testa V, Capasso G. Use of a tourniquet in the internal fixation of fractures of the distal part of the fibula. A prospective, randomized trial. J Bone Joint Surg Am 1993;75:700-3.
• Tibrewal SB. The pneumatic tourniquet in arthroscopic surgery of the knee. Int Orthop 2001;24:347-9.
• Daruwalla ZJ, Rowan F, Finnegan M, Fennell J, Neligan M. Exsanguinators and tourniquets: do we need to change our practice? Surgeon 2012;10:137-42.
• Oragui E, Parsons A, White T, Longo UG, Khan WS. Tourniquet use in upper limb surgery. Hand (N Y) 2011;6:165-73.
• Estebe JP, Le Naoures A, Chemaly L, Ecoffey C. Tourniquet pain in a volunteer study: effect of changes in cuff width and pressure. Anaesthesia 2000;55:21-6.
• Rajpura A, Somanchi BV, Muir LT. The effect of tourniquet padding on the efficiency of tourniquets of the upper limb. J Bone Joint Surg Br 2007;89:532-4.
• Olivecrona C, Tidermark J, Hamberg P, Ponzer S, Cederfjäll C. Skin protection underneath the pneumatic tourniquet during total knee arthroplasty: a randomized controlled trial of 92 patients. Acta Orthop 2006;77:519-23.
• Pedowitz RA, Gershuni DH, Fridén J, Garfin SR, Rydevik BL, Hargens AR. Effects of reperfusion intervals on skeletal muscle injury beneath and distal to a pneumatic tourniquet. J Hand Surg Am 1992;17:245-55.
• Cunningham L, McCarthy T, O’Byrne J. A survey of upper and lower limb tourniquet use among Irish orthopaedic surgeons. Ir J Med Sci 2013;182:325-30.
• Sato J, Ishii Y, Noguchi H, Takeda M. Safety and efficacy of a new tourniquet system. BMC Surg 2012;12:17.
• Sadri A, Braithwaite IJ, Abdul-Jabar HB, Sarraf KM. Understanding of intra-operative tourniquets amongst orthopaedic surgeons and theatre staff--a questionnaire study. Ann R Coll Surg Engl 2010;92:243-5.