AST Guidelines for Best Practices for Safe Use of Pneumatic Tourniquets

15 If tie ribbons are used to achieve a secure application, the tie ribbons and the fastener straps should be pulled in opposite directions around the limb and then engage the fasteners. The tie ribbons and fastener straps should not be pulled away from the extremity as this may result in a loose cuff. 73 When the cuff is correctly positioned, the cuff tubing should be located on the lateral side of the extremity to avoid placing pressure on nerves or the tube kinking. 11,73 A securely applied cuff should allow the CST to easily slide two fingers under the proximal and distal cuff edges. 73 If only one finger can be slid under the cuff is too tight; if three fingers can be slid under the cuff is too loose. E. When applying the cuff to an obese patient, it is recommended that the assistant circulator CST apply distal traction to the skin and subcutaneous tissue of the extremity with the use of the hands to smooth out the skin and tissue while the cast padding and tourniquet cuff are applied. 25 F. When applying the cuff to a pediatric patient it is recommended that the most proximal portion of the limb is selected as the cuff location. 71 G. After the cuff is applied and the patient skin prep is being performed, the prep solution should not be allowed to pool around or under the cuff to prevent chemical burn to the patient’s skin. 6,10,64 A self-adhesive plastic drape should be positioned around the distal edge of the cuff while the skin prep is performed. 74,75 H. If a non-sterile cuff is used it should be covered to reduce gross contamination from the surgery site and also prevent a SSI. Typically, the edge of a sterile plastic U-drape is positioned around the distal edge of the cuff and unfolded towards the patient’s head to cover the cuff. 63,76 8. When possible, the extremity should be exsanguinated prior to inflating the cuff. The assistant circulator CST may be responsible for elevating the extremity to contribute to exsanguination of blood. An Esmarch bandage or Rhys-Davies exsanguinator are commonly used to obtain adequate exsanguination in creating a bloodless field. 9 Exsanguination increases the risk of forcing infectious fluid, thrombi or tumor cells into the systemic circulation of the patient. 9 The thrombi can possibly result in causing fatal pulmonary emboli. 77 Exsanguination with an Esmarch bandage or other type of elastic bandage is not recommended in patients with a traumatic injury or a patient who has recently been in a cast to prevent dislodging thrombi. 78 The CST may be responsible for continuing to elevate the extremity while the anesthesia provider applies an Esmarch bandage. If the Esmarch bandage is not used to exsanguinate an extremity, to attain maximum exsanguination, the arm should be elevated at 90° and the leg at 45° each for five minutes. 9 9. The lowest possible cuff pressure should be established to achieve vascular occlusion. 10,25 Nerve and muscle injuries can result from excessive or uneven distribution of pressure under the cuff. 9,50 Nerve injuries can range from temporary minor paresthesia to paralysis; however, the incidence of permanent injury is very low estimated as 0.032% of surgical procedures that involve the use