AST Guidelines for Best Practices for Safe Use of Pneumatic Tourniquets

6 tourniquet can enhance fibrinolysis and prevent DVT in patients undergoing a TKA. 23 B. Arterial complications after tourniquet use are rare, but they could damage the intravascular endothelium. 9 Complications after TKA could lead to vascular reconstructive surgery or extremity amputation, especially if the patient suffers from PAD or underwent previous peripheral arterial reconstruction on the extremity in which the TKA was performed. 24 The CST should know when the tourniquet may be used when the patient suffers from arterial calcifications such as what occurs with diabetes mellitus. Risks could include failure to achieve a blood-less surgical site causing difficulties for the surgeon to view the site, systemic toxicity from anesthetic agents that were not blocked from escaping; and an increase in the risks of tourniquet-related complications because a higher cuff pressure is required to achieve arterial occlusion. 25 Jeyaseelan et al. (2007) reported a case of a patient with calcification of the femoral artery wall and the tourniquet failed. 26 Excessive hemorrhaging occurred at the surgical site due to the failure to achieve arterial occlusion, but venous occlusion was achieved. 26 C. Berman et al. (1998) studied the effect of tourniquet release on hemodynamic stability by imaging the right atrium and left ventricle of fifty-five patients during fifty-nine total knee arthroplasties. A tourniquet was used inflated to 350 mm Hg. The authors observed echogenic material travelling through the right atrium, left ventricle and pulmonary artery in all patients after the tourniquet was deflated, lasting three to fifteen minutes. 21 Blood aspirated from five of the ten femoral vein catheters displayed fresh venous thrombus, but the histological evaluation of the aspirates did not show evidence of particles of polymethyl methacrylate. 21 The authors concluded that the time period after deflation of the cuff is the critical period for hemodynamic instability and pulmonary embolism as a potential cause. 21 D. Hirota et al. (2001) conducted a study of thirty patients undergoing arthroscopic knee surgery and compared the use of a tourniquet to pulmonary emboli using transesophageal echocardiography (TEE) to obtain the results. The authors reported that TEE detected emboli in all patients and the peak level of emboli occurred forty to fifty seconds after the cuff was deflated, but no patients experienced symptoms of pulmonary embolism. 27 The authors concluded that acute pulmonary embolism can occur within one minute of cuff deflation and the peak amount of emboli is related to the time length of cuff inflation. 27 2. It is the decision of the surgeon and/or anesthesia provider to perform a procedure with the use of a tourniquet in the presence of a patient’s hematologic disorder. 28 In sickle cell disease, sickling can be triggered by acidosis, circulatory stasis and hypoxemia which occur during tourniquet use. 11 Al-Ghamdi (2004) reported the use of a pneumatic tourniquet performing a bilateral total knee replacement on a patient with sickle cell disease. He reported the patient was stable throughout the procedure and the results of six arterial blood samples taken during tourniquet