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Orthopaedics

Procedures under tourniquet tourniquet for use in limb surgery in place of rubber tourniquets.
One hundred years on, it is still considered an essential tool in
orthopaedic and plastic surgery. However, the use of the tourni-
Livia Malanjum quet is not without its risks and complications.
Barrie Fischer
Applying the tourniquet
The diameter of the cuff used should be wider than half the
diameter of the limb. It should be applied furthest away from the
surgical site and preferably over an area with the most fat and
muscle padding. The edges of the cuff must overlap to provide
even pressure all around. The use of soft-cast padding under-
Abstract neath the cuff is advised. When using padding, there should be
The pneumatic tourniquet is used widely in operations involving the no creases or ridges as this is associated with significant skin
limbs. However, despite its everyday use, a clinicians knowledge of this irritation and blistering. When the skin is prepared prior to sur-
instrument is often limited to the pressure and time limit. Although the gery, the organic iodine or alcohol solution can become soaked
principle behind the tourniquet is simple, anaesthetists and surgeons up by the padding and can cause chemical burns and blistering.
should appreciate the effects of the tourniquet as well as the various To prevent this from happening, an adhesive, transparent surgi-
complications associated with its use. Safe use of the tourniquet starts cal barrier can be used to isolate the tourniquet and its padding
from the point of setting up the pneumatic machine. It is important to (Figure 1).
choose the appropriate pressure. Overinflation can lead to nerve dam-
age. On the other hand, underinflation will lead to a bloody surgical
Exsanguinating the limb
field and unnecessary blood loss. The tourniquet should be applied with
care to avoid local damage to the skin. Pathophysiological effects of the There are two ways to exsanguinate the limb:
tourniquet can vary from a simple tachycardia and increase in systolic 1 Passive method: achieved by elevating the arm or leg for
pressure to fatal events such as large pulmonary embolus and cardiac ar- 5 minutes at 90 and 45, respectively, without mechanical
rest. Prolonged use of the tourniquet can lead to a phenomenon known compression.
as tourniquet pain. Other complications associated with the use of the 2 Active method: by using the Esmarch bandage or a Rhys-
tourniquet include nerve and vascular damage and muscle contracture. Davies exsanguinator (Figure 2). This method is contraindi-
In the past, the use of the tourniquet was avoided in patients with sickle cated in patients with infection, tumour or painful fractures.
cell disease for fear of triggering a sickle cell crisis. However, it has been
shown that by creating the optimum conditions sufficient hydration,
Inflation pressures and time limit
good oxygenation, warmth and mild hyperventilation this group of
patients should not be deprived of the choice of having their limb opera- To achieve complete arterial occlusion, inflation pressures should
tions with a tourniquet. be related to a patients systolic blood pressure (Figure 3):
Inflation pressures for lower limbs: at least 100 mm Hg above
Keywords machine check; nerve damage; pathophysiology; pneumatic systolic arterial blood pressure (usually 300500 mm Hg).
tourniquet; pulmonary embolus; sickle cell disease Inflation pressures for upper limbs: at least 50 mm Hg above
systolic arterial blood pressure (usually 250300 mm Hg).
In order to minimize the risk of nerve damage, the lowest
The use of a tourniquet in operative procedures dates back to inflation pressure should be used.1 In normotensive patients with
Roman times. However, it was specifically used in limb ampu- compliant vessels, lower inflation pressures would be sufficient
tations. In 1864, Lister became the first surgeon to apply the
concept of the bloodless surgical field in operations other than
amputations. The tourniquet is applied around the upper and
lower extremities to reduce blood loss and create good operating
conditions. In 1904, Harvey Cushing introduced the pneumatic

Livia Malanjum, MBChB, is a Specialty Registrar in Anaesthesia and


Critical Care Medicine and is currently working at Leicester General
Hospital, Leicester, UK. She qualified from the University of Bristol.
Conflicts of interest: none declared.

Barrie Fischer, FRCA, is Consultant Anaesthetist at the Worcestershire


Acute Hospitals Trust (Alexandra Hospital, Redditch). He qualified from
Bristol University and trained in Cornwall, Cambridge and Cardiff. His
research and teaching interests are the role of regional anaesthesia in
surgery and acute pain medicine. Conflicts of interest: none declared. Figure 1 Tourniquet cuff, soft padding and Esmarch bandage.

