AST Guidelines for Best Practices for Safe Use of Pneumatic Tourniquets

20 13. If the location of the cuff needs to be adjusted or changed, the cuff and underlying padding should be completely removed, new padding placed and the cuffed reapplied. 52 The cuff should never be repositioned by pulling it up or down or rotating while on the extremity; this can cause a shearing injury to the skin. 41,52 14. During the procedure, the CST in the assistant circulator role should help in monitoring the cuff pressure display and time. The surgeon may request the tourniquet pressure to be adjusted during the procedure. If any changes occur to the cuff pressure, the CST should immediately report it to the surgeon since this can be an indicator of a cuff malfunction. 15. Tissue may be prone to drying due to the heat generated by the surgical lights or use of powered surgical instruments since the heat cannot be dispersed by extremities that are affected by a tourniquet. 78 To reduce the risk low-power surgical lights are recommended and the CST in the first scrub role should occasionally wet the tissues with irrigating fluid. Additionally, when the surgeon is using a powered surgical instrument such as a saw, the CST should apply drops of irrigating fluid to the area that is being cut to reduce the heat generated by the powered instrument. 16. The cuff(s) should be deflated at the end of the surgical procedure; the CST should confirm with the surgeon and/or anesthesia provider that the cuff(s) can be deflated. A. The CST should follow the manufacturer’s IFU for deflation. B. Upon deflation the cuff and cast padding should be immediately removed. 6,50,63 The deflated tourniquet and cast padding should not be left on the patient as he/she is transported to the PACU or another department. The tourniquet and padding could contribute to poor venous return causing venous pooling and thrombosis. C. Deflation of the cuff prior to or after wound closure is a subject that has not been definitively decided upon and studies have various conclusions. Therefore, it cannot be overemphasized for the CST to confirm with the surgeon if he/she wants the cuff deflated. 1) Cuff deflation results in an immediate 10% increase in extremity circumference due to vessels being refilled and hyperemia. 9 The results in an increase in compartmental pressure in the extremity. During the first postoperative day the initial extremity circumference can increase up to 50% and the swelling remain for up to six weeks. 92 The surgeon may request the cuff to be deflated prior to achieving hemostasis and performing wound closure to allow the extremity to be reperfused and swelling to take place before the sterile dressing and cast are applied. 9 This may assist in reducing the complications associated with compartment syndrome. 90 2) Ishii and Matsuda (2005) studied perioperative blood loss as related to cuff release before and after wound closure in fifty-five patients during 60 total knee arthroplasties. The cuff was deflated in thirty procedures of twenty-nine patients and after wound closure in thirty procedures of twenty-six patients. The authors