AST Guidelines for Best Practices for Safe Use of Pneumatic Tourniquets

13 variable contour cuffs are designed to fit one specific limb shape. 67 Variable-fit contour cuffs incorporate fasteners with pivoting securing straps that allow the cuff to adapt to and match the proximal and distal circumference of limbs of different sizes and shapes while also allowing the cuff to be secured by dual independent fasteners for improved safety. 67 This design allows the cuff to fit uniformly onto extremities that have a wide range of shapes and circumference. 7. The tourniquet cuff should be applied according to manufacturer’s IFU, HDO policies and procedures, and standards that have been established through evidence-based research. A. The cuff should be positioned on the limb at the point of maximum circumference which provides maximum protection for the prevention of nerve and tissue injury. 10,11 For the arm the cuff should be placed in the middle between the shoulder and elbow; upper leg, the cuff should be placed on the proximal third of the thigh. The cuff should not be placed directly over a bony prominence such as the fibular head as this can place undue compression on a nerve(s). 10 Therefore, it is recommended that the edge of the cuff should be at least 2 – 4 centimeters distal to the fibular head to avoid injury to the common peroneal nerve and two centimeters proximal to the malleoli when the cuff is placed on the gastrocnemius muscle. 9,10 B. Tourniquets are usually positioned on upper arm for upper extremity surgery. However, studies have confirmed that surgeons have ordered the tourniquet to be positioned on the forearm and the literature supports the efficacy and safety of the practice. 68 During IVRA, forearm tourniquets have been shown to require a lower dose of local anesthetic. 69 Odinsson et. al (2006) agreed with the results of studies, however, they reported that surgeons had greater difficulty in performing the surgical procedure when the tourniquet is positioned more distally. 5 Therefore, as previously stated, the CST in the assistant circulator role should confirm with the surgeon and anesthesia provider the location/position of the tourniquet. C. Studies have proven that it is necessary to protect the skin underlying the cuff to prevent blisters and other more serious injuries to the skin and subcutaneous layer. 70 Additionally, studies have given evidence that limb protection sleeves provide the optimal protection of skin that underlies a tourniquet and the greatest protection is provided by using limb protection sleeves that are specifically matched to the limb size and cuff. 1) Olivecrona et al. (2006) conducted a randomized study of 92 patients undergoing a TKA who were divided into three groups – group one the extremity was protected by a two-layer elastic stockinette; group two the extremity was protected by cast padding; group three no protective material was used. The two groups with skin protection had fewer skin injuries and no patient with the stockinette protection experienced blisters, three blisters