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Procedures under tourniquet
Orthopaedics
Procedures under tourniquet
tourniquet for use in limb surgery in place of rubber tourniquets. One hundred years on, it is still considered an essential tool in orthopaedic and plastic surgery. However, the use of the tourniquet is not without its risks and complications.
Livia Malanjum Barrie Fischer
Applying the tourniquet The diameter of the cuff used should be wider than half the diameter of the limb. It should be applied furthest away from the surgical site and preferably over an area with the most fat and muscle padding. The edges of the cuff must overlap to provide even pressure all around. The use of soft-cast padding underneath the cuff is advised. When using padding, there should be no creases or ridges as this is associated with significant skin irritation and blistering. When the skin is prepared prior to surgery, the organic iodine or alcohol solution can become soaked up by the padding and can cause chemical burns and blistering. To prevent this from happening, an adhesive, transparent surgical barrier can be used to isolate the tourniquet and its padding (Figure 1).
Abstract The pneumatic tourniquet is used widely in operations involving the limbs. However, despite its everyday use, a clinician’s knowledge of this instrument is often limited to the pressure and time limit. Although the principle behind the tourniquet is simple, anaesthetists and surgeons should appreciate the effects of the tourniquet as well as the various complications associated with its use. Safe use of the tourniquet starts from the point of setting up the pneumatic machine. It is important to choose the appropriate pressure. Overinflation can lead to nerve damage. On the other hand, underinflation will lead to a bloody surgical field and unnecessary blood loss. The tourniquet should be applied with care to avoid local damage to the skin. Pathophysiological effects of the tourniquet can vary from a simple tachycardia and increase in systolic pressure to fatal events such as large pulmonary embolus and cardiac arrest. Prolonged use of the tourniquet can lead to a phenomenon known as tourniquet pain. Other complications associated with the use of the tourniquet include nerve and vascular damage and muscle contracture. In the past, the use of the tourniquet was avoided in patients with sickle cell disease for fear of triggering a sickle cell crisis. However, it has been shown that by creating the optimum conditions – sufficient hydration, good oxygenation, warmth and mild hyperventilation – this group of patients should not be deprived of the choice of having their limb operations with a tourniquet.
Exsanguinating the limb There are two ways to exsanguinate the limb: 1 Passive method: achieved by elevating the arm or leg for 5 minutes at 90° and 45°, respectively, without mechanical compression. 2 Active method: by using the Esmarch bandage or a RhysDavies exsanguinator (Figure 2). This method is contraindicated in patients with infection, tumour or painful fractures.
Inflation pressures and time limit To achieve complete arterial occlusion, inflation pressures should be related to a patient’s systolic blood pressure (Figure 3): • Inflation pressures for lower limbs: at least 100 mm Hg above systolic arterial blood pressure (usually 300–500 mm Hg). • Inflation pressures for upper limbs: at least 50 mm Hg above systolic arterial blood pressure (usually 250–300 mm Hg). In order to minimize the risk of nerve damage, the lowest inflation pressure should be used.1 In normotensive patients with compliant vessels, lower inflation pressures would be sufficient
Keywords machine check; nerve damage; pathophysiology; pneumatic tourniquet; pulmonary embolus; sickle cell disease
The use of a tourniquet in operative procedures dates back to Roman times. However, it was specifically used in limb amputations. In 1864, Lister became the first surgeon to apply the concept of the ‘bloodless surgical field’ in operations other than amputations. The tourniquet is applied around the upper and lower extremities to reduce blood loss and create good operating conditions. In 1904, Harvey Cushing introduced the pneumatic
Livia Malanjum, MBChB, is a Specialty Registrar in Anaesthesia and Critical Care Medicine and is currently working at Leicester General Hospital, Leicester, UK. She qualified from the University of Bristol. Conflicts of interest: none declared. Barrie Fischer, FRCA, is Consultant Anaesthetist at the Worcestershire Acute Hospitals Trust (Alexandra Hospital, Redditch). He qualified from Bristol University and trained in Cornwall, Cambridge and Cardiff. His research and teaching interests are the role of regional anaesthesia in surgery and acute pain medicine. Conflicts of interest: none declared.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 10:1
Figure 1 Tourniquet cuff, soft padding and Esmarch bandage.
