Comments on “tourniquet/strangulation” application and time in reconstructive surgery in leprosy

Leprosy Mailing List – February 27^th, 2010

Ref.: Comments on “tourniquet/strangulation” application and time in reconstructive surgery in leprosy.

From: Latif Ahmed, Karachi , Pakistan

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Dear Dr Noto,

I thank Dr Warren for her detailed explanation on nerve block anaesthesia (LML Feb. 1^st, 2010 and LML Feb 22^nd, 2010). I had an opportunity to assist her in some operations at Marie Adelaide Leprosy Centre (MALC) Karachi in the period between 1976 - 1993, only when her trainee doctor was not available. I also had an opportunity to work as a resident doctor in orthopaedics at Jinnah Postgraduate Medical Centre (JPMC) Karachi . I have nothing to add in nerve blocks as Dr Warren has covered all the aspects. However, if you allow me to put some points on tourniquet application and time, and please allow me to use the term "strangulation" in place for tourniquet.

Dr Warren used a maximum of 2 hours continuous strangulation in arms and legs in a cool atmosphere at MALC operation room, while at JPMC anaesthetists released strangulation intermittently every half an hour for few minutes to allow circulation. That also helped surgeons to clamp and ligate small bleeders. It is worth mentioning that atmospheric temperature remains 30 - 40 degrees C in Karachi for most of the year.

For upper limb sphygmomanometer cuff was used where it is easier to monitor pressure. At MA LC 100 mm Hg was added in systolic pressure while at JPMC 30 - 50 mm Hg was added especially in thin individuals. For lower limbs MALC used a rubber band which was applied spirally up from distal to proximal to squeeze blood out first and then applied circularly at mid thigh region. It was impossible to monitor pressure.

The operating team at MALC consisted of a trainee doctor, an inexperienced ward-girl and a girl from central sterilisation room (CSR). The trainee doctor took double the time for operations like tibialis posterior tendon transfer (TPT) and other tendon transfers, sequestrectomies, bone trim of foot etc. In this setting I had seen horrible results post operative, most of the patients developed avascular necrosis in and around operation field, few had to go for below knee amputations and very few (about 4) above knee amputations. I had see good results when duration of operation was short (less than 1 hour. I wonder why Dr Warren did not pick a surgeon to train in reconstructive surgery .

My fimal comment is: "USE INTERMITTENT RELEASE OF TOURNIQUET IF DURATION OF OPERATION IS MORE THAN 1 HOUR.

I hope that my observations will not offend anyone.

With regards,

Dr Latif Ahmed

Ex Medical Director MALC