dovelopment of tourniquet

1. APPLICATION OF TOURNIQUET
IN ORTHOPAEDICS
PRESENTED BY – DR SUNIL POONIA MODERATED BY – DR. A. K.
DAOLAGUPU
PGT MS ORTHOPAEDICS PROFESSOR, MS
ORTHO
SMCH,SILCHAR . SMCH,SILCHAR .

2. Development of tourniquets
 The term tourniquet was coined by petit in 1718,to
describe the action of his screw device to stop
hemorrhage.
 lister was the first surgeon to employ it to provide
blood less field for operation other than
amputation. but he drained the blood of limb by
elevation.
 In 1873 Johann von Esmarch, Professor of
surgery ,he used it to exsanguinate the limb , but
prevented blood from re-entering by applying
,around the limb, heavy rubber tubing . but it is
associated with nerve palsies.

3.  Harvey cushing ,in 1904, invented pneumatic
tourniquet . doveloping it from standard riva-rocci
blood pressure apparatus.
 he described its use in craniotomies , but soon it
was used for operations on limbs.

4. Types of tourniquet
 Non pneumatic tourniquet
 Pneumatic tourniquet(non automatic ,
automatic)

5. Non pneumatic tourniquet
 It is permissible only in exceptional
circumstances.
 Pressure exerted by them on underlying tissue
is unknown.(Adult up to 900mm of Hg ,
children up to 1015 mm of Hg ).
 Esmarch bandage can be autoclaved ( if rolled
properly with cloth between each layer. Thus
in sterile situation it can be used ( only a few
pneumatic cuff can be autoclaved )

6. Pneumatic tourniquet
 Are based on same principles on blood
pressure cuffs but they are stronger.
 Their fastening are more secure and they
usually have stiff backing piece to maintain the
effective width of the inflated cuff.

7. Non automated pneumatic
tourniquet
 Tourniquet consist of a pneumatic cuff & hand
operated pump and pressure gauge.
 There is no automatic compensation for leak in
the system so regular check is required.
 Hand pump is small so it is difficult to raise
pressure above systolic pressure rapidly thus
it can causes venous engorgement if esmarch
bandage is not applied for exsanguination.

8. Automated pneumatic
tourniquet
 In this type of tourniquet ,there is constant
supply of gas to compensate any leak in
system.
 Inflation of the cuff is very rapid and controllable
thus essentially eliminating the chance of
venous engorgement.

9. Contra-indication to the use of
tourniquet
 Peripheral arterial disease.
 Severe crush injuries.
 Sickle cell disease( if tourniquet must be used ,
the limb must be exsanguinated thoroughly
before inflation of cuff)
 Severe infection

10. Contra-indication to expressive
exsanguination
 Severe infection
 Malignant tumor
 Proven or suspected DVT

11. Site for application of
tourniquet.
 Must only be placed around upper arm and
thigh (exception – digital tourniquet). b/c these
are the only site where there is sufficient bulk
to distribute the pressure in the cuff evenly.
 Must not be placed around forearm ,leg ,wrist
,ankle.

12. Width of pressure cuff
 According to American Heart Association ,if width of
cuff is
20% greater than the diameter of upper arm
40% of the circumference of the thigh
8 inch (20 cm)
then pressure in them need only be little above systolic
pressure, to maintain bloodless field.
 length 10 cm in arm , 15 cm in thigh
 If narrow cuff is used high pressure is needed to
occlude the artery.
 With narrow cuff tissue immediate beneath a cuff may
be submitted to excessive damaging pressure

13. Exsanguination
 The simplest and safest way to remove most of
blood from a limb ,to elevate as vertical as
possible for 4 minute.
 The blood drain from the vein under gravity and
this followed by reflex arteriolar constriction
which makes emptying more complete.
 More efficient way is to cover whole limb in
envelope and then inflation of that envelope.
 Or by applying esmarch bandage from the digits
to the cuffs.

14. Tourniquet pressure
 upper limb = SBP + 50 mm of Hg
 Lower limb = SBP × 2 mm of Hg

15. Tourniquet time
 Must apply for the shortest possible time.
 For a healthy person safe limit is for one hour .
 For difficult operation it can be used for 1 & ½ - 2 hrs.
but 2 hrs is not safe for all patient.
 Longer duration is safe as the minimum effective
pressure is used.
 Care must be taken for elderly , alcoholic , sub clinical
neuropathy and unwell patient.

16. Braithwaite and Klenerman's
Modification of Bruner's Ten
Rules
 Application - Apply only to a healthy limb
or with caution to an unhealthy limb
 Size of tourniquet - Arm, 10 cm; leg, 15
cm or wider in large legs
 Site of application - Upper arm; mid/upper
thigh ideally
 Padding - At least two layers of
orthopaedic wool

17.  Skin preparation - Occlude to prevent soaking
of wool. 50– 100 mm Hg above systolic for the
arm; double systolic for the thigh; or arm 200–
250 mm Hg, leg 250–350 mm Hg (large cuffs
are recommended for larger limbs instead of
increasing pressure)
 Time - Absolute maximum 3 hr (recovers in 5–
7 days) generally not to exceed 2 hr
 Temperature - Avoid heating (e.g., hot lights),
cool if feasible, and keep tissues moist

18.  Documentation calibration and maintenance -
Duration and pressure at least weekly against
mercury manometer or test gauge; 3-monthly
maintenance

19.  Application of more than 2 layer of padding
result in significant decrease in pressor
transmission to underlying tissue
 For obese pt – assistant grasp flesh just distal
to level of extremity – pull this loose tissue
distally until padding and tourniquet applied –
greater protection of subcutaneous tissue and
push tourniