AST Guidelines for Best Practices for Safe Use of Pneumatic Tourniquets

11 A. In 1982, ECRI reported an adverse event whereas oxygen that leaked from a tourniquet connector was trapped under the surgical drape; the drape became ignited by a disconnected fiberoptic cable and the patient suffered severe burns to the legs when a flash fire occurred. 60 5. The patient’s general health and skin condition should be assessed prior to tourniquet placement. Accurate patient assessment prior to surgery assists in making decisions that individualize the use of the tourniquet, e.g. size of tourniquet; contour or straight tourniquet required; and identifying patient complications that could occur during inflation and deflation of the cuff. A. The integrity and quality of the patient’s skin should be assessed prior to tourniquet placement and documented in the OR record. Skin injuries are uncommon but can occur due to excessive tourniquet time and poorly positioned cuffs that result in cutaneous abrasions, blisters and possibly pressure necrosis. 11 Patients at highest risk for skin injuries are elderly, obese, and pediatric patients as well as those with peripheral vascular disease. 11 B. A baseline measure of the peripheral pulses should be recorded to evaluate the risk of using a tourniquet. 61 Other circulatory indicators to take under consideration include capillary filling time and the presence of varicose veins. 61 C. CSTs should be knowledgeable of the contraindications for tourniquet use. However, it must be emphasized that the final decision of whether or not to use a tourniquet is that of the surgeon. 1) Exsanguination and the use of a tourniquet is usually avoided when the patient has an open fracture or other extremity injuries because it is necessary for the surgeon to be able to assess the devascularized area of the injury if debridement is necessary. 62 Use of the tourniquet could cause the surgeon to underestimate the extent of the zone of the injury. 62 Additionally, the anoxia produced by the tourniquet interferes with the surgeon’s ability to assess the viability of the muscle and increase the pre-existing anoxia associated with the injury. 62 In the instance of a closed fracture, exsanguination may not be able to be accomplished with the use of an Esmarch bandage; use of the bandage could further injure the patient. Elevation of the extremity may be the only route of accomplishing some degree of exsanguination. However, elevation also may not be able to be performed due to the severity of the closed fracture and the possibility of causing further neurovascular damage. 2) Exsanguination of the extremity with an Esmarch bandage prior to inflating the cuff is not recommended in the presence of infection, malignant tumor or thrombin in the extremity. 11 Using the bandage could push the infectious fluid, malignant cells or thrombi into the patient’s systemic circulation. 11