Tourniquet Cuff Selection

In the United States, pneumatic tourniquet cuffs are regulated as Class I medical device by the Food and Drug Administration (FDA). Risks of injuries to patients and legal liability for users arise from use of a pneumatic tourniquet cuff not meeting the FDA requirements. Therefore, it is important to only use pneumatic tourniquet cuffs that meet all relevant FDA requirements. Click here to learn more about FDA requirements for pneumatic tourniquets in the United States.

If available, the perioperative staff should select a personalized tourniquet cuff with a matching limb protection sleeve. Personalized 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 to be used [1, 2]. Matching limb protection sleeves improve safety by protecting the skin underlying tourniquet cuffs during tourniquet use [1, 2]. Click here to learn more about personalized tourniquet cuffs and matching limb protection sleeves.

The following factors should be considered when determining the appropriate cuff based on the tourniquet instrument used, and surgical and patient limb considerations.

Tourniquet Instrument

Select a single-port tourniquet cuff if a single-port tourniquet instrument is used. Select a dual-port tourniquet cuff if a dual-port tourniquet instrument is used. Click here to learn more about single-port and dual-port cuffs.

Surgical Procedure

Select a dual-bladder, IVRA tourniquet cuff or two single-bladder tourniquet cuffs if the surgical procedure requires intravenous regional anesthesia, otherwise select a single-bladder cuff. Click here to learn more about IVRA procedures.

Select a sterile, disposable cuff for situations that require placement of a sterile tourniquet near the operative site, or for use in contaminated surgical cases.

Select a reusable cuff if there are no surgical restrictions. Reusable cuffs are not designed to be sterilized and must be used with sufficient sterile draping to isolate the cuff from the sterile field.

Limb shape and size

Whenever possible, select a personalized tourniquet cuff with matching limb protection sleeves. Personalized cuffs and sleeves are designed to better match a range of patient limb sizes and shapes and thus provide more efficient application of cuff pressure to the limb, allowing lower and safer tourniquet pressures levels and lower and safer pressure gradients.

Limb shape

For a cylindrically shaped limb, select a cylindrical cuff. For a tapered limb, select a variable-contour cuff if available.

Limb size

For infants and children, select an appropriately sized cuff from a pediatric cuff line. For large patients, select an appropriately sized cuff from a bariatric cuff line. For other patients, select an appropriately sized cuff from an adult cuff line. Click here to learn more about tourniquet cuff technology.

Figure 1: Cuff selection based on limb shape and sizes. Click here for a printable pdf version. © JA McEwen tourniquets.org.

Cuff width

It has been shown that a cuff with a wider bladder occludes blood flow at a lower pressure level than a cuff with a narrower bladder [3, 4]. This is related to more efficient pressure transmission to the deeper tissues with a wider cuff. Lower pressures and associated lower cuff pressure gradients reduce the risk of pressure-related injuries to the patient [1, 5]. Therefore, perioperative staff should select a tourniquet cuff that is as wide as possible without inhibiting the access of the surgical site. Click here to find out why lower tourniquet pressures are safer for patients. Extra care must be taken with unusually small adult patients and pediatric patients to ensure that the correct cuff width is used and that the cuff edges do not lie close to the joints of the limb to reduce the risk of nerve injury.

Cuff length

The length of the cuff is dependent on the patient’s limb size. The perioperative staff should select the shortest length of tourniquet cuff that allows the inflatable portion of the cuff to completely encircle the limb at the location, and that allows sufficient overlap to fully engage the fasteners. Selecting a cuff that is too long (resulting in excessive overlap may be difficult to apply snugly and may be less stable (causing the cuff to move distally or shift on the patient’s limb). Both problems may prevent occlusion of arterial blood flow at normal cuff pressures, lead to loss of occlusion during the procedure, and lead to skin injury. Selecting a cuff that is too short (resulting in too little overlap of the inflatable bladder portion of the cuff) produces uneven distribution of pressure and can lead to loosening of the cuff or an inability to sustain occlusion. Perioperative staff should measure the operative limb and consult the manufacturer’s guideline to determine the appropriate cuff length.

Other considerations

The perioperative staff should be aware of additional tourniquet cuff features that can make the tourniquet cuff application and removal easier, and improve patient safety. Some advanced features include:

Tourniquet cuffs with pivoting fasteners

Variable-contour cuffs contain pivoting fasteners that allow the cuff to adjust to a variety of patient limb shapes and sizes, and thus be personalized for each individual patient. These cuffs provide a better fit around a tapered limb than cylindrical and fixed-contour cuffs, resulting in reduction in tourniquet pressures and thereby improving patient safety.

Tourniquet cuffs with stabilizer consisting of a releasable application handle

In some tourniquet cuffs a releasable application handle makes cuff application more consistent, the cuff removal faster, and helps maintain the cuff in a stable position on the limb. Click here to see a comparison between the two types of stabilizers’ and cuff application.

Tourniquet cuffs with offset port connector(s) design

Offset port connectors (Figure 2) included in some types of tourniquet cuffs allow 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 connections. Some cuffs with an offset port design have extended port tubes to ensure the pneumatic tubing are clear of the surgical site.

Perioperative staff should refer to the manufacturer’s guideline to ensure all requirements are met by the selected cuff.

Figure 2: Cuff designs with offset ports (top and middle), and cuff design without offset ports (bottom).

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] Jeyasurya J, Jameson M, Glinz K, Sadr Hooman, Day B, Masri B, McEwen J. Current concepts in tourniquets. CMBES Proceedings. 2014 May.

[3] Graham B, Breault MJ, Mcewen JA, Mcgraw RW. Occlusion of arterial flow in the extremities at subsystolic pressures through the use of wide tourniquet cuffs. Clinical orthopaedics and related research. 1993 Jan 1;286:257-61.

[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] 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.

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