Surgical Tourniquets

A tourniquet is a device that is applied to reduce the blood flow. It is a widely used device in the field of surgery specially in orthopedics and plastic surgery to minimize the blood loss and to create a bloodless field. 

The guidelines for applications (Inflation pressure, duration and release time) is repeatedly being changed.

It is very important to apply the tourniquet correctly and to monitor the pressure and duration of inflation throughout the procedure to minimize complications.

These parameters are being monitored by a pressure monitoring system.

The history of tourniquet will take us back the Romans, since then the tourniquet has evolved significantly to the pneumatic tourniquet which we are using nowadays.

Physiological Effects Of Tourniquet Applications

Physiology of tourniquet

Deflation of the tourniquet can cause reperfusion injury

Proper Application Of Tourniquet

  • Pre-application preparation
    • Exclude contraindications (Mentioned below)
    • Check whether device is functioning
      • Cuff and tubing, regulator, pressuring device
    • Find the best possible widest cuff which suits the patient
      •  Wider cuffs reduce tourniquet pain 
    • Individualize the cuff according to the length and circumference of patients limb
  • Application of tourniquet
    • Adequate padding should be done
      • To avoid skin complications
    • Tourniquet is applied proximal to distal
    • Should be 2 cm away from bony prominence 
      • Avoid bony prominence 
      • Can cause nerve damage 
    • Overlap – should be at least  3 inches, but not more than 6 inches 
    • Apply adhesive drapes to the two ends of the tourniquet 
      • Prevent the entry of any liquids into the tourniquet 
    • Exsanguinate the limb 
      • Several methods can be used 
        • Esmarch bandage can be used – Risk of nerve injury
        • Elevation of the limbs 
          • Arm – 5 min at 90° angle
          • Leg – 5 min at 45° angle 
    • Inflation
  • Duration and pressure of tourniquet applications 
    • This still remains a controversy 
    • Safe duration is 1 – 3 hrs 
    • Fixed inflation pressures are used in most cases
      • 250 mmHg for upper arm
      • 300 mmHg for thigh
    • But when tourniquets are applied for more than 3 hours – Need intermittent deflations
      • deflated for 5 min for every 30 min of inflation

Complications Of Tourniquet Application

  • Nerve injury – Neuropraxia 
    • Pathophysiology is unclear 
  • Damage to skin 
    • Pressure sores 
    • Chemical burn 
  • Damage to muscles 
    • Ischemia damages muscles more than nerves
    • Ischemic changes starts to occur 30 – 60 mins after cuff inflation 
  • Intraoperative bleeding 
    • Due to an under-pressurized cuff, insufficient exsanguination, calcified vessels and problems in application 
  • Compartment syndrome
  • Deep venous thrombosis
  • Tourniquet pain

Contraindications Of Tourniquet Application

  • Absolute
    • AV fistula
    • Severe PVD
    • Previous history of vascular surgery
    • Bone fracture
    • Thrombosis at the site of tourniquet application
  • Relative
    • Sickle cell disease
    • Previous history of thromboembolic events
    • Skin grafts
    • Localized infection 
    • Lymphoeodema 
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