Morbidity and mortality associated with ischemia-reperfusion injury after prolonged tourniquet use: A wartime single-center treatment algorithm

BACKGROUND: The evolving warfare tactics used by near-peer adversaries are expected to increase the incidence of severe extremity injuries and delayed evacuations. Initial reports from combat in Ukraine suggest high complication rates associated with prolonged tourniquet use. This study aimed to evaluate the systemic effects of limb reperfusion following tourniquet application lasting 4 hours or more in patients with isolated extremity injuries. Patients were treated according to an evidence-based protocol designed to mitigate ischemia-reperfusion injuries. METHODS: This retrospective review was conducted at a forward surgical facility in Ukraine during combat operations from May 2023 to February 2024. Patients with tourniquets in place for at least 4 hours were included, while those with contraindications to limb salvage or significant confounding injuries were excluded. Short-term outcomes assessed included limb salvage, organ failure, and survival rates. RESULTS: Of the 1,945 casualties screened, 90 (4.6%) met the inclusion criteria. After excluding 16 patients, outcomes were analyzed for 74 males, with an average age of 41.6 ± 8.5 years and a mean tourniquet duration of 7.1 ± 2.9 hours. Among these, 19 patients (25.67%) had vascular injuries, and compartment syndrome was present in all cases. Hemodialysis was required for 58 patients (70.8%), while 27 (36.3%) needed a delayed limb amputation, and 5 patients (6.7%) died. Patients requiring dialysis underwent an average of 3 ± 2 sessions to recover kidney function. Longer tourniquet times increased the need for dialysis, which increased the likelihood of patient death. CONCLUSION: We used a standardized ischemia-reperfusion algorithm to reduce the systemic effects of ischemia and reperfusion during attempts to salvage limbs following 4 hours or more of tourniquet time. Preliminary outcomes indicate that survival is probable, kidney function may improve with brief periods of dialysis, and limb salvage is possible in most cases. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.