Tourniquet-induced ischemia creates increased risk of organ dysfunction and mortality following delayed limb amputation

Tourniquets are critical for the control of traumatic extremity hemorrhage. In this study, we sought to determine, in a rodent blast-related extremity amputation model, the impact of prolonged tourniquet application and delayed limb amputation on survival, systemic inflammation, and remote end organ injury. Adult male Sprague Dawley rats were subjected to blast overpressure (120 +/- 7 kPa) and orthopedic extremity injury consisting femur fracture, one-minute soft tissue crush injury (20 psi), +/- 180 min of tourniquet-induced hindlimb ischemia followed by delayed (60 min of reperfusion) hindlimb amputation (dHLA). All animals in the non-tourniquet group survived whereas 7/21 (33%) of the animals in the tourniquet group died within the first 72 h with no deaths observed between 72 and 168 h post-injury. Tourniquet induced ischemia-reperfusion injury (tIRI) likewise resulted in a more robust systemic inflammation (cytokines and chemokines) and concomitant remote pulmonary, renal, and hepatic dysfunction (BUN, CR, ALT. AST, IRI/inflammation-mediated genes). These results indicate prolonged tourniquet application and dHLA increases risk of complications from tIRI, leading to greater risk of local and systemic complications including organ dysfunction or death. We thus need enhanced strategies to mitigate the systemic effects of tIRI, particularly in the military prolonged field care (PFC) setting. Furthermore, future work is needed to extend the window within which tourniquet deflation to assess limb viability remains feasible, as well as new, limb-specific or systemic point of care tests to better assess the risks of tourniquet deflation with limb preservation in order to optimize patient care and save both limb and life. Crown Copyright (c) 2023 Published by Elsevier Ltd. All rights reserved.

Automated summary

Tourniquets are critically important for controlling traumatic extremity hemorrhage. This study investigated the effects of prolonged tourniquet application and delayed limb amputation on survival, systemic inflammation, and remote organ injury. The results showed that prolonged tourniquet application and delayed limb amputation increased the risk of complications, including systemic inflammation and dysfunction of remote organs. Improved strategies are needed to mitigate these systemic effects, especially in military settings. Additionally, further research is necessary to extend the time window for evaluating limb viability after tourniquet deflation and develop new point of care tests to assess the risks of tourniquet deflation for limb preservation and patient care optimization.