In briefTourniquet Usage in Upper Extremity Surgery
Section snippets
Tourniquet Location
Common placements are on the upper arm, proximal forearm, wrist, and tourniquet rings of the fingers. Several studies have compared the use of arm versus forearm tourniquets. In general, whereas patient tolerance has been greater for forearm than arm tourniquets,2, 3 other studies showed equivalent tolerance.4 Comparable subjective and objective measures on the quality of the bloodless field have been reported. Wrist tourniquets also demonstrate good efficacy.5
Safety Concerns
Microprocessor-based systems have introduced numerous safety features including audiovisual alarms, improved pressure regulation, and self-detection of potential hardware hazards. Modern cuffs are wider and more conforming. Graham et al.6 showed that Doppler occlusion pressures needed to cease arterial flow decrease with higher ratios of cuff width/arm circumference.
Temporary or irreversible tissue damage may occur even with appropriate usage of a tourniquet. Complications most frequently cited
Padding
Padding should be used beneath the tourniquet. This decreases sheer stresses at the skin surface that may cause injury, particularly in elderly patients with delicate skin. Two randomized controlled trials9, 10 documented fewer skin injuries with use of protective material beneath the tourniquet in lower extremity surgery. In their randomized trial, Olivecrona et al.10 reported skin blisters in 7 of 30 patients without padding, compared with 3 of 29 with padding and 0 of 33 with stockinette.
Occlusive Draping
After tourniquet application, an occlusive drape is applied around the distal edge. This prevents skin preparation solution from soaking the cast padding. Several case reports describe severe chemical burns under the tourniquet, particularly when povidone iodine solutions are used.11, 12, 13 Occlusive draping is probably less important when chlorhexadine-based preparatory solutions are used.
Exsanguination
Several studies have compared methods of exsanguination before tourniquet inflation. Blønd and Madsen14 used scintigraphy with technetium-labeled erythrocytes to evaluate exsanguination in volunteers using various techniques. They showed 44% reduction with elevation for 5 seconds, 42% at 4 minutes, 53% with the squeeze method, and 69% with an Esmarch bandage. The squeeze technique was expeditious and inexpensive, although not as effective as the Esmarch bandage.
Blønd et al.15 performed a
Tourniquet Pressure
No consensus has been reached regarding optimum pressure. As such, the lowest pressure providing for adequate tissue identification and visualization is used. Most surgeons employ a set pressure for most cases with modifications in certain scenarios (ie, hypertension, obesity, children). Others advocate adding a set pressure (50–100 mm Hg) above the systolic pressure.
Levy et al.16 inflated a tourniquet to 300 mm Hg in 50 patients and measured average Doppler opening pressure during deflation.
Tourniquet Time
A safe period of tourniquet inflation time for the upper extremity has not been well elucidated. The most commonly cited value is 120 minutes, in keeping with reported means from the Norwegian survey. Recommended times for both upper- and lower-extremity use vary widely.
Efforts can be made to decrease tourniquet time. Planning should be carried out preoperatively, and cutaneous markings should be made before tourniquet inflation.
Methods have been devised to prolong safe tourniquet time.
References (17)
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Upper extremity tourniquet tolerance
J Hand Surg
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A prospective, randomized, controlled trial of forearm versus upper arm tourniquet tolerance
J Hand Surg
(2002) - et al.
Povidone-iodine related burns
Burns
(2001) - et al.
Minimal tourniquet pressure to maintain arterial closure in upper limb surgery
J Hand Surg
(1993) Tourniquet time in hand surgery
Arch Surg
(1972)- et al.
The position of the tourniquet on the upper limb
J Bone Joint Surg
(2002) - et al.
Wrist tourniquet: the most patient-friendly way of bloodless hand surgery
J Trauma
(2007) - et al.
Occlusion of arterial flow in the extremities at subsystolic pressures through the use of wide tourniquet cuffs
Clin Orthop Relat Res
(1993)
Cited by (16)
Tourniquet use in trauma and orthopaedics, how and when: current evidence
2023, Surgery (United Kingdom)Use of Tourniquets in Limb Trauma Surgery
2018, Orthopedic Clinics of North AmericaCitation Excerpt :Simple elevation is effective in cases when pressure is contraindicated, such as sickle cell anemia.2 Tourniquet use is also contraindicated in malignancy and infection.1,19 The timing of antibiotic administration has been controversial, with some investigators advocating that a period of at least 5 minutes is necessary before tourniquet inflation to allow antibiotics to penetrate the limb.2
Upper extremity deep vein thrombosis with tourniquet use
2015, International Journal of Surgery Case ReportsUnderstanding and optimizing tourniquet use during extremity surgery
2019, AORN Journal
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