Surgical tourniquet

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Surgical tourniquets enable surgeons to work in a bloodless operative field by preventing blood flow to a limb. This allows surgical procedures to be performed with improved precision, safety and speed. Tourniquets are widely used in orthopedic and plastic surgery, as well as in intravenous regional anesthesia (Bier block anesthesia) where they serve the additional function of preventing local anesthetic in the limb from entering general circulation.

In the early 1980s, microprocessor-controlled pneumatic tourniquets were invented by James McEwen.[1][2] Automatic tourniquets based on this invention are now standard equipment in operating rooms worldwide, and these systems have significantly improved the safety and convenience of tourniquet use.

Despite many advances in tourniquet technology, tourniquet-related injuries continue to be of concern.[3] High pressures under a tourniquet cuff can cause nerve, muscle and skin injury. Minimizing tourniquet pressure, reducing inflation time and using a microprocessor-controlled pneumatic tourniquet, which allows pressure to be accurately monitored and controlled, reduce the risk of tourniquet-related injury.

Surgical tourniquet equipment

Modern pneumatic tourniquets have three basic components: an inflatable cuff, a compressed gas source, and an instrument which automatically monitors and controls cuff pressure. The cuff is secured around the limb proximal to the operative site. Pressure is exerted on the circumference of the limb by means of compressed gas which is introduced into the tourniquet cuff by a microprocessor-controlled source, via connection tubing. When sufficient pressure is exerted, vessels and arteries beneath the cuff become temporarily occluded, preventing blood flow past the cuff. While the cuff is inflated, the tourniquet system automatically monitors and maintains the pressure chosen by the user. Cuff pressure and inflation time are displayed, and an audiovisual alarm alerts the user to alarm conditions, such as a cuff leak.

Contoured cuffs

Wide, contoured thigh, arm and lower leg tourniquet cuffs

Studies have shown that tourniquet cuff pressures can be substantially reduced without compromising the quality of surgical field by using wide, contoured cuffs.[4] Wide cuffs also reduce the risk of injury to underlying tissue by dispersing the cuff’s force over a greater surface area. Standard cuffs are relatively narrow in width and are cylindrical in shape. Where there is a significant difference in limb circumference between the distal and proximal edges of the cuff, a contoured cuff with a tapered, conical shape provides a more anatomical fit and maximizes the contact area between cuff and limb. Wide cuffs with an adjustable, variable taper have recently been introduced, permitting one cuff to conform to a variety of limb shapes.[5]

Limb occlusion pressure

Limb occlusion pressure (LOP) is the minimum tourniquet pressure required to occlude blood flow to a specific patient's limb at a specific time, and takes into account a patient’s limb and vessel characteristics, and the type and fit of the cuff. LOP can be determined by gradually increasing tourniquet pressure until distal arterial pulses cease, as indicated by a device sensing blood flow, such as a Doppler stethoscope. Studies have shown that cuff pressure based on LOP measured immediately prior to surgery is generally lower than pressure from commonly used cuffs and is sufficient to maintain a satisfactory surgical field.[6] Traditionally, this method has not been used because it is time consuming and technically demanding. However, a pneumatic tourniquet that uses an automated plethysmographic system to calculate LOP in approximately 30 seconds at the beginning of surgery has recently been developed.[7] This device has similar accuracy to the standard Doppler technique and addresses the practicality of using LOP in the operating room.

Limb protection

Wide, contoured arm cuff applied over matching limb protection sleeve

For some cuffs, a matching limb protection sleeve is available to help protect soft tissues under the cuff.[5][8] Without proper protection, underlying soft tissue is prone to damage caused by wrinkling, pinching or shearing.[9] Sleeves are sized according to the cuff width and the patient’s limb circumference. They are intended to fit snugly and extend beyond the edge of the cuff to ensure that there is no direct contact between cuff and skin. Sleeve materials that do not shed loose fibers are chosen to avoid lint becoming trapped in the cuff’s hook and loop fasteners, which reduces their effectiveness.

See also

References

  1. ↑ McEwen, James A. US Patent No. 4,469,099, September 4, 1984, “Pneumatic Tourniquet”.
  2. ↑ McEwen, James A. US Patent No. 4,479,494, October 30, 1984, “Adaptive Pneumatic Tourniquet”.
  3. ↑ Murphy CG, Winter DC, Bouchier-Hayes DJ. “Tourniquet injuries: Pathogenesis and modalities for attenuation.” Acta Orthop Belg. 2005; 71(6):635-645.
  4. ↑ Pedowitz RA, Gershuni DH, Botte MJ, et al. “The use of lower tourniquet inflation pressures in extremity surgery facilitated by curved and wide tourniquets and an integrated cuff inflation system.” Clin Orthop Relat Res. 1993; 287:237-244.
  5. ↑ 5.0 5.1 Delfi Medical Specialty tourniquets
  6. ↑ McEwen JA, Inkpen KB, Younger A. “Thigh tourniquet safety: Limb occlusion pressure measurement and a wide contoured cuff allow lower cuff pressure.” Surg Tech. 2002; 34:8-18.
  7. ↑ McEwen, James A; Jameson, Michael. US Patent No. 5,607,447, March 4, 1997, “Physiologic Tourniquet”.
  8. ↑ McEwen, James A. US Patent No. 6,361,548, March 26, 2002, “Limb Protection Sleeve for Matching Tourniquet Cuff”.
  9. ↑ McEwen JA, Kelly DL, Jardanowski T, Inkpen K. “Tourniquet safety in lower leg applications.” Orthop Nurs. 2002; 21(5):55-62.
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