14
© 2008 Elsevier Ltd. All rights reserved.
Orthopaedics
Contraindications to the use of a tourniquet Absolute contraindications • Presence of arteriovenous fistula • Peripheral vascular disease • Active malignancy • History of vascular surgery in the involved limbs Relative contraindication • Sickle cell disease • History of deep vein thrombosis, thromboembolic disease or pulmonary embolus • Obese thigh • Multiply scarred legs • Diabetes • Rheumatoid arthritis • Revision surgery
Figure 2 The Rhys-Davies exsanguinator.
to occlude arterial flow. In contrast, morbidly obese and hypertensive patients would require much higher inflation pressures. Recommendations and advice on the time limit for the use of the tourniquet varies from 30 minutes to 4 hours, with 2 hours being the most widely accepted figure. The risk of muscular and neurological damage increases with prolonged ischaemia. Unfortunately, in complicated operations, the actual procedure may take longer than 2 hours. In such situations, ideally the tourniquet should be deflated after 2 hours for 15–20 minutes to allow reperfusion of the muscle beneath and distal to the tourniquet cuff. After this period of reperfusion, the tourniquet should be used for only a further 60 minutes.2 The contraindications to the use of a tourniquet are shown in Table 1.
Table 1
moderate increase in central venous pressure and systolic blood pressure.3 If bilateral simultaneous inflation of a lower limb tourniquet is carried out, the rise in central venous pressure may be significant enough to cause volume overload or even cardiac arrest. • A sudden marked rise in heart rate and systolic and diastolic blood pressures may occur after 30–60 minutes. This phenomenon in also known as tourniquet pain. Increasing the depth of anaesthesia and the use of opiates may not be able to reverse these changes. It will improve only once the tourniquet is deflated. The mechanism of tourniquet pain is poorly understood. It is more likely to occur with increasing age and increasing duration of surgery.
Effects of the tourniquet The pathophysiological changes related to the use of the tourniquet can be divided into two phases: during inflation and after deflation.
Temperature effect: • Increase in core body temperature due to reduction in surface area for heat loss. • Decrease in temperature of the non-perfused limb. This may provide some protective effect from ischaemic changes.
During inflation Cardiovascular effects: • Increase in circulating blood volume (up to 15%) and systemic vascular resistance (up to 20%), leading to a transient slight-to-
Haematological effects: • Systemic hypercoagulability may occur in response to tourniquet and surgical pain. Platelet aggregation is promoted by catecholamine release. • Pulmonary embolus has been associated with the use of a tourniquet and there are case reports in which these incidents have been fatal. It can occur during lower limb exsanguinations and tourniquet inflation as well as during tourniquet deflation. There is a 5.33-fold increased risk of large venous embolism associated with the use of a tourniquet in patients undergoing total knee arthroplasty.4 • The incidence of deep vein thrombosis associated with the use of a tourniquet and total knee replacements is reported to be between 50% and 84%.5 Metabolic effects: • After 30 minutes, anaerobic metabolism occurs. This leads to mixed acidosis, hypoxaemia, hypercapnia, hyperkalaemia and
Figure 3 Tourniquet inflation unit.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 10:1
15
© 2008 Elsevier Ltd. All rights reserved.
Orthopaedics
by stiffness, pallor, weakness without paralysis and subjective numbness of the extremity without subjective anaesthesia.
formation of free radicals. These changes may be slight, but they may be of consequence in those with limited cardiopulmonary reserve.
Sickle cell disease
After deflation Cardiovascular effect: • During limb reperfusion, a transient decrease in systemic vascular resistance accompanied by a compensatory increase in cardiac index may occur. This avoids a severe decrease in mean arterial pressure. • Reactive hyper-reperfusion and vasospasm.
The use of tourniquets in patients with sickle cell disease remains a subject of debate. Low oxygen concentration in the ischaemic limb, circulatory stasis and acidosis may precipitate a sickle cell crisis. Traditionally, tourniquets were avoided in patients with sickle cell disease. However, Gyamfi et al.6 reported the successful use of tourniquets in patients with sickle cell disease – both those who are heterozygous and those who are homozygous for the disease. Precautions must be taken to optimize conditions – adequate hydration, warmth and blood volume as well as maintaining oxygenation and mild hyperventilation – in order to reduce the risk of precipitating a sickle cell crisis.
