Pneumatic tourniquets and other pneumatic compression devices
have applications in both surgical and nonsurgical settings.
With the exception of phlebotomy, the primary objective of
tourniquet use in surgical settings is the creation of a
bloodless operative field. In certain situations, tourniquets may
be useful for preventing the undesirable escape of vascular
fluids into body areas or to confine local anesthetics to an
extremity. Orthopaedics and plastic surgery are two specialties
that frequently utilize pneumatic tourniquets. Intravenous
regional anesthesia also requires the application of a
Orthopaedic uses for tourniquets include procedures undertaken
to diagnose and/or correct pathology of nerves, tendons, muscles,
joints, and bones of either upper or lower extremities. The
following are examples of orthopaedic procedures that utilize
- Reduction of certain fractures.
- Kirschner wire removal.
- Replacement or revision of the joints of the knee, wrist,
digits, hand, or elbow.
- Arthroscopy of the knee, elbow, wrist, hand, or digits.
- Bone grafts.
- Graft and repair of lacerated tendons.
- Subcutaneous fasciotomy.
- Repair of traumatic nerve damage.
- Carpal tunnel release.
- Traumatic or nontraumatic amputation.
- Correction of a hammer toe.
Plastic and Reconstructive Surgery
The goal of plastic and reconstructive surgery is to improve a
patient's self - image or level of function, thereby improving
the quality of life. Plastic surgery involves primarily the
subcutaneous tissue, up to and including the skin. Examples of
plastic repair procedures that might utilize a pneumatic
- Repair of burn contractures.
- Excision of lesions or tumors of the limbs.
- Split - thickness skin grafts on burned patients.
By using a tourniquet, larger burn areas may be excised and
grafted because of the bloodless field; a compression dressing is
applied before the tourniquet is released.
Reconstructive surgery is more extensive than plastic surgery
and may include:
- Amputations or replantations.
- Repair of bone, cartilage, tendons, nerves, or blood
- Resection of invasive tumors or lesions.
- Repair of congenital anomalies (e.g., syndactyly or
- Bilateral extremity surgery (e.g., foot - to - hand
transfer of digits, related to the amputation).
Intravenous Regional Anesthesia
Regional anesthesia is the interruption of sensory nervous
conduction in an isolated part of the body. Intravenous refers to
the route by which the anesthetic agent is introduced. In
intravenous regional anesthesia (IVRA), local anesthesia and a
bloodless operative field are produced by inflation of a dual -
bladder tourniquet proximal to the operative site, followed by
injection of a local anesthetic agent distal to the tourniquet.
When used appropriately, IVRA is a safe and effective
anesthesia technique for extremity surgery. The inflated
tourniquet cuff prevents the anesthetic agent from entering the
systemic circulation. However, if a bolus of local anesthetic and
metabolic waste products inadvertently enters the general
circulation after tourniquet release, particularly if
hypersensitivity to the anesthetic agent exists, there is a risk
of toxic reactions. Hence, IVRA is not used on trauma patients
whose physiological status may already be impaired or who
probably do not have a premorbid physical history available. IVRA
is best used for elective surgery patients who have had a
physical assessment and are able to tolerate the procedure.
Use in a Non - surgical
The nonsurgical use of pneumatic compression devices is
commonly directed toward manipulation of venous and arterial
circulation for the purpose of reducing primary or secondary
circulatory problems. In the rotating tourniquet approach,
tourniquets might be used to increase blood pressure in shock
patients; by limiting the area over which the circulating blood
must be distributed, the circulating volume is also raised,
resulting in increased blood pressure. Likewise, tourniquets
might be used to decrease blood pressure in patients whose
pressure is dangerously elevated; by isolating blood in the
extremities, the pressure in the nonisolated portions of the
circulatory system is decreased.
Some pneumatic compression devices do not look like
tourniquets. Two such devices are external pneumatic calf
compression boots and the MAST suit.
External Pneumatic Calf Compression
External pneumatic calf compression is a preventive therapy
for patients at risk for deep venous thrombosis. Knee - length
inflatable plastic boots with an alternating pressure cycle are
used to prevent sluggish venous blood flow.
Military Anti - Shock Trousers (MAST suits) can be used for
early treatment of hypovolemic shock in trauma victims. The
trouser pressure acts like an inflatable tourniquet to reverse
shock by redirecting blood from the legs and pelvis into central
circulation, thus raising the blood pressure and increasing
perfusion to vital body organs.
The final decision on whether or not to use a tourniquet rests
with the attending physician. A few possible contraindications
that the physician may take into consideration are:
- Open fractures of the leg.
- Post - traumatic lengthy hand reconstruction.
- Severe crushing injuries.
- Elbow surgery (with concomitant excess swelling).
- Severe hypertension
- Skin grafts (to help distinguish all bleeding points).
- Compromised circulation (e.g., peripheral artery
- Diabetes mellitus.
The presence of sickle cell disease is a relative
contraindication to tourniquet use. The use of a tourniquet has
been discouraged in patients who carry the sickle cell gene,
because tourniquet use may lead to circulatory stasis, acidosis,
and hypoxemia - the triad of clinical conditions that is known to
induce sickling. However, recent studies have suggested that the
use of a tourniquet in sickle cell patients may not be associated
with harmful effects, provided that optimum acid - base status
and oxygenation are maintained throughout anesthesia. Before
using a tourniquet on patients with sickle cell disease or trait,
it may be useful to test for hemoglobin type and level. If the
decision is made to apply a tourniquet, exsanguinate the limb
carefully and closely monitor the patient's PO2 and