ANAESTHESIA AND INTENSIVE CARE MEDICINE 10:1 14 2008 Elsevier Ltd. All rights reserved.
Orthopaedics

Contraindications to the use of a tourniquet

Absolute contraindications
Presence of arteriovenous fistula
Peripheral vascular disease
Active malignancy
History of vascular surgery in the involved limbs

Relative contraindication
Sickle cell disease
History of deep vein thrombosis, thromboembolic disease or
pulmonary embolus
Obese thigh
Figure 2 The Rhys-Davies exsanguinator. Multiply scarred legs
Diabetes
Rheumatoid arthritis
to occlude arterial flow. In contrast, morbidly obese and hyper-
Revision surgery
tensive patients would require much higher inflation pressures.
Recommendations and advice on the time limit for the use of
Table 1
the tourniquet varies from 30 minutes to 4 hours, with 2 hours
being the most widely accepted figure. The risk of muscular and
neurological damage increases with prolonged ischaemia. Unfor- moderate increase in central venous pressure and systolic blood
tunately, in complicated operations, the actual procedure may pressure.3 If bilateral simultaneous inflation of a lower limb
take longer than 2 hours. In such situations, ideally the tourni- tourniquet is carried out, the rise in central venous pressure may
quet should be deflated after 2 hours for 1520 minutes to allow be significant enough to cause volume overload or even cardiac
reperfusion of the muscle beneath and distal to the tourniquet arrest.
cuff. After this period of reperfusion, the tourniquet should be A sudden marked rise in heart rate and systolic and diastolic
used for only a further 60 minutes.2 blood pressures may occur after 3060 minutes. This phenome-
The contraindications to the use of a tourniquet are shown non in also known as tourniquet pain. Increasing the depth of an-
in Table 1. aesthesia and the use of opiates may not be able to reverse these
changes. It will improve only once the tourniquet is deflated.
The mechanism of tourniquet pain is poorly understood. It is
Effects of the tourniquet
more likely to occur with increasing age and increasing duration
The pathophysiological changes related to the use of the tourni- of surgery.
quet can be divided into two phases: during inflation and after
deflation. Temperature effect:
Increase in core body temperature due to reduction in surface
During inflation area for heat loss.
Cardiovascular effects: Decrease in temperature of the non-perfused limb. This may
Increase in circulating blood volume (up to 15%) and systemic provide some protective effect from ischaemic changes.
vascular resistance (up to 20%), leading to a transient slight-to-
Haematological effects:
Systemic hypercoagulability may occur in response to tourni-
quet and surgical pain. Platelet aggregation is promoted by cat-
echolamine release.
Pulmonary embolus has been associated with the use of a
tourniquet and there are case reports in which these incidents
have been fatal. It can occur during lower limb exsanguinations
and tourniquet inflation as well as during tourniquet deflation.
There is a 5.33-fold increased risk of large venous embolism as-
sociated with the use of a tourniquet in patients undergoing total
knee arthroplasty.4
The incidence of deep vein thrombosis associated with the
use of a tourniquet and total knee replacements is reported to be
between 50% and 84%.5

Metabolic effects:
After 30 minutes, anaerobic metabolism occurs. This leads to
Figure 3 Tourniquet inflation unit. mixed acidosis, hypoxaemia, hypercapnia, hyperkalaemia and

ANAESTHESIA AND INTENSIVE CARE MEDICINE 10:1 15 2008 Elsevier Ltd. All rights reserved.
Orthopaedics

formation of free radicals. These changes may be slight, but they by stiffness, pallor, weakness without paralysis and subjective
may be of consequence in those with limited cardiopulmonary re- numbness of the extremity without subjective anaesthesia.
serve.
Sickle cell disease
After deflation
Cardiovascular effect: The use of tourniquets in patients with sickle cell disease remains
During limb reperfusion, a transient decrease in systemic a subject of debate. Low oxygen concentration in the ischaemic
vascular resistance accompanied by a compensatory increase in limb, circulatory stasis and acidosis may precipitate a sickle cell
cardiac index may occur. This avoids a severe decrease in mean crisis. Traditionally, tourniquets were avoided in patients with
arterial pressure. sickle cell disease. However, Gyamfi et al.6 reported the success-
Reactive hyper-reperfusion and vasospasm. ful use of tourniquets in patients with sickle cell disease both
those who are heterozygous and those who are homozygous
Temperature effect: for the disease. Precautions must be taken to optimize condi-
As blood returns to cold ischaemic tissues, the core tempera- tions adequate hydration, warmth and blood volume as well as
ture may fall by up to 0.6C for each hour the tourniquet was maintaining oxygenation and mild hyperventilation in order to
used. reduce the risk of precipitating a sickle cell crisis.