Temperature effect: • As blood returns to cold ischaemic tissues, the core temperature may fall by up to 0.6°C for each hour the tourniquet was used. Respiratory effects: • There may be a transient increase in end-tidal carbon dioxide tension by 0.1–2.4 kPa that peaks within 1 minute and returns to baseline within 10–13 minutes. • There may be increased oxygen consumption.
Machine check Equipment failure may contribute to the range of complications that can result from the use of tourniquets. This may be from overpressurization or underpressurization, adding to the complications related to the use of tourniquets. Therefore, all tourniquets should undergo regular maintenance checks to determine reliability (Table 3).
Metabolic effects: • Increase in lactate and Paco2. • Decrease in pH. • Increase in plasma K+ level. The complications associated with the use of tourniquets are shown in Table 2.
Ischaemic preconditioning The concept of ‘ischaemic preconditioning’ has been described in the protection of cardiac muscles in cardiac surgery. Exposing cardiac tissues to short periods of non-damaging ischaemic stress prior to the main ischaemic phase produces an adaptive protective response. Ischaemic preconditioning can lead to the production of protective substances such as adenosine, bradykinin and nitric oxide. Adenosine has been particularly identified as it prevents leucocyte sequestration, increases the activity of antioxidant enzymes and preserves ATP levels.7 However, although the protective role of ischaemic preconditioning has been studied in animal skeletal muscles, to date no human studies have been conducted. If it is proven that preconditioning can benefit human skeletal muscles, then the principle can be applied to reduce the various complications involved with the use of tourniquets.
Post-tourniquet syndrome This is the most common morbidity from tourniquet use but is the least appreciated. It is the result of muscle ischaemia, oedema and microvascular congestion. The syndrome is characterized
Complications associated with the use of tourniquets Local effects • Skin damage, bruising • Neuralgia, paraesthesia • Vascular damage: thrombosis to atherosclerotic vessels • Muscle contracture • Prolonged oedema and stiffness • Bone and soft-tissue necrosis • Compartment syndrome • Delayed wound healing
Safety check • Visual inspection of the machine: rubber tubing, connections and cuff • Check accuracy of aneroid pressure gauges against a suitable calibration device • When inflating the cuff, monitor the pressure gauge to ensure it achieves the pre-set inflation pressure • Monitor the pressure gauge intermittently throughout the procedure to detect any changes and exclude any leaks • The anaesthetic record should include the position of the cuff, pressure used and time
Systemic effects • Pulmonary embolus • Pulmonary oedema • Transient increase in blood pressure • Tourniquet pain • Post-tourniquet syndrome • Tourniquet-induced rhabdomyolysis • Cardiac arrest
Table 3
Table 2
ANAESTHESIA AND INTENSIVE CARE MEDICINE 10:1
16
© 2008 Elsevier Ltd. All rights reserved.
Orthopaedics
References 1 Odinsson A, Finsen V. Tourniquet use and its complications in Norway. J Bone Joint Surg Br 2006; 88-B: 1090–2. 2 Worland RL, Arredondo J, Lopez-Jimenez F, Jessup DE. Thigh pain following tourniquet application in simultaneous bilateral total knee arthroplasty. J Arthroplasty 1997; 12: 848–52. 3 Girardis M, Milesi S, Donato S, et al. The hemodynamic and metabolic effects of tourniquet application during knee surgery. Anesth Analg 2000; 91: 727–31. 4 Parmet JL, Berman AT, Horrow JC, et al. Thromboembolism coincident with tourniquet deflation during total knee arthroplasty. Lancet 1993; 341: 1057–8. 5 Stulberg BN, Insall JN, Williams GW, Ghelman B. Deep vein thrombosis following total knee replacement: an analysis of six hundred and thirty eight arthroplasties. J Bone Joint Surg Am 1984; 66-A: 194–201. 6 Gyamfi YA, Sankarankutty M, Marwa S. Use of a tourniquet in patients with sickle cell disease. Can J Anaesth 1993; 40: 24–7. 7 Bushell AJ, Klenerman L, Taylor S, et al. Ischaemic preconditioning of skeletal muscle. J Bone Joint Surg Br 2002; 84-B: 1184–8, 1189–93. 8 Wakankar HM, Nicholl JE, Koka R, D’Arcy JC. The tourniquet in total knee arthroplasty. J Bone Joint Surg Br 1999; 81-B: 30–3.
