3. Introduction
• Use of arterial tourniquet greatly facilitates bloodless field during
upper and lower limb orthopedic surgeries.
4. Indications
To provide bloodless field for surgery:
• For better identification of structures
• Reduced operative time
• Reduced surgical complications
• Reduced need for blood transfusion
5. Contraindications
• Peripheral vascular disease (Raynaud’s disease)
• Deep vein thrombosis
• AV fistula/arterial calcific disease
• Peripheral neuropathy/CNS disorder
• Severely injured/traumatized limb
• Severe infection in limb
• Bone abscess
• Sickle cell disease: Use is controversial as sickling is
• promoted by hypoxia/acidosis
9. Changes On Cuff Deflation
• Mild systemic metabolic acidosis (preinflation pH of 7.4 reduces to 6.9, 2
hours after deflation)
• Increased PaCO2 (1–8 mm Hg)
• Raised lactate levels
• Increased K+ levels (5–10% increase)
• Transient rise in ETCO2 levels
• Transient fall in systolic BP: 14–19 mm Hg
• Transient fall in heart rate: 6–12 bpm
• Transient fall in temperature by 0.7°C
• All these changes are due to release of toxic metabolites from the occluded
limb, such as carbon dioxide, lactic acid, and potassium
11. 1. Tourniquet Pain
• Occurs in 66% cases 30–60 minutes after giving RA
• Clinical features:
Dull, deep, burning, and poorly localized pain
Hypertension, tachycardia, diaphoresis
12. 2. Haemodynamic Changes
• Exsanguination: Results in movement of blood from peripheral to central
circulation
• Causes increased SVR and preload to heart
• 10–15% increase in heart rate and HTN on cuff inflation
• Cardiac arrest, LV failure
• Deflation of cuff: Causes reduced SVR
• This causes acute blood loss which may continue for 24 hours
• Also causes release of metabolites: May require cardiac support with inotropes
13. 3. Tourniquet Hypertension
• Occurs due to tourniquet pain
• Begins three-fourths to 1 hour after cuff inflation
4. Pulmonary Embolism
• Pulmonary embolism possible following exsanguinations/ cuff deflation in
TKR
• Silent DVT may be the cause and high index of suspicion is required
14. 5. Metabolic Changes
• Increased PaCO2 (1–8 mm Hg), reduced pH, increased lactate and K+ levels
• Only increase in PaCO2, in head injury patients may cause increased CBF and
raised ICP
• Body temperature increases in pediatric patients during tourniquet inflation
6. Postoperative Edema
• Due to return of exsanguinated blood and postischemic reactive hyperemia
• Can be due to arterial flow with no venous return during cuff inflation
• Post-tourniquet syndrome: Pale and swollen limb for 1–6 weeks
postoperatively
15. 7. Delayed Return of Blood Flow After Tourniquet Release
• Causes are:
Arterial injury
Compartment syndrome
Reperfusion injury
16. 8. Trauma
• Skin trauma:
Due to improper placement of padding under cuff
Causes bruising, abrasions, and blistering
• Arterial trauma: Causes arterial spasm, arterial thrombus
• Venous trauma: Venous thrombus due to stagnant blood
• Muscle rhabdomyolysis: If inflation time more than 2 hours
9. Nerve injury:
• Called tourniquet palsy
• Paroneal and tibial nerve palsy common following TKA with tourniquet
inflation ≥ 2 hours
