AST Guidelines for Best Practices for Safe Use of Pneumatic Tourniquets
19 experiences is pain that continues to increase and is not relieved by pain medications. 90 Other symptoms that eventually develop are absent pulses, muscle weakness, paresthesia and tense skin; if left untreated irreversible paralysis can occur. 90 The only treatment is a fasciotomy surgical procedure. 90 Preventative measures include during the preoperative assessment of the patient confirm if the patient and/or family has a history of compartment syndrome symptoms; as previously stated, cuff inflation time should be as minimal as possible; and not applying a cast prior to cuff deflation. 90 There is no established rule for how long a tourniquet may remain safely inflated and the length of time may vary due to several factors including age of patient, health status including pre-existing conditions and vascularity of the extremity. 6.10.24 The following are general recommendations regarding cuff inflation. A. Tourniquet inflation should be performed under the direction of the surgeon who coordinates with the anesthesia provider for the purposes of patient management during the rapid physiological changes that are caused prior to and after limb exsanguination and cuff inflation. 11 B. The cuff should be rapidly inflated by the tourniquet machine; rapid inflation simultaneously compresses the arteries and veins preventing the veins from filling before compression of the arteries. 11 C. For adults, sixty minutes is the recommended inflation time for upper extremities and ninety minutes for lower extremities, and sixty minutes for both upper and lower extremities for the pediatric patient. 10,91 Tissue edema begins to develop once the tourniquet time exceeds sixty minutes. 10 The surgeon should be notified when the cuff has been inflated for a minimum of two hours. 11 When the recommended time limit has been reached, the surgeon may deflate the cuff for ten to fifteen minutes to allow for re-perfusion of the extremity and then the cuff is reinflated for another time period, e.g., sixty or ninety minutes. 11 For pediatric patients, an inflation time of less than seventy-five minutes has been recommended for the lower extremities. 10 The surgeon may want to re-exsanguinate the limb prior to reinflation to avoid venous thrombosis; the CST in the first scrub role should have a sterile Esmarch bandage ready to use on the sterile field or available in the OR. 1) Odinsson et al. (2006) reported that of the 265 surgeons that responded to the survey, eighty percent deflated the tourniquet during surgery for fifteen minutes if the surgical procedure lasted >two hours and thirteen percent did not deflate the tourniquet if the procedure lasted >two hours. 5 The authors concluded that surgeons should not exceed two hours of ischemia time to avoid the occurrence of permanent nerve damage and to reduce the patient’s pain from the tourniquet. 5,25 12. To ensure patient safety, the tourniquet system alarm should not be turned off or turned down so far that the surgical team cannot heart it. The alarm can be activated by cuff leaks, excessively low or high cuff pressures, kinks in tubing, mechanical failure, and prolonged tourniquet time. 6,25
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