Other techniques that have been used in place of tourniquets or in combination with tourniquets • Hypotensive epidural anaesthesia in total knee replacements without use of tourniquets • Adrenaline and local anaesthetic infiltration in total knee replacements • Controlled hypotension and minimal inflation pressure in upper limb surgery Table 4
Future of tourniquets in orthopaedic surgery There have been questions as to whether tourniquets are absolutely indispensable in limb surgery. The concern is that, without using a tourniquet, blood loss would be significant. It will not only increase the need for transfusion but, as the surgical field would be greatly obscured, the operation would take longer than necessary. Nevertheless, this is not completely true in all limb surgeries. Wakankar et al.8 compared the outcome for total knee replacements with and without the use of tourniquets. The study showed that there was no significant difference in the surgical time, postoperative pain, need for analgesia, the volume collected in the drains, postoperative swelling and the incidence of wound complications. If the outcome is similar, should surgeons be considering performing total knee replacements without tourniquets? It is indeed an issue of balancing the risks and benefits as well as the skills of the surgeon performing the operation. Other techniques that have been used in place of tourniquets are shown in Table 4. ◆
ANAESTHESIA AND INTENSIVE CARE MEDICINE 10:1
Further reading Anaesthesia UK. Procedures under tourniquet. Available from: www.frca.co.uk Kam PCA, Kavanaugh R, Yoong FFY. The arterial tourniquet: pathophysiological consequences and anaesthetic implications. Anaesthesia 2001; 56: 534–45. Klenerman L. The tourniquet in surgery. J Bone Joint Surg Br 1962; 44-B: 937–43.
17
© 2008 Elsevier Ltd. All rights reserved.
Procedures under tourniquet
tourniquet for use in limb surgery in place of rubber tourniquets. One hundred years on, it is still considered an essential tool in orthopaedic and plastic surgery. However, the use of the tourniquet is not without its risks and complications.
Livia Malanjum Barrie Fischer
Applying the tourniquet The diameter of the cuff used should be wider than half the diameter of the limb. It should be applied furthest away from the surgical site and preferably over an area with the most fat and muscle padding. The edges of the cuff must overlap to provide even pressure all around. The use of soft-cast padding underneath the cuff is advised. When using padding, there should be no creases or ridges as this is associated with significant skin irritation and blistering. When the skin is prepared prior to surgery, the organic iodine or alcohol solution can become soaked up by the padding and can cause chemical burns and blistering. To prevent this from happening, an adhesive, transparent surgical barrier can be used to isolate the tourniquet and its padding (Figure 1).
Abstract The pneumatic tourniquet is used widely in operations involving the limbs. However, despite its everyday use, a clinician’s knowledge of this instrument is often limited to the pressure and time limit. Although the principle behind the tourniquet is simple, anaesthetists and surgeons should appreciate the effects of the tourniquet as well as the various complications associated with its use. Safe use of the tourniquet starts from the point of setting up the pneumatic machine. It is important to choose the appropriate pressure. Overinflation can lead to nerve damage. On the other hand, underinflation will lead to a bloody surgical field and unnecessary blood loss. The tourniquet should be applied with care to avoid local damage to the skin. Pathophysiological effects of the tourniquet can vary from a simple tachycardia and increase in systolic pressure to fatal events such as large pulmonary embolus and cardiac arrest. Prolonged use of the tourniquet can lead to a phenomenon known as tourniquet pain. Other complications associated with the use of the tourniquet include nerve and vascular damage and muscle contracture. In the past, the use of the tourniquet was avoided in patients with sickle cell disease for fear of triggering a sickle cell crisis. However, it has been shown that by creating the optimum conditions – sufficient hydration, good oxygenation, warmth and mild hyperventilation – this group of patients should not be deprived of the choice of having their limb operations with a tourniquet.
