Pediatric Tourniquets

Pediatric patients are different from adult patients in that they have smaller limb circumferences and limb lengths, different mass of muscle and other soft tissues, and different physiological characteristics such as blood pressures and heart rate. These characteristics can vary greatly within the pediatric population from neonatal to adolescent patients. To ensure safe and effective tourniquet use in this population, it is important to use personalized tourniquet cuffs and personalized tourniquet pressures.

Personalized tourniquet cuffs

Personalized tourniquet cuffs designed for pediatric patients are available in a variety of sizes, and can have a cylindrical or a variable-contour design. Multiple cuff widths and lengths are available for neonatal to adolescent patients. For adolescent patients with tapered limbs, variable-contour designs are also available. These cuffs are designed to better match patient limb size and shape and thus provide more efficient application of cuff pressure to the limb, allowing lower and safer tourniquet pressures and tourniquet pressure gradients to be applied.

Figure 1: (from top to bottom) 1.5”, 2.25”, 3.0” and 3.5” wide cylindrical pediatric cuffs.

Figure 2: (from top to bottom) 18”, 24”, and 34” long contour pediatric cuffs.

 

Matching limb protection sleeves are also available to improve safety by protecting the skin underneath the tourniquet cuffs during tourniquet use [1].

Figure 3: Matching limb protection sleeves for pediatric tourniquet cuffs.

Figure 2: Matching limb protection sleeves for pediatric tourniquet cuffs.

Personalized pediatric tourniquet pressures

Personalized tourniquet pressures reduce the risk of tourniquet-related injuries by enabling the use of lower tourniquet pressure levels and lower tourniquet cuff pressure gradients to the patient.  This is accomplished by measuring each patient’s Limb Occlusion Pressure (LOP) and setting a tourniquet pressure for that patient based on LOP. LOP can be defined as the minimum pressure required, at as specific time in a specific tourniquet cuff applied to a specific patient’s limb at a specific location, to stop the flow of arterial blood into the limb distal to the cuff [1]. Click here to learn more about Limb Occlusion Pressure (LOP).

The benefits of using personalized tourniquet pressures have been demonstrated in the pediatric population. Reily et. al. [2] conducted a study on pediatric patients aged 10 to 17 comparing the quality of surgical field using standard cuffs with a standard pressure of 300 mmHg to using wide contour cuffs with a pressure of LOP plus a safety margin of 50 or 100 mm Hg (depending on the level of the measured LOP). They found that the use of an automatic LOP measurement with the use of wide contour cuffs significantly reduced the mean tourniquet cuff pressure in pediatric patients from typical practice of 300 mmHg to 151 mmHg [2].

Need for a pediatric tourniquet guideline

In adults, optimal personalized tourniquet pressures for individual adults can now be determined easily based on Limb Occlusion Pressure (LOP).  Studies have shown that the use of an automated plethysmographic system that measures LOP and wide contoured cuff can significantly reduce tourniquet pressures in adults compared to standard pressures [3-5]. As such, guidelines for setting optimal tourniquet pressures for adults are now based on LOP [6].

However, at present, there is no guideline for determining and setting the optimal pediatric tourniquet pressure for individual patients [7]. Tourniquet cuff pressures in pediatric patients are commonly set at standard pressures based on experience, which can be hazardously high, or on rule-of-thumb formulas such as systolic blood pressure plus a standard margin or multiple, which does not correlate well to LOP and therefore can be unnecessarily high or low [4, 7].  In view of the widespread inconsistencies and lack of specific guidelines regarding the use of tourniquet pressure settings, pediatric patients are unnecessarily at risk of tourniquet-related complications [7]. A pediatric tourniquet guideline based on LOP and specialized pediatric cuffs should be formulated as quickly as possible to facilitate the safer use of pneumatic tourniquets in pediatric patients [7].

Sources

[1] Noordin S, McEwen JA, Kragh Jr CJ, Eisen A, Masri BA. Surgical tourniquets in orthopaedics. JBJS. 2009 Dec 1;91(12):2958-67.

[2] Reilly CW, McEwen JA, Leveille L, Perdios A, Mulpuri K. Minimizing tourniquet pressure in pediatric anterior cruciate ligament reconstructive surgery: a blinded, prospective randomized controlled trial. Journal of Pediatric Orthopaedics. 2009 Apr 1;29(3):275-80.

[3] Olivecrona C, Ponzer S, Hamberg P, Blomfeldt R. Lower tourniquet cuff pressure reduces postoperative wound complications after total knee arthroplasty. J Bone Joint Surg Am. 2012 Dec 19;94(24):2216-21.

[4] 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.

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

[6] Association of periOperative Registered Nurses (AORN):  Recommend practice for care of patients undergoing pneumatic tourniquet-assisted procedures, In Perioperative standards and recommended practices. Denver 2015.

[7] Misra A, Panda A, Sharma R. Tourniquet cuff pressures in pediatric patients: urgent need to device guidelines?. Pediatric Anesthesia. 2010 Apr 1;20(4):369-70.