1. Pneumatic Tourniquets
AORN page
PeriOperative Consortium

2. Purpose Occlude blood flow
Obtain a near bloodless field for extremity surgery
Confine a bolus of anesthetic in an extremity for IV regional anesthesia (ex. Bier block)
Although uncommon, serious patient injury is a risk
AORN- Pg 153
Complications noted in 1:2,442 procedures
Article- p Perioperative nurses should recognize that the patient’s tissues undergo anaerobic metabolism and circulatory occlusion when the tourniquet is inflated. As the anesthesia professional or surgeon deflates the tourniquet, the patient has a systemic response to accommodate the return of blood flow to the limb and the shift back to normal tissue metabolism and circulation.
Purpose

3. History Ancient Greeks- compression devices
1718 – Dr. L Petit, developed screw device and coined name, tourniquet
1904 – Harvey Cushing developed inflatable device.
1908 – August Bier administered segmental anesthesia
History

4. Contraindications Impaired circulation or compromise
Extremity with dialysis access
VTE
Infection in extremity
Tumor in the limb
Open fracture
Increased ICP
AORN pg 156
Contraindications

5. Risks Nerve Injuries Skin injuries Compartment syndrome Pain DVTs
Blistering
Bruising
Necrosis
Compartment syndrome
Pain
DVTs
AORN pg
Patients with pre-existing medical conditions, such as: arterial calcification, abnormal clotting, diabetes, sickle cell, tumor, infection, hypertension; are at greater risk
Risks

6. Minimizing Risk Wider cuffs Contoured cuff Proper padding
Disperse pressure over a greater surface area
Allows for use of a lower pressure
Contoured cuff
Makes better fit for tapered extremity
Proper padding
Low lint, soft padding
Wrinkle free
Use a protector or drape
Prevent contamination by fluid, blood, betadine, etc
AORN p
Padding should not pinch the skin.
Skin complication rate was lower when padding was used; however higher pressure may be needed if the padding is loose.
AORN p 51- prolonged exposure to betadine/iodine can cause irritation and present like a chemical burn on the skin
Minimizing Risk

7. Proper Placement Correct size cuff Proper padding
Overlap of 3-6”
Contoured cuff use
Proper padding
Proper exsanguination before inflation
Use of elastic wrap or Esmarch bandage
Proper placement
Avoid over body of neurovascular structure
AORN- pg 162
Exsanguination- elevate the extremity to allow blood to exit the limb; prior to inflation for most effective bloodless field and minimizes the pain
Article- p Role of the perioperative nurse is to confirm the size and shape of the cuff, obtain the appropriate cuff, and prepare necessary equipment before the patient comes into the OR. Cuffs that are the wrong size have the potential to create uneven compression.
Padding: Should be applied snugly
Proper Placement

8. Determining Pressure Typical settings (healthy adult):
Thigh mmHg
Arm or lower leg mmHg
Determine LOP (limb occlusion pressure)
Measure the baseline systolic blood pressure
Allows for use of lower pressure
Formula for safety margin:
Add mmHg for LOP <130
Add mmHg for LOP
Add 80 mmHg for LOP >190
AORN p 163
Newer tourniquet machines allow for determination of limb occlusion pressure. This tests what pressure is needed to occlude the limb. Studies have shown that occlusion can be achieved using lower pressure. There is a safety margin added.
Article- p 387- The nurse should collaborate with the surgeon and anesthesia professional to determine the lowest inflation or cuff pressure setting possible based on the patient’s systolic blood pressure or limb occlusion pressure. Optimal cuff pressure should reduce the risk of tissue injury that can result from overinflation.
Determining Pressure

9. Inflation Time Start infusion of antibiotic prior to inflation
Inflation time is directly correlated to complications
Muscle is susceptible to ischemia
Excessive inflation time results in metabolic changes and muscle damage
Typical set to alarm after 60 minutes
At 2 hours, it should be deflated for minutes for reperfusion
AORN p 164
Excessive time- 2-3 hours; Irreversible skeletal muscle damage begins after 3 hours and is extensive at 6 hours
Article; P 388- Ensure that timing and administration of the ordered antibiotic results in optimal tissue concentration. In some instances, this may mean that administration occurs at least 20 minutes before inflation of the tourniquet cuff.
Inflation Time

10. Decrease in BP occurs as blood is shunted back to the extremity
Decrease in core body temperature
Risk of emboli releasing
Products of anaerobic metabolism enter the systemic circulation
Can result in myocardial depression and cardiac arrest
Remove the cuff and padding to check the skin
AORN 165
Should be coordinated with anesthesia and surgeon
Deflation

11. Documentation Site Pressure
Duration including inflation/deflation times
Serial # of tourniquet machine
Pre and post assessment of extremity
Documentation

12. Common Complications Pain is most common Ischemic changes
Temperature changes
Prolonged swelling
Arterial Injury
AORN- pg 153
Ischemia due to the tourniquet can cause cardiac, respiratory, cerebral circulation, and hematological effects related to metabolic changes
Common Complications

13. AORN. (2015). Guidelines for perioperative practice. Denver, CO: AORN.
Hicks, R. W. & Denholm, B. (2013). Implementing AORN recommended practices for care of patients undergoing pneumatic tourniquet-assisted procedures. AORN Journal, 98(4), Retrieved from:
References