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Proposed recommended practices for
T
Proposed recommended practices for
preparation, utilization, and maintenance of the pneumatic tourniquet
he following draft is being published for review and comment by AORN members. The AORN Recommended Practices Subcommittee of the Technical Practices Coordinating Committee (TPCC) is interested in receiving comments on this proposal from the members. These are intended as achievable recommendations representing what is believed to be an optimal level of practice. Variations in institutional environment and/or clinical situations may determine the degree to which the recommended practices can be fulfilled. Although nonmembers may submit comments, the subcommittee's intent is to reach a consensus among AORN members. All comments from members will be acknowledged and considered by the subcommittee before the final approval of these recommendations by the TPCC and the AORN Board of Directors. Comments should be sent to Recommended Practices Subcommittee AORN 10170 E Mississippi Ave Denver, Colo 80231 Attention: Colleen K Harvey, RN The deadline for comments is May 15.
Purpose.These recommendedpractices provide guidelinesfor testing, applying, and cleaning pneumatic tourniquet equipment and documenting its use. The pneumatic tourniquet includes a pressure source, pressure gauge, regulator tubing, connectors, and inflatable cuff. Because of the variety and complexity of current tourniquet equipment, these recommended practices are designed to assist in the development of individual institutional policies and procedures. Recommended Practice I. Pneumatic tourniquets should be regularly tested before use, monitored during use, and maintained in working order. Interpretive statements 1. The method and criteria for testing pressure gauges should be established by institutional policy. 2. The effectiveness of the tourniquet cuff should be tested prior to each use. The cuff, tubing, connectors, contact closure, and ties should be intact on inspection. 3. Intraoperatively, the pressure gauge
dAORN Journal, April 1983. V o l 3 7 , N o 5
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should be checked periodically to detect fluctuations
Rationale 1 Prior to the use of tourniquet the accuracy of the aneroid pressure gauge should be checked by comparing it to a mercury manometer ' 2 Tourniquet equipment should be kept in good repair by a program of preventive maintenance Tourniquets should be calibrated regularly The results of the calibration check should be included in the operative record 3 Pressure drifts can be detected by wrapping the cuff around a rigid object (eg a size D medical gas cylinder) and inflating it to approximately 300 mm Hg The cuff should be observed for pressure variations for 30 min These checks should be performed at least once a month Recommended Practice II. Selection and placement of the tourniquet cuff should be determined by the patient's age, anatomy, and medical condition. Interpretive statements 1 Cuff length should exceed the circumference of the extremity by 3 to 6 in 2 Cuff width should be appropriate to the size of the extremity 3 The cuff should be positioned at the point of maximum circumference of the limb Rationale 1 Potential for nerve damage is affected by the width of the cuff in relation to the size of the limb the amount of soft tissue between the cuff and nerve and the degree and duration of cuff pressure 2 Lower extremity tourniquets should be applied to the proximal third of the thigh avoiding vulnerable neurovascular structures 6 Recommended Practice 111. The tourniquet cuff should be applied to the extremity so that underlying skin and tissues are protected. Interpretive statements 1. The skin under the cuff should be protected
2
3
4
5
from mechanical injury by keeping the cuff and padding wrinkle free Padding should allow for cuff compliance Once applied a tourniquet cuff should not be rotated to a new position because the shearing forces may damage underlying tissue Skin preparation solutions should not be allowed to collect or pool under the tourniquet cuff Tourniquet inflation time should be kept to a minimum Tourniquet pressure should depend on the patient's age blood pressure and size of limb
Rationale 1 The duration of tourniquet time should be determined by the patients age and the presence of vascular disease in the limb 2 The correct pressure is the minimum pressure required to produce a bloodless field * Recommended Practice IV. The pneumatic tourniquet should be cleaned and stored after each patient use according to institutional policy. Rationale 1 All items that have come in contact with the patient and/or the sterile field should be considered contaminated and their disposition should reflect appropriate control measures 2 Containers or cylinders of gases used as pressure sources for the pneumatic tourniquet should be stored in strict adherence to current regulations l o Recommended Practice V. Policies and procedures for the use of the pneumatic tourniquet should be written, reviewed annually, and readily available within the institution. Interpretive statements 1 Information regarding the location of tho cuff, cuff pressure time of inflation and deflation and identification number of the specific tourniquet should be recorded on the patient record 2 The surgeon should be alerted to the dura tion of tourniquet time at frequent estab-
lished intervals. 3. These policies and procedures establish authority, responsibility, and accountability for pneumatic tourniquet management in the institution. 4. This information should be included in the orientation and ongoing education of all appropriate personnel in the institution.
