Tourniquets

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  • The pneumatic tourniquet was introduced in 1904 by Harvey Cushing to maintain a bloodless field during extremity surgery.
  • Tourniquets should be deflated at the time of application, proximal to the intended surgical field. The tourniquet cuff bladder requires a source of compressed gas to supply a carefully controlled amount of tourniquet pressure. The gas used may be nitrogen, ambient air, or some other gas.

Indications:

  1. Emergency: control of life/limb threatening bleeding.
  2. Elective: minimise intra-operative bleeding and improve visibility within the surgical field.

Contraindications:

  1. Underlying vascular graft
  2. Peripheral vascular disease
  3. Poor skin
  4. Deep vein thrombosis
  5. Arterovenous fistula
  6. Sickle cell disease
  • Exsanguination of the limb prior to tourniquet inflation decreases the amount of blood distal to the cuff. This reduces blood in the surgical field. This can be performed by elevation, Esmarch bandage distal to proximal for tissue compression. Rhys Davies exsanguinator (partially inflated rubber ‘sausage’).

Complications (total approximately 1:2400):1,2

  1. Skin burns: this is thought to be due to the result of pooling of skin prep beneath the tourniquet on the padded dressing, having a sustained local irritant effect.
  2. Muscle injury
  3. Nerve injury
  4. Reperfusion injury
  • Padding: the tourniquet should be padded with a soft dressing to prevent the wrinkles and blisters that may occur when the skin is pinched. However, using more than two layers of padding results in a significant reduction in the transmitted pressure, which is likely to limit the effectiveness of the tourniquet.3
  • Shape: standard straight tourniquets fit well on cylindrically shaped limbs but conical tourniquets fit better on conical shaped (e.g. obese) limbs and are associated with lower arterial occlusion pressures, as are wide tourniquets.4
  • Duration: tourniquet times greater than 2 hours are associated with a higher risk of muscular injury and neurological complications. This can be offset by temporarily deflating the cuff, to allow reperfusion, prior to re-inflation. Longer deflation times are associated with fewer complications. Neuromuscular injury is greater beneath the cuff than distal to it.5,6
Tournequet 1.web jpg.jpgTournequet 2 .web jpg.jpg

Figure 1.Tournequet

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Figure 2.Esmarch bandage 

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Figure 3.Rhys Davies Exsanguinator

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Figure 4.Velband

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Figure 5.Disposable upper limb tournequet

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Figure 6.Tournequet time 
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References

  • 1. Odinsson A, Finsen V, Tourniquet use and its complications in Norway. Journal of Bone & Joint Surgery, British Volume 2006; 88(8): 1090–1092.
  • 2. Dickinson J, Bailey B Chemical burns beneath tourniquets. BMJ 1988; 297(6662): 1513.
  • 3. Rajpura A, Somanchi B, Muir L. The effect of tourniquet padding on the efficiency of tourniquets of the upper limb. Journal of Bone & Joint Surgery, British Volume 2007; 89(4): 532–534.
  • 4. Pedowitz RA, et al. The use of lower tourniquet inflation pressures in extremity surgery facilitated by curved and wide tourniquets and an integrated cuff inflation system. Clinical Orthopaedics and Related Research 1993; 287: 237–244.
  • 5. Pedowitz RA. Tourniquet-induced neuromuscular injury: a recent review of rabbit and clinical experiments. Acta Orthopaedica Scandinavica 1991; 62(suppl 245): 1–33.
  • 6. Horlocker TT, et al. Anesthetic, patient, and surgical risk factors for neurologic complications after prolonged total tourniquet time during total knee arthroplasty. Anesthesia & Analgesia 2006; 102(3): 950–955.
  • 7. Rutala WA, Weber DJ and Healthcare Infection Control Practices Advisory Committee. Guideline for disinfection and sterilization in healthcare facilities. http://www.cdc.gov/hicpac/pdf/guidelines/Disinfection_Nov_2008.pdf 2008.
  • 8. Tanner J, Norrie P, Melen K. Preoperative hair removal to reduce surgical site infection. Cochrane Database Systematic Reviews 2011; 11: CD004122.
  • 9. King JT, et al., Glycemic control and infections in patients with diabetes undergoing noncardiac surgery. Annals of Surgery 2011; 253(1): 158–165.
  • 10. Marchant MH, et al. The impact of glycemic control and diabetes mellitus on perioperative outcomes after total joint arthroplasty. The Journal of Bone & Joint Surgery 2009; 91(7): 1621–1629.
  • 11. Hill HR, et al. Impaired leukotactic responsiveness in patients with juvenile diabetes mellitus. Clinical Immunology and Immunopathology 1974; 2(3): 395–403.
  • 12. Nolan CM, Beaty HN, Bagdade JD. Further characterization of the impaired bactericidal function of granulocytes in patients with poorly controlled diabetes. Diabetes 1978; 27(9): 889–894.
  • 13. Tan JS, et al. Neutrophil dysfunction in diabetes mellitus. Journal of Laboratory and Clinical Medicine 1975; 85(1): 26–33.
  • 14. Lidwell O, et al. Effect of ultraclean air in operating rooms on deep sepsis in the joint after total hip or knee replacement: a randomised study. BMJ 1982; 285(6334): 10–14.
  • 15. Sanzén L, Walder M. Air contamination during total hip arthroplasty in an ultraclean air enclosure using different types of staff clothing. Journal of Arthroplasty 1990; 5(2): 127–130.
  • 16. Hooper G, et al. Does the use of laminar flow and space suits reduce early deep infection after total hip and knee replacement? Bone & Joint Journal 2011; 93(1): 85–90.
  • 17. Reynolds L1, Beckmann J, Kurz A. Perioperative complications of hypothermia. Best Pract Res Clin Anaesthesiol 2008; 22(4): 645
  • 18. http://www.nice.org.uk/guidance/mtg7/resources/guidance-inditherm-patient-warming-mattress-for-the-prevention-of-inadvertent-hypothermia-pdf.
  • 19. WHO Guidelines for Safe Surgery. World Health Organization, Geneva, 2009.