Exsanguinating the limb There are two ways to exsanguinate the limb: 1 Passive method: achieved by elevating the arm or leg for 5 minutes at 90° and 45°, respectively, without mechanical compression. 2 Active method: by using the Esmarch bandage or a RhysDavies exsanguinator (Figure 2). This method is contraindicated in patients with infection, tumour or painful fractures.
Inflation pressures and time limit To achieve complete arterial occlusion, inflation pressures should be related to a patient’s systolic blood pressure (Figure 3): • Inflation pressures for lower limbs: at least 100 mm Hg above systolic arterial blood pressure (usually 300–500 mm Hg). • Inflation pressures for upper limbs: at least 50 mm Hg above systolic arterial blood pressure (usually 250–300 mm Hg). In order to minimize the risk of nerve damage, the lowest inflation pressure should be used.1 In normotensive patients with compliant vessels, lower inflation pressures would be sufficient
Keywords machine check; nerve damage; pathophysiology; pneumatic tourniquet; pulmonary embolus; sickle cell disease
The use of a tourniquet in operative procedures dates back to Roman times. However, it was specifically used in limb amputations. In 1864, Lister became the first surgeon to apply the concept of the ‘bloodless surgical field’ in operations other than amputations. The tourniquet is applied around the upper and lower extremities to reduce blood loss and create good operating conditions. In 1904, Harvey Cushing introduced the pneumatic
Livia Malanjum, MBChB, is a Specialty Registrar in Anaesthesia and Critical Care Medicine and is currently working at Leicester General Hospital, Leicester, UK. She qualified from the University of Bristol. Conflicts of interest: none declared. Barrie Fischer, FRCA, is Consultant Anaesthetist at the Worcestershire Acute Hospitals Trust (Alexandra Hospital, Redditch). He qualified from Bristol University and trained in Cornwall, Cambridge and Cardiff. His research and teaching interests are the role of regional anaesthesia in surgery and acute pain medicine. Conflicts of interest: none declared.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 10:1
Figure 1 Tourniquet cuff, soft padding and Esmarch bandage.
14
© 2008 Elsevier Ltd. All rights reserved.
Orthopaedics
Contraindications to the use of a tourniquet Absolute contraindications • Presence of arteriovenous fistula • Peripheral vascular disease • Active malignancy • History of vascular surgery in the involved limbs Relative contraindication • Sickle cell disease • History of deep vein thrombosis, thromboembolic disease or pulmonary embolus • Obese thigh • Multiply scarred legs • Diabetes • Rheumatoid arthritis • Revision surgery
Figure 2 The Rhys-Davies exsanguinator.
to occlude arterial flow. In contrast, morbidly obese and hypertensive patients would require much higher inflation pressures. Recommendations and advice on the time limit for the use of the tourniquet varies from 30 minutes to 4 hours, with 2 hours being the most widely accepted figure. The risk of muscular and neurological damage increases with prolonged ischaemia. Unfortunately, in complicated operations, the actual procedure may take longer than 2 hours. In such situations, ideally the tourniquet should be deflated after 2 hours for 15–20 minutes to allow reperfusion of the muscle beneath and distal to the tourniquet cuff. After this period of reperfusion, the tourniquet should be used for only a further 60 minutes.2 The contraindications to the use of a tourniquet are shown in Table 1.
Table 1
moderate increase in central venous pressure and systolic blood pressure.3 If bilateral simultaneous inflation of a lower limb tourniquet is carried out, the rise in central venous pressure may be significant enough to cause volume overload or even cardiac arrest. • A sudden marked rise in heart rate and systolic and diastolic blood pressures may occur after 30–60 minutes. This phenomenon in also known as tourniquet pain. Increasing the depth of anaesthesia and the use of opiates may not be able to reverse these changes. It will improve only once the tourniquet is deflated. The mechanism of tourniquet pain is poorly understood. It is more likely to occur with increasing age and increasing duration of surgery.
Effects of the tourniquet The pathophysiological changes related to the use of the tourniquet can be divided into two phases: during inflation and after deflation.