Respiratory effects:
Machine check
There may be a transient increase in end-tidal carbon dioxide
tension by 0.12.4 kPa that peaks within 1 minute and returns to Equipment failure may contribute to the range of complications
baseline within 1013 minutes. that can result from the use of tourniquets. This may be from
There may be increased oxygen consumption. overpressurization or underpressurization, adding to the com-
plications related to the use of tourniquets. Therefore, all tourni-
Metabolic effects: quets should undergo regular maintenance checks to determine
Increase in lactate and Paco2. reliability (Table 3).
Decrease in pH.
Increase in plasma K+ level.
Ischaemic preconditioning
The complications associated with the use of tourniquets are
shown in Table 2. The concept of ischaemic preconditioning has been described
in the protection of cardiac muscles in cardiac surgery. Expos-
ing cardiac tissues to short periods of non-damaging ischaemic
Post-tourniquet syndrome
stress prior to the main ischaemic phase produces an adaptive
This is the most common morbidity from tourniquet use but is protective response. Ischaemic preconditioning can lead to the
the least appreciated. It is the result of muscle ischaemia, oedema production of protective substances such as adenosine, brady-
and microvascular congestion. The syndrome is characterized kinin and nitric oxide. Adenosine has been particularly identi-
fied as it prevents leucocyte sequestration, increases the activity
of antioxidant enzymes and preserves ATP levels.7 However,
although the protective role of ischaemic preconditioning has
Complications associated with the use of tourniquets
been studied in animal skeletal muscles, to date no human stud-
ies have been conducted. If it is proven that preconditioning
Local effects
can benefit human skeletal muscles, then the principle can be
Skin damage, bruising
applied to reduce the various complications involved with the
Neuralgia, paraesthesia
use of tourniquets.
Vascular damage: thrombosis to atherosclerotic vessels
Muscle contracture
Prolonged oedema and stiffness
Safety check
Bone and soft-tissue necrosis
Compartment syndrome
Visual inspection of the machine: rubber tubing, connections
Delayed wound healing
and cuff
Systemic effects Check accuracy of aneroid pressure gauges against a suitable
Pulmonary embolus calibration device
Pulmonary oedema When inflating the cuff, monitor the pressure gauge to ensure
Transient increase in blood pressure it achieves the pre-set inflation pressure
Tourniquet pain Monitor the pressure gauge intermittently throughout the
Post-tourniquet syndrome procedure to detect any changes and exclude any leaks
Tourniquet-induced rhabdomyolysis The anaesthetic record should include the position of the
Cardiac arrest cuff, pressure used and time

Table 2 Table 3

ANAESTHESIA AND INTENSIVE CARE MEDICINE 10:1 16 2008 Elsevier Ltd. All rights reserved.
Orthopaedics

References
Other techniques that have been used in place of 1 Odinsson A, Finsen V. Tourniquet use and its complications in
tourniquets or in combination with tourniquets Norway. J Bone Joint Surg Br 2006; 88-B: 10902.
2 Worland RL, Arredondo J, Lopez-Jimenez F, Jessup DE. Thigh pain
Hypotensive epidural anaesthesia in total knee replacements following tourniquet application in simultaneous bilateral total knee
without use of tourniquets arthroplasty. J Arthroplasty 1997; 12: 84852.
Adrenaline and local anaesthetic infiltration in total knee 3 Girardis M, Milesi S, Donato S, et al. The hemodynamic and
replacements metabolic effects of tourniquet application during knee surgery.
Controlled hypotension and minimal inflation pressure in Anesth Analg 2000; 91: 72731.
upper limb surgery 4 Parmet JL, Berman AT, Horrow JC, et al. Thromboembolism
coincident with tourniquet deflation during total knee arthroplasty.
Table 4 Lancet 1993; 341: 10578.
5 Stulberg BN, Insall JN, Williams GW, Ghelman B. Deep vein
thrombosis following total knee replacement: an analysis of six
Future of tourniquets in orthopaedic surgery
hundred and thirty eight arthroplasties. J Bone Joint Surg Am 1984;
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lutely indispensable in limb surgery. The concern is that, without 6 Gyamfi YA, Sankarankutty M, Marwa S. Use of a tourniquet in
using a tourniquet, blood loss would be significant. It will not patients with sickle cell disease. Can J Anaesth 1993; 40: 247.
only increase the need for transfusion but, as the surgical field 7 Bushell AJ, Klenerman L, Taylor S, et al. Ischaemic preconditioning of
would be greatly obscured, the operation would take longer than skeletal muscle. J Bone Joint Surg Br 2002; 84-B: 11848, 118993.
necessary. Nevertheless, this is not completely true in all limb 8 Wakankar HM, Nicholl JE, Koka R, DArcy JC. The tourniquet in total
surgeries. Wakankar et al.8 compared the outcome for total knee knee arthroplasty. J Bone Joint Surg Br 1999; 81-B: 303.
replacements with and without the use of tourniquets. The study
showed that there was no significant difference in the surgical
time, postoperative pain, need for analgesia, the volume col- Further reading
lected in the drains, postoperative swelling and the incidence of Anaesthesia UK. Procedures under tourniquet. Available from:
wound complications. If the outcome is similar, should surgeons www.frca.co.uk
be considering performing total knee replacements without tour- Kam PCA, Kavanaugh R, Yoong FFY. The arterial tourniquet:
niquets? It is indeed an issue of balancing the risks and benefits pathophysiological consequences and anaesthetic implications.
as well as the skills of the surgeon performing the operation. Anaesthesia 2001; 56: 53445.
Other techniques that have been used in place of tourniquets Klenerman L. The tourniquet in surgery. J Bone Joint Surg Br 1962;
are shown in Table 4. 44-B: 93743.

ANAESTHESIA AND INTENSIVE CARE MEDICINE 10:1 17 2008 Elsevier Ltd. All rights reserved.