Factors Associated with Intraoperative Pulmonary Embolism Following Lower Limb Exsanguination with Esmarch and Pneumatic Tourniquet Deflation: A Systematic Review of the Literature

Pulmonary embolism (PE) following lower limb exsanguination with an Esmarch bandage is a rare but often fatal complication of orthopedic surgery.Given the severity and high associated mortality, this study aims to identify contributing factors and inform potential prevention strategies.A secondary objective is to evaluate factors associated with intraoperative PE occurring after tourniquet deflation, possibly resulting from thrombus formation during surgery with subsequent embolization upon tourniquet release.A systematic review was conducted across four databases.Inclusion criteria consisted of case reports and case series available in the English language describing patients who underwent surgery at or below the level of the tibial plateau and experienced an intraoperative PE caused by thrombus.Nine cases of PE occurring during limb exsanguination were identified.In this limited data set, all were fatal.Additionally, four cases of PE occurring after tourniquet deflation were identified, two of which resulted in death.All cases occurred during open reduction and internal fixation procedures for tibia and/or fibula fractures in patients with a history of lower extremity trauma.These findings support existing literature recommending the avoidance of Esmarch bandage exsanguination in immobilized trauma patients.Limb elevation may represent a safer alternative to Esmarch bandage exsanguination when utilizing a tourniquet intraoperatively.