of perioperative nursing care." AORN Standards and Recommended Practices for Perioperative Nursing (Denver: Association of Operating Room Nurses, Inc. 1982) Part I l l , section 3, 1. 12. W K Hamilton, M D Sokoll, "Tourniquet paralysis," Journal of the American Medical Association 199 (Jan 2, 1967) 37. 13. Accreditation Manual for Hospitals, 1982, 76.
Rationale
Suggested reading Adams, J C. Standard Orthopaedic Operations. New York: Churchill and Livingstone, 1975. Boyes,Joseph. Bunnell'sSurgery of the Hand, 4th ed. Philadelphia:J B Lippincott. 1964, 132. Bruner, J M. "Time, pressure and temperature factors in the safe use of the tourniquet." The Hand 2 (March 1970) 39-42. Fahmy, N R; Patel, D G. "Hemostatic changes and postoperative deep-vein thrombosis associated with use of a pneumatic tourniquet." Journal of Bone and Joint Surgery 63A (March 1981) 461465. Griffiths. J C; Heywood. 0 B. "Bio-mechanical aspects of the tourniquet." The Hand 5 (June 1973) 113-118. Johnson, D L; Neufeld, P D; Hussey. R G. "Hazards in single-stage regulation of pressure cuffs." Journal of Clinical Engineering 5 (JanuaryMarch 1980) 59-62. Klenerman. L. "The tourniquet in surgery." Journal of Bone and Joint Surgery 448 (1962) 937-943. Klenerman, L. "Tourniquet time-how long?" The Hand 12 (October 1980) 231-234. Klenerman. L; Biswas, M; Hulands, G H; Rhodes, A M. "Systemic and local effects of the applicationof a tourniquet." The Journal of Bone and Joint Surgery 62 (August 1980) 385-388. McEwen. J A. "Complicationsof and improvements in pneumatic tourniquets used in surgery." Medical lnslrumentation 15 (July-August 1981) 253257. Moldaver, J. "Tourniquet paralysis syndrome." Archives of Surgery 68 (1954) 136-144. Parkes, A. "lschaemic effects of external and internal pressure on the upper limb." The Hand 5 (June 1973) 105-112. Patterson,S ; Klenerman, L. "The effect of pneumatic tourniquets on ultrastructure of skeletal muscle."JournalofBoneand JointSurgery61 (May 1979) 179- 183. Rau, R W; Waylonis, G W. "Pneumatic tourniquet electromyographic changes." (Letters.)Journalof the American Medical Association 242 (Nov 2, 1979) 1967. Rhodes. Marie J; Gruendemann, Barbara J; Ballinger,Walter F. Alexander's Care of the Patientin Surgery, 6th ed. St Louis: C V Mosby, 1978 495497.
