Recommended practices for use of the pneumatic tourniquet

AORN Journal,  Feb, 2002  

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6. The tourniquet cuff should be protected to keep fluids (eg, skin prep solutions) from collecting under the cuff and causing chemical burns. (17) The tourniquet cuff also should be protected from contamination during surgery. Tourniquet protectors (eg, U-shaped drapes, adhesive drapes, plastic bags, tourniquet covers) should be used to minimize soiling.

7. Skin integrity under the tourniquet should be maintained. The cuff should be applied to the extremity so that underlying skin and tissue are not traumatized unduly. Some tourniquets are manufactured with gel padding for conforming pressures. If at any time cuff adjustment is necessary, the cuff should be removed and reapplied to the desired position to avoid shearing forces. (18)

8. An elastic wrap (eg, Esmarch's bandage) should be available for exsanguination. After the extremity is elevated, an elastic wrap often is used to compress superficial vessels to force blood out of the extremity. Adequate exsanguination helps reduce the pain associated with tourniquet use. Exsanguination with an elastic wrap may not be appropriate following traumatic injury or if the extremity has been in a cast. Thrombi in vessels could become dislodged, resulting in emboli. (19) In the presence of infection, painful fractures, or malignant tumors, exsanguination is accomplished by extremity elevation only. (20)

9. The use of a pneumatic tourniquet is contraindicated for patients with vascular disease or poor peripheral circulation. (21)

10.Tourniquets should be inflated rapidly. Rapid cuff inflation occludes arteries and veins almost simultaneously, preventing filling of superficial veins before occlusion of arterial blood flow. (22)

11. Tourniquet inflation pressure should be kept to a minimum. Nerve damage may result from excessive tourniquet pressure or uneven padding. (23) While the cuff is inflated, the pressure gauge or digital display should be clearly visible and monitored for excessive fluctuation. Catastrophic neurological complications (eg, permanent nerve palsy) can occur with excessive tourniquet inflation pressures. (24) The physician considers the patient's age and systolic blood pressure, circumference of the extremity, tourniquet width, and other clinical factors when determining tourniquet inflation pressure. The ideal pressure to which a tourniquet should be inflated has not been determined. The minimum pressure that will produce a bloodless field should be used as a guideline for inflation pressure. The basic guidelines are to add

* 50 to 75 mm Hg to the patient's systolic blood pressure for the upper extremities of adult patients,

* 100 to 150 mm Hg to the patient's systolic blood pressure for the lower extremities of adult patients, (25) and

* 100 mm Hg to the patient's systolic blood pressure for pediatric patients. (26)

12. Tourniquet technology continues to evolve. Emerging technology includes a modified tourniquet control unit that automatically measures the limb occlusion pressure (LOP [ie, the minimum cuff pressure necessary to stop arterial blood flow distal to the cuff]). This feature maintains the cuff at the lowest pressure necessary to maintain a bloodless surgical field. Clinical trials in 2001 established suggested pressures for adult and pediatric limb occlusion using this technology. Over time, technology may change the way tourniquets are used. It is the responsibility of the health care practitioner and facility to stay abreast of new technology and its impact on patient care and safety, as well as its cost.