Tourniquet Application

About Proper Tourniquet Application

After the patient is brought into the OR, apply the tourniquet at the desired location on the limb, pressurized within the appropriate pressure range for an appropriate period of time. The following sections provide a general sequence of events for preparation, cuff application and setting up the tourniquet instrument (Note: This sequence may vary based on the cuff selected (reusable/sterile) and/or each institution’s internal guideline.)

Preparation

  1. If the patient is to be awake during the procedure, explain any tourniquet alarm sounds that may be heard during the procedure. This is particularly applicable for microprocessor-controlled tourniquet systems.
  2. If general anesthesia is planned, record the patient’s blood pressure prior to induction.
  3. The cuff location should be selected such that as much tissue as possible lies between the cuff and any nerves or vascular structures that could be subject to damage:
    • Place an arm cuff midway between the shoulder and elbow.
    • Place a thigh cuff on the proximal third of the thigh.
    • Position a lower leg cuff so the distal edge of the cuff is at least 2 inches (5 cm) proximal to the ankle malleoli and the proximal edge is at least 2 inches distal to the head of the fibula. Normally the proximal edge of the cuff will lie in the mid-range of the calf near the point of maximum calf circumference.
  4. Apply the appropriate limb protection material to the limb in the area selected for the cuff, unless the selected cuff is specifically recommended to be used without limb protection. Ensure the limb protection material (if used) and the skin under the cuff are wrinkle-free.
    • High pressures, high pressure gradients and shear forces applied to skin and soft tissues underlying a tourniquet cuff can cause injuries to the skin and soft tissues. To reduce the nature and extent of these injuries, studies have been published that evaluate the relative effectiveness of no protective material, underlying padding, underlying stockinette, and underlying limb protection sleeves that are matched to specific limb sizes and cuff sizes [1-3]. Study results provide evidence that limb protection sleeves improve safety by protecting the skin underlying tourniquet cuffs during tourniquet use, and further provide evidence that greatest safety is achieved through the use of limb protection sleeves specifically matched to the limb size and cuff size.
  5. Exsanguinate the limb. Careful and complete exsanguination reportedly prolongs pain-free tourniquet time; however, partial exsanguination may be desirable in certain cases where residual blood flow will aid in visualization and identification of vascular structures. Elevate the limb for a minimum of 2 minutes and, if the surgeon indicates, wrap an elastic bandage around the limb beginning at the distal end and ending about 1 inch (2.5 cm) distal to the cuff to prevent the cuff from slipping distally during exsanguination. Do not use an elastic bandage for exsanguination in cases where bacteria, exotoxins, or malignant cells could be spread to the general circulation, or where it could dislodge thrombi that may have formed in the vessels. In these cases, exsanguination may be accomplished by elevating the limb for 3-5 minutes.

Tourniquet cuff application

Tourniquet cuff with tie ribbons stabilizer

If a tourniquet cuff with tie ribbon stabilizer is used (see Figure 1):

tourniquet application

Figure 1: Cylindrical cuff with a tie ribbon stabilizer. Note the direction of strap and tie ribbons during application is around the limb.

  1. Hold the tie ribbons in one hand and the fastening strap in the other hand.
  2. Tension the cuff for a snug application by pulling the tie ribbons and the fastener straps in opposite directions around the limb, then engaging the fasteners (see Figure 1). Pulling away from the limb may result in a loosely applied cuff.
  3. When properly applied the port connector should end up on or near the lateral aspect of the extremity to avoid pressure on the nerves, kinking of the tubing, and pneumatic occlusion at the port connector.
  4. If the cuff port connector is not on or near the lateral aspect of the extremity, do not shift or move the cuff after it has been applied, as this may cause shearing of the underlying tissues and cause subsequent injury. Correct procedure is to disengage the fasteners and reapply the cuff.
  5. To help prevent antimicrobial skin prep solutions and other fluids from running under the cuff, cover the tourniquet cuff with adhesive drape.

Figure 2: Proper, snug application of a tourniquet cuff.

Tourniquet cuff with releasable application handle stabilizer

If a tourniquet cuff with releasable application handle and offset port design is used (See Figure 3)

  1. Grasp the application handle and position the port connector in the desired position on the limb.
    1. The offset port design allows the ports to be positioned in the desired location prior to securing the cuff around the limb. By positioning the cuff port connectors on or near the lateral aspect of the extremity, the perioperative staff can avoid pressure on the nerves, kinking of the tubing, and pneumatic occlusion at the port connector.
  2. Slide the fastening strap under the application handle.
  3. Tension the cuff and secure the strap for a snug application of the cuff on the limb (see Figure 2 and 3).

Figure 3: Tourniquet Cuff with a Releasable Application Handle Stabilizer and Offset Ports.

  1. To help prevent antimicrobial skin prep solutions and other fluids from running under the cuff, cover the tourniquet cuff with adhesive drape.

Setting up the tourniquet instrument

  1. Connect the cuff to the tourniquet instrument using the hose assembly. For procedures that require a dual-bladder cuff or two single-bladder cuffs, use two hose assemblies and ensure all OR personnel who may be operating the tourniquet clearly understand which bladder or cuff is connected to the first and second cuff channels on the tourniquet instrument.
  2. If your tourniquet system has an elapsed time display and alarm function, set the elapsed time to zero and set the time alarm to the desired period, normally 60 to 90 minutes depending on the surgical procedure.
  3. If possible, measure the Limb Occlusion Pressure (LOP) using the applied tourniquet cuff. LOP can be measured through the use of Doppler ultrasound probe, a photoplethysmography, or the use of advanced dual-purpose cuff and personalized instruments. Click here to learn more about how the use of LOP increases patient safety and how LOP can be measured. The physician may use the LOP plus a safety margin for the desired cuff pressure.
  4. Rapidly inflate the tourniquet to the set pressure specified by the physician. (Rapid inflation of the cuff occludes arteries and veins simultaneously, avoiding return of blood into the limb, thus preventing the filling of superficial veins before occlusion of the arterial blood flow.) Ensure that the pressure display is clearly visible. IMPORTANT: Record the time of inflation, the tourniquet pressure, and the patient’s blood pressure at time of inflation.
  5. If used, remove the bandage used for exsanguination.
  6. Before the surgical procedure begins, verify full occlusion by arterial palpation and/or auscultation. This ensures that the pressure setting and cuff application for the patient is correct and successful.
  7. Prepare the skin according to standard procedure and drape the operative site in preparation for the incision.
  8. In the event that arterial blood flow is observed past the tourniquet cuff, the surgeon may request that tourniquet pressure be increased.

Sources

[1] McEwen JA, Inkpen K. Tourniquet safety: preventing skin injuries. Surgical Technologist. 2002;34(8):6-15.

[2] Tredwell SJ, Wilmink M, Inkpen K, McEwen JA. Pediatric tourniquets: analysis of cuff and limb interface, current practice, and guidelines for use. Journal of Pediatric Orthopaedics. 2001 Sep 1;21(5):671-6.

[3] Olivecrona C, Tidermark J, Hamberg P, Ponzer S, Cederfjäll C. Skin protection underneath the pneumatic tourniquet during total knee arthroplasty: a randomized controlled trial of 92 patients. Acta orthopaedica. 2006 Jan 1;77(3):519-23.