Recommended practices for use of the pneumatic tourniquet

AORN Journal,  Feb, 2002  

• E-mail
• Print
• Link

13. Tourniquet inflation time should be kept to a minimum. The surgeon should be informed of the duration of the tourniquet time at regular, established intervals. Paralysis may result from prolonged use of the tourniquet. It has not been determined exactly how long a tourniquet may be inflated safely. The time varies with the patient's age and physical status and the vascular supply to the extremity. One hour is the recommended inflation time limit for an upper extremity and one and one-half to two hours for a lower extremity. In addition, after a period of reperfusion (ie, 10 minutes or more), the tourniquet may be rein-flated for another full period as above. (27)

14. Use of bilateral extremity tourniquets has become more common and presents a unique set of potential complications. Tourniquet use causes anaerobic metabolism, which produces lactic acid and other metabolites. Lactic acidosis causes a decrease in vascular resistance and allows an increased blood flow when the tourniquet is deflated. The larger the muscle mass, the greater the production of these by-products. To reduce the rapid release of large amounts of these metabolic by-products, tourniquets should be deflated individually 30 to 45 minutes apart when bilateral tourniquets are used (eg, during simultaneous bilateral total knee anlaroplasty). Sequential deflation lessens the potential for adverse patient reactions (eg, fat embolism) to these by-products. (28)

15. Tourniquets should be deflated as recommended by the manufacturer. Upon deflation of the tourniquet, the cuff and sleeve/padding should be removed from the extremity. Even slight impedance of venous return by the padding or deflated cuff may lead to congestion and pooling of blood at the surgical site. (29)

16. A number of adverse reactions have been identified in relation to tourniquet use. Overpressurization may cause pain at the cuff site; muscle weakness; compression injuries to blood vessels, nerves, muscle, or skin; or extremity paralysis. Underpressurization may result in blood in the surgical field, passive congestion of the limb, shock, and hemorrhagic infiltration of a nerve. Excessive inflation time may result in excessive hyperemia, muscle weakness, ischemic injury, or extremity paralysis. Improper cuff application may lead to venous congestion, bruising, blistering, pinching, ecchymosis, or necrosis of the skin.

17. Safety measures should be implemented to prevent injury. These measures include, but are not limited to,

* following manufacturers' written instructions,

* performing a complete patient assessment preoperatively,

* applying the cuff to the extremity with care and attention,

* ensuring proper fit of the cuff on the extremity,

* avoiding fluid retention under the cuff,

* using the minimal effective pressure required to suppress arterial circulation in an extremity,

* monitoring the pressure display to ensure that it accurately reflects the pressure in the cuff bladder, and

* monitoring tourniquet inflation time.