Hazards of Narrow, Non-Pneumatic Tourniquets

Hazards, injuries and death associated with high tourniquet pressure levels and gradients

A recent report of a serious injury and a death associated with the use of an elastic, non-pneumatic tourniquet provides motivation for reviewing the underlying mechanism of tourniquet-related hazards and injuries, and for establishing tourniquet safety guidelines for minimizing the probability of such injuries. Elastic, non-pneumatic tourniquets have been associated with numerous reports of serious and irreversible injuries to nerves, muscles, blood vessels and soft tissues since the late 1800s (eg  [1-8]).    The level of pressure applied by elastic non-pneumatic cuffs, and the pressure gradients produced when used as tourniquets or exanguinators, is not known to, or controllable by, clinical users.  However, many published reports show that such injuries largely result from the application of unnecessarily high tourniquet pressure levels, well above the minimum pressure needed to stop arterial blood flow (eg [9-12]), and from the application of cuffs producing a high pressure gradient along a patient’s limb (eg [11, 13-15]).   The introduction of pneumatic tourniquets has allowed the tourniquet pressure level to be known, regulated, and maintained (eg [10, 14, 16, 17]).  Additionally, more recent improvements in the design of certain pneumatic tourniquet cuffs reduce the pressure gradient produced by the cuff on the underlying limb to be reduced, thus reducing another mechanism of injury.  (eg [13,18-22]).  It is now well established in the clinical literature, and by decreasing reports of the incidence and severity of pneumatic tourniquet injuries, that lower tourniquet pressure levels, and lower tourniquet pressure gradients beneath cuffs, are associated with lower probabilities of tourniquet-related injuries (eg [23]).  Elastic and other non-pneumatic tourniquets which do not provide for the monitoring, control and minimization of tourniquet pressure levels and pressure gradients are hazardous for surgical usage (eg [1]).   In contrast, new personalized tourniquet instruments allow the optimal “limb occlusion pressure” (LOP) to be identified for each patient, surgery, application (etc, from definition [14]).  Optimal tourniquet safety results when LOP is routinely used to establish lowest tourniquet pressures in conjunction with tourniquet cuffs that produce lowest cuff pressure gradients.   Published evidence and evolving clinical practice guidelines recognize that employing such low tourniquet pressure levels and cuffs producing low tourniquet pressure gradients lowers the probability of tourniquet-related hazards and injuries.

Sources

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[22] Younger AS, McEwen JA, Inkpen K. Wide contoured thigh cuffs and automated limb occlusion measurement allow lower tourniquet pressures. Clinical orthopaedics and related research. 2004 Nov 1;428:286-93.

[23] McEwen JA, Kelly DL, Jardanowski T, Inkpen K. Tourniquet safety in lower leg applications. Orthopaedic nursing. 2002 Sep 1;21(5):61-2.