1. Since surgical and anesthesia personnel are involved in using pneumatic tourniquet equipment, they should be aware of the potential problems and how to prevent them.'* 2. Written guidelines shall be available for all personnel involved with procedures that are commonly used in patient care.'3 Notes 1. S J Prevoznik, "Injury from use of pneumatic tourniquets," (letter) Anesthesiology 32 (February 1970) 177. 2. L N Hurst et al, "The pneumatic tourniquet: A biomechanical and electrophysiological study," Plastic and Reconstructive Surgery 67 (May 1981) 648-652. 3. "Recommended practices for documentation of perioperative nursing care," AORN Standards and Recommended Practices for Perioperative Nursing (Denver: Association of Operating Room Nurses, Inc, 1982) Part 111, section 3, 1-3. 4. D L Johnson, P D Neufeld. R G Hussey, "Summary of paper entitled: 'Analysis of regulator malfunction in the Kidde 400 Automatic Tourniquet,'" Bureau of Medical Devices, Health and Welfare Canada, unpublished. 5. C F Bolton, R M McFarlane, "Human pneumatic tourniquet paralysis," Neurology 28 (August 1978) 787-793. 6. D J Arenson, L S Weil, "The uses and abuses of tourniquets in bloodless field foot surgery," Journ a l of American Podiatry Association 66 (November 1976) 854-861. 7. A E Flatt, "Tourniquet time in hand surgery," Archives ofsurgery 104 (February 1972) 190-192. 8. R Sanders, "The tourniquet, instrument or weapon?" The Hand 5 (June 1973) 119-123. 9. "Recommended practicesfor OR sanitation," AORN Standards and Recommended Practices for Perioperative Nursing (Denver: Association of Operating Room Nurses, Inc, 1982) Part 111, section 8, 1. 10. Accreditation Manual for Hospitals, 7982 (Chicago: Joint Commission on Accreditation of Hospitals) 41. 11. "Recommended practices for documentation
AORN J<,urnal,April 1983, V o l 3 7 , No 5
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Rorabeck. C H; Kennedy, J C. "Tourniquet-induced nerve ischemia complicating knee ligament surgery." American Journal of Sports Medicine 8 (March-April 1980) 98- 102. Saunders, K C: Louis, D L; Weingarden, S I; Waylonis. G W. "Effect of tourniquet time on postoperative quadriceps function." Clinical Orthopedics 143 (September 1979) 194-199. Smith, H. "Surgical technique" in Campbell's Operative Orthopaedics. 5th ed. St Louis: C V Mosby. 1971. 19-21.
"The tourniquet, instrument or weapon?" Canadian Medical Association Journal 109 (November 1973) 827. Watson-Jones, Reginald. fractures and Joint lnjuries, vol 1, 4th ed. Baltimore: Williams and Wilkins. 1962, 101 and 121. Weingarden, S I; Louis, D L; Waylonis. G W. "Electromyographic changes in postmenisectomy patients: Role of the pneumatic tourniquet." Journal of the American Medical Associahon 241 (March 23, 1979) 1248-1250.
Safety of injectable contraceptive debated The US Food and Drug Administration (FDA) and other agencies have raised questions about the safety of Depo-Provera. an injectable contraceptive. The primary issue before the three-member FDA review panel is the interpretation by Upjohn Co, maker of the injectable contraceptive, of its animal studies. The FDA along with the Centers for Disease Control, the Environmental Protection Agency, and the National Cancer Institute are concerned that drug-related cancer of the breast and cervix was undetected in the monkeys injected with Depo-Provera. Nearly two million women are using Depo-Provera worldwide. The FDA spokesman asked that additional pathological specimens be taken from the monkeys Upjohn injected with the drug. Upjohn's defense is that it found endometrial carcinoma in two monkeys that were given 50 times the human dose of the drug, and mammary nodular hyperplasia was found in three monkeys given 10 times the human dose, according to a report in the American Medical News. It was concluded that there was no threat of breast or uterine cancer in humans. Although the FDA says the drug's effects were "poorly studied," Upjohn continues to stand by its analysis. Upjohn is pushing for FDA approval of Depo-Provera alleging that the safe and effective use by women in other countries shows that Depo-Provera should be available in the United States. It seems unlikely that the FDA will approve Depo-Provera. Robert Temple, MD, acting director of the FDA Office of
988
New Drug Evaluation, said that Upjohn has not been able to provide adequate data on the risks of Depo-Provera "because the drug isn't safe." Because of FDA's ban, several foreign countries have begun to limit the sale of the drug.
New policy for CCRN recertification deadline The American Association of Critical-Care Nurses (AACN) Certification Corp has made a policy change regarding the deadline for renewal of CCRN certification status. The new deadline is the end of the month in which the certification expires. For example, a CCRN certified through July 1 , 1983, must have all materials, including all supporting documents to recertify submitted by July 31, 1983. The required documentation includes the completed application and fee, US RN licensure and clinical practice verification, materials showing appropriate continuing education credit, and other supporting materials. Immediately after certification, CCRNs should review the recertification handbook and develop a plan with personal deadlines for meeting the recertification requirements. The AACN Certification Corp welcomes any questions or comments from CCRNs. Letters should be mailed to the national office, One Civic Plaza, Suite 315, Newport Beach, Calif 92660.