Temperature effect: • Increase in core body temperature due to reduction in surface area for heat loss. • Decrease in temperature of the non-perfused limb. This may provide some protective effect from ischaemic changes.
During inflation Cardiovascular effects: • Increase in circulating blood volume (up to 15%) and systemic vascular resistance (up to 20%), leading to a transient slight-to-
Haematological effects: • Systemic hypercoagulability may occur in response to tourniquet and surgical pain. Platelet aggregation is promoted by catecholamine release. • Pulmonary embolus has been associated with the use of a tourniquet and there are case reports in which these incidents have been fatal. It can occur during lower limb exsanguinations and tourniquet inflation as well as during tourniquet deflation. There is a 5.33-fold increased risk of large venous embolism associated with the use of a tourniquet in patients undergoing total knee arthroplasty.4 • The incidence of deep vein thrombosis associated with the use of a tourniquet and total knee replacements is reported to be between 50% and 84%.5 Metabolic effects: • After 30 minutes, anaerobic metabolism occurs. This leads to mixed acidosis, hypoxaemia, hypercapnia, hyperkalaemia and
Figure 3 Tourniquet inflation unit.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 10:1
15
© 2008 Elsevier Ltd. All rights reserved.
Orthopaedics
by stiffness, pallor, weakness without paralysis and subjective numbness of the extremity without subjective anaesthesia.
formation of free radicals. These changes may be slight, but they may be of consequence in those with limited cardiopulmonary reserve.
Sickle cell disease
After deflation Cardiovascular effect: • During limb reperfusion, a transient decrease in systemic vascular resistance accompanied by a compensatory increase in cardiac index may occur. This avoids a severe decrease in mean arterial pressure. • Reactive hyper-reperfusion and vasospasm.
The use of tourniquets in patients with sickle cell disease remains a subject of debate. Low oxygen concentration in the ischaemic limb, circulatory stasis and acidosis may precipitate a sickle cell crisis. Traditionally, tourniquets were avoided in patients with sickle cell disease. However, Gyamfi et al.6 reported the successful use of tourniquets in patients with sickle cell disease – both those who are heterozygous and those who are homozygous for the disease. Precautions must be taken to optimize conditions – adequate hydration, warmth and blood volume as well as maintaining oxygenation and mild hyperventilation – in order to reduce the risk of precipitating a sickle cell crisis.
Temperature effect: • As blood returns to cold ischaemic tissues, the core temperature may fall by up to 0.6°C for each hour the tourniquet was used. Respiratory effects: • There may be a transient increase in end-tidal carbon dioxide tension by 0.1–2.4 kPa that peaks within 1 minute and returns to baseline within 10–13 minutes. • There may be increased oxygen consumption.
Machine check Equipment failure may contribute to the range of complications that can result from the use of tourniquets. This may be from overpressurization or underpressurization, adding to the complications related to the use of tourniquets. Therefore, all tourniquets should undergo regular maintenance checks to determine reliability (Table 3).
Metabolic effects: • Increase in lactate and Paco2. • Decrease in pH. • Increase in plasma K+ level. The complications associated with the use of tourniquets are shown in Table 2.
Ischaemic preconditioning The concept of ‘ischaemic preconditioning’ has been described in the protection of cardiac muscles in cardiac surgery. Exposing cardiac tissues to short periods of non-damaging ischaemic stress prior to the main ischaemic phase produces an adaptive protective response. Ischaemic preconditioning can lead to the production of protective substances such as adenosine, bradykinin and nitric oxide. Adenosine has been particularly identified as it prevents leucocyte sequestration, increases the activity of antioxidant enzymes and preserves ATP levels.7 However, although the protective role of ischaemic preconditioning has been studied in animal skeletal muscles, to date no human studies have been conducted. If it is proven that preconditioning can benefit human skeletal muscles, then the principle can be applied to reduce the various complications involved with the use of tourniquets.
Post-tourniquet syndrome This is the most common morbidity from tourniquet use but is the least appreciated. It is the result of muscle ischaemia, oedema and microvascular congestion. The syndrome is characterized
Complications associated with the use of tourniquets Local effects • Skin damage, bruising • Neuralgia, paraesthesia • Vascular damage: thrombosis to atherosclerotic vessels • Muscle contracture • Prolonged oedema and stiffness • Bone and soft-tissue necrosis • Compartment syndrome • Delayed wound healing
Safety check • Visual inspection of the machine: rubber tubing, connections and cuff • Check accuracy of aneroid pressure gauges against a suitable calibration device • When inflating the cuff, monitor the pressure gauge to ensure it achieves the pre-set inflation pressure • Monitor the pressure gauge intermittently throughout the procedure to detect any changes and exclude any leaks • The anaesthetic record should include the position of the cuff, pressure used and time
Systemic effects • Pulmonary embolus • Pulmonary oedema • Transient increase in blood pressure • Tourniquet pain • Post-tourniquet syndrome • Tourniquet-induced rhabdomyolysis • Cardiac arrest
Table 3
Table 2
ANAESTHESIA AND INTENSIVE CARE MEDICINE 10:1
16
© 2008 Elsevier Ltd. All rights reserved.
Orthopaedics
References 1 Odinsson A, Finsen V. Tourniquet use and its complications in Norway. J Bone Joint Surg Br 2006; 88-B: 1090–2. 2 Worland RL, Arredondo J, Lopez-Jimenez F, Jessup DE. Thigh pain following tourniquet application in simultaneous bilateral total knee arthroplasty. J Arthroplasty 1997; 12: 848–52. 3 Girardis M, Milesi S, Donato S, et al. The hemodynamic and metabolic effects of tourniquet application during knee surgery. Anesth Analg 2000; 91: 727–31. 4 Parmet JL, Berman AT, Horrow JC, et al. Thromboembolism coincident with tourniquet deflation during total knee arthroplasty. Lancet 1993; 341: 1057–8. 5 Stulberg BN, Insall JN, Williams GW, Ghelman B. Deep vein thrombosis following total knee replacement: an analysis of six hundred and thirty eight arthroplasties. J Bone Joint Surg Am 1984; 66-A: 194–201. 6 Gyamfi YA, Sankarankutty M, Marwa S. Use of a tourniquet in patients with sickle cell disease. Can J Anaesth 1993; 40: 24–7. 7 Bushell AJ, Klenerman L, Taylor S, et al. Ischaemic preconditioning of skeletal muscle. J Bone Joint Surg Br 2002; 84-B: 1184–8, 1189–93. 8 Wakankar HM, Nicholl JE, Koka R, D’Arcy JC. The tourniquet in total knee arthroplasty. J Bone Joint Surg Br 1999; 81-B: 30–3.
Other techniques that have been used in place of tourniquets or in combination with tourniquets • Hypotensive epidural anaesthesia in total knee replacements without use of tourniquets • Adrenaline and local anaesthetic infiltration in total knee replacements • Controlled hypotension and minimal inflation pressure in upper limb surgery Table 4
Future of tourniquets in orthopaedic surgery There have been questions as to whether tourniquets are absolutely indispensable in limb surgery. The concern is that, without using a tourniquet, blood loss would be significant. It will not only increase the need for transfusion but, as the surgical field would be greatly obscured, the operation would take longer than necessary. Nevertheless, this is not completely true in all limb surgeries. Wakankar et al.8 compared the outcome for total knee replacements with and without the use of tourniquets. The study showed that there was no significant difference in the surgical time, postoperative pain, need for analgesia, the volume collected in the drains, postoperative swelling and the incidence of wound complications. If the outcome is similar, should surgeons be considering performing total knee replacements without tourniquets? It is indeed an issue of balancing the risks and benefits as well as the skills of the surgeon performing the operation. Other techniques that have been used in place of tourniquets are shown in Table 4. ◆
ANAESTHESIA AND INTENSIVE CARE MEDICINE 10:1
Further reading Anaesthesia UK. Procedures under tourniquet. Available from: www.frca.co.uk Kam PCA, Kavanaugh R, Yoong FFY. The arterial tourniquet: pathophysiological consequences and anaesthetic implications. Anaesthesia 2001; 56: 534–45. Klenerman L. The tourniquet in surgery. J Bone Joint Surg Br 1962; 44-B: 937–43.
17
© 2008 Elsevier Ltd. All rights reserved.