AST Guidelines for Best Practices for Safe Use of Pneumatic Tourniquets

18 6) Clarke et al. (2001) studied thirty-one patients undergoing total knee arthroplasty to determine if the use of a tourniquet had any influence on postoperative wound hypoxia. The patients were divided into three groups of ten - one group had no tourniquet; second group had a tourniquet applied at 125 mm Hg above mean arterial blood pressure and the third group at 250 mm Hg also above mean arterial blood pressure. The authors concluded that the use of a high-pressure tourniquet increases the postoperative wound hypoxia and recommended that the lowest possible cuff pressure should be used to decrease complications. 79 E. A thigh tourniquet should not be inflated with the leg flexed followed by straightening the leg which fixates the sciatic nerve to the femur causing severe stretching of the nerve. 10. When the surgical team performs the time-out procedure this also serves in verifying that the tourniquet has been positioned on the correct extremity. 6,86 A. In 2010, the Pennsylvania Patient Safety Advisory reported two instances of the cuff being applied to the wrong extremity. 6 1) A patient was transported to the OR to undergo a right knee arthroscopy. A tourniquet was placed on the left leg and inflated by the RN who also performed the skin prep on the left leg. The surgeon performed the time-out confirming “right knee”. The tourniquet was immediately deflated and positioned on the right leg. 2) A tourniquet was positioned on the incorrect leg, even though the site for the incision had been marked on the correct leg. The surgical team did not perform the time-out procedure and the incision was made in the incorrect knee. When the surgeon noticed there was a lack of an incision mark the procedure was discontinued. 11. The cuff inflation time should be as minimal as possible. Extended application time can cause compartment syndrome , muscle ischemia, temporary or permanent limb paralysis or weakness due to nerve damage and tissue bruising. 6.50 Reports of temporary or persistent nerve damage are uncommon in the literature, but nerve injuries do occur particularly when the cuff pressure is high and/or after lengthy cuff inflation. 87 According to the literature, the risk of nerve injury is between 0.1 and 7.7%. 5,88,89 Horlocker et. al (2006) reported a strong connection between nerve injury and tourniquet time with a threefold increase in the risk of neurological complications for each thirty minutes of increase in cuff inflation. Additionally, the length of uninterrupted cuff inflation also increased the chances of neurological complications. 88 In most cases of nerve injury, the damage occurs to the section of nerve that is directly under or near the edges of the cuff. 65 Muscle ischemia generally occurs within one to three hours. 6 A rare, but serious complication of muscle ischemia is acute compartment syndrome. Extended tourniquet time causes a decrease in tissue pH, increases capillary permeability and prolongs clotting; in combination, these can lead to the development of acute compartment syndrome. 78 The first symptom the patient