AORN Journnl. April 1983. Vol 37, N o 5
Proposed recommended practices for
preparation, utilization, and maintenance of the pneumatic tourniquet
he following draft is being published for review and comment by AORN members. The AORN Recommended Practices Subcommittee of the Technical Practices Coordinating Committee (TPCC) is interested in receiving comments on this proposal from the members. These are intended as achievable recommendations representing what is believed to be an optimal level of practice. Variations in institutional environment and/or clinical situations may determine the degree to which the recommended practices can be fulfilled. Although nonmembers may submit comments, the subcommittee's intent is to reach a consensus among AORN members. All comments from members will be acknowledged and considered by the subcommittee before the final approval of these recommendations by the TPCC and the AORN Board of Directors. Comments should be sent to Recommended Practices Subcommittee AORN 10170 E Mississippi Ave Denver, Colo 80231 Attention: Colleen K Harvey, RN The deadline for comments is May 15.
Purpose.These recommendedpractices provide guidelinesfor testing, applying, and cleaning pneumatic tourniquet equipment and documenting its use. The pneumatic tourniquet includes a pressure source, pressure gauge, regulator tubing, connectors, and inflatable cuff. Because of the variety and complexity of current tourniquet equipment, these recommended practices are designed to assist in the development of individual institutional policies and procedures. Recommended Practice I. Pneumatic tourniquets should be regularly tested before use, monitored during use, and maintained in working order. Interpretive statements 1. The method and criteria for testing pressure gauges should be established by institutional policy. 2. The effectiveness of the tourniquet cuff should be tested prior to each use. The cuff, tubing, connectors, contact closure, and ties should be intact on inspection. 3. Intraoperatively, the pressure gauge
dAORN Journal, April 1983. V o l 3 7 , N o 5
981
should be checked periodically to detect fluctuations
Rationale 1 Prior to the use of tourniquet the accuracy of the aneroid pressure gauge should be checked by comparing it to a mercury manometer ' 2 Tourniquet equipment should be kept in good repair by a program of preventive maintenance Tourniquets should be calibrated regularly The results of the calibration check should be included in the operative record 3 Pressure drifts can be detected by wrapping the cuff around a rigid object (eg a size D medical gas cylinder) and inflating it to approximately 300 mm Hg The cuff should be observed for pressure variations for 30 min These checks should be performed at least once a month Recommended Practice II. Selection and placement of the tourniquet cuff should be determined by the patient's age, anatomy, and medical condition. Interpretive statements 1 Cuff length should exceed the circumference of the extremity by 3 to 6 in 2 Cuff width should be appropriate to the size of the extremity 3 The cuff should be positioned at the point of maximum circumference of the limb Rationale 1 Potential for nerve damage is affected by the width of the cuff in relation to the size of the limb the amount of soft tissue between the cuff and nerve and the degree and duration of cuff pressure 2 Lower extremity tourniquets should be applied to the proximal third of the thigh avoiding vulnerable neurovascular structures 6 Recommended Practice 111. The tourniquet cuff should be applied to the extremity so that underlying skin and tissues are protected. Interpretive statements 1. The skin under the cuff should be protected
2
3
4
5
from mechanical injury by keeping the cuff and padding wrinkle free Padding should allow for cuff compliance Once applied a tourniquet cuff should not be rotated to a new position because the shearing forces may damage underlying tissue Skin preparation solutions should not be allowed to collect or pool under the tourniquet cuff Tourniquet inflation time should be kept to a minimum Tourniquet pressure should depend on the patient's age blood pressure and size of limb
Rationale 1 The duration of tourniquet time should be determined by the patients age and the presence of vascular disease in the limb 2 The correct pressure is the minimum pressure required to produce a bloodless field * Recommended Practice IV. The pneumatic tourniquet should be cleaned and stored after each patient use according to institutional policy. Rationale 1 All items that have come in contact with the patient and/or the sterile field should be considered contaminated and their disposition should reflect appropriate control measures 2 Containers or cylinders of gases used as pressure sources for the pneumatic tourniquet should be stored in strict adherence to current regulations l o Recommended Practice V. Policies and procedures for the use of the pneumatic tourniquet should be written, reviewed annually, and readily available within the institution. Interpretive statements 1 Information regarding the location of tho cuff, cuff pressure time of inflation and deflation and identification number of the specific tourniquet should be recorded on the patient record 2 The surgeon should be alerted to the dura tion of tourniquet time at frequent estab-
lished intervals. 3. These policies and procedures establish authority, responsibility, and accountability for pneumatic tourniquet management in the institution. 4. This information should be included in the orientation and ongoing education of all appropriate personnel in the institution.
of perioperative nursing care." AORN Standards and Recommended Practices for Perioperative Nursing (Denver: Association of Operating Room Nurses, Inc. 1982) Part I l l , section 3, 1. 12. W K Hamilton, M D Sokoll, "Tourniquet paralysis," Journal of the American Medical Association 199 (Jan 2, 1967) 37. 13. Accreditation Manual for Hospitals, 1982, 76.
Rationale
Suggested reading Adams, J C. Standard Orthopaedic Operations. New York: Churchill and Livingstone, 1975. Boyes,Joseph. Bunnell'sSurgery of the Hand, 4th ed. Philadelphia:J B Lippincott. 1964, 132. Bruner, J M. "Time, pressure and temperature factors in the safe use of the tourniquet." The Hand 2 (March 1970) 39-42. Fahmy, N R; Patel, D G. "Hemostatic changes and postoperative deep-vein thrombosis associated with use of a pneumatic tourniquet." Journal of Bone and Joint Surgery 63A (March 1981) 461465. Griffiths. J C; Heywood. 0 B. "Bio-mechanical aspects of the tourniquet." The Hand 5 (June 1973) 113-118. Johnson, D L; Neufeld, P D; Hussey. R G. "Hazards in single-stage regulation of pressure cuffs." Journal of Clinical Engineering 5 (JanuaryMarch 1980) 59-62. Klenerman. L. "The tourniquet in surgery." Journal of Bone and Joint Surgery 448 (1962) 937-943. Klenerman, L. "Tourniquet time-how long?" The Hand 12 (October 1980) 231-234. Klenerman. L; Biswas, M; Hulands, G H; Rhodes, A M. "Systemic and local effects of the applicationof a tourniquet." The Journal of Bone and Joint Surgery 62 (August 1980) 385-388. McEwen. J A. "Complicationsof and improvements in pneumatic tourniquets used in surgery." Medical lnslrumentation 15 (July-August 1981) 253257. Moldaver, J. "Tourniquet paralysis syndrome." Archives of Surgery 68 (1954) 136-144. Parkes, A. "lschaemic effects of external and internal pressure on the upper limb." The Hand 5 (June 1973) 105-112. Patterson,S ; Klenerman, L. "The effect of pneumatic tourniquets on ultrastructure of skeletal muscle."JournalofBoneand JointSurgery61 (May 1979) 179- 183. Rau, R W; Waylonis, G W. "Pneumatic tourniquet electromyographic changes." (Letters.)Journalof the American Medical Association 242 (Nov 2, 1979) 1967. Rhodes. Marie J; Gruendemann, Barbara J; Ballinger,Walter F. Alexander's Care of the Patientin Surgery, 6th ed. St Louis: C V Mosby, 1978 495497.
1. Since surgical and anesthesia personnel are involved in using pneumatic tourniquet equipment, they should be aware of the potential problems and how to prevent them.'* 2. Written guidelines shall be available for all personnel involved with procedures that are commonly used in patient care.'3 Notes 1. S J Prevoznik, "Injury from use of pneumatic tourniquets," (letter) Anesthesiology 32 (February 1970) 177. 2. L N Hurst et al, "The pneumatic tourniquet: A biomechanical and electrophysiological study," Plastic and Reconstructive Surgery 67 (May 1981) 648-652. 3. "Recommended practices for documentation of perioperative nursing care," AORN Standards and Recommended Practices for Perioperative Nursing (Denver: Association of Operating Room Nurses, Inc, 1982) Part 111, section 3, 1-3. 4. D L Johnson, P D Neufeld. R G Hussey, "Summary of paper entitled: 'Analysis of regulator malfunction in the Kidde 400 Automatic Tourniquet,'" Bureau of Medical Devices, Health and Welfare Canada, unpublished. 5. C F Bolton, R M McFarlane, "Human pneumatic tourniquet paralysis," Neurology 28 (August 1978) 787-793. 6. D J Arenson, L S Weil, "The uses and abuses of tourniquets in bloodless field foot surgery," Journ a l of American Podiatry Association 66 (November 1976) 854-861. 7. A E Flatt, "Tourniquet time in hand surgery," Archives ofsurgery 104 (February 1972) 190-192. 8. R Sanders, "The tourniquet, instrument or weapon?" The Hand 5 (June 1973) 119-123. 9. "Recommended practicesfor OR sanitation," AORN Standards and Recommended Practices for Perioperative Nursing (Denver: Association of Operating Room Nurses, Inc, 1982) Part 111, section 8, 1. 10. Accreditation Manual for Hospitals, 7982 (Chicago: Joint Commission on Accreditation of Hospitals) 41. 11. "Recommended practices for documentation
AORN J<,urnal,April 1983, V o l 3 7 , No 5
985
Rorabeck. C H; Kennedy, J C. "Tourniquet-induced nerve ischemia complicating knee ligament surgery." American Journal of Sports Medicine 8 (March-April 1980) 98- 102. Saunders, K C: Louis, D L; Weingarden, S I; Waylonis. G W. "Effect of tourniquet time on postoperative quadriceps function." Clinical Orthopedics 143 (September 1979) 194-199. Smith, H. "Surgical technique" in Campbell's Operative Orthopaedics. 5th ed. St Louis: C V Mosby. 1971. 19-21.
"The tourniquet, instrument or weapon?" Canadian Medical Association Journal 109 (November 1973) 827. Watson-Jones, Reginald. fractures and Joint lnjuries, vol 1, 4th ed. Baltimore: Williams and Wilkins. 1962, 101 and 121. Weingarden, S I; Louis, D L; Waylonis. G W. "Electromyographic changes in postmenisectomy patients: Role of the pneumatic tourniquet." Journal of the American Medical Associahon 241 (March 23, 1979) 1248-1250.
Safety of injectable contraceptive debated The US Food and Drug Administration (FDA) and other agencies have raised questions about the safety of Depo-Provera. an injectable contraceptive. The primary issue before the three-member FDA review panel is the interpretation by Upjohn Co, maker of the injectable contraceptive, of its animal studies. The FDA along with the Centers for Disease Control, the Environmental Protection Agency, and the National Cancer Institute are concerned that drug-related cancer of the breast and cervix was undetected in the monkeys injected with Depo-Provera. Nearly two million women are using Depo-Provera worldwide. The FDA spokesman asked that additional pathological specimens be taken from the monkeys Upjohn injected with the drug. Upjohn's defense is that it found endometrial carcinoma in two monkeys that were given 50 times the human dose of the drug, and mammary nodular hyperplasia was found in three monkeys given 10 times the human dose, according to a report in the American Medical News. It was concluded that there was no threat of breast or uterine cancer in humans. Although the FDA says the drug's effects were "poorly studied," Upjohn continues to stand by its analysis. Upjohn is pushing for FDA approval of Depo-Provera alleging that the safe and effective use by women in other countries shows that Depo-Provera should be available in the United States. It seems unlikely that the FDA will approve Depo-Provera. Robert Temple, MD, acting director of the FDA Office of
988
New Drug Evaluation, said that Upjohn has not been able to provide adequate data on the risks of Depo-Provera "because the drug isn't safe." Because of FDA's ban, several foreign countries have begun to limit the sale of the drug.
New policy for CCRN recertification deadline The American Association of Critical-Care Nurses (AACN) Certification Corp has made a policy change regarding the deadline for renewal of CCRN certification status. The new deadline is the end of the month in which the certification expires. For example, a CCRN certified through July 1 , 1983, must have all materials, including all supporting documents to recertify submitted by July 31, 1983. The required documentation includes the completed application and fee, US RN licensure and clinical practice verification, materials showing appropriate continuing education credit, and other supporting materials. Immediately after certification, CCRNs should review the recertification handbook and develop a plan with personal deadlines for meeting the recertification requirements. The AACN Certification Corp welcomes any questions or comments from CCRNs. Letters should be mailed to the national office, One Civic Plaza, Suite 315, Newport Beach, Calif 92660.
AORN Journnl. April 1983. Vol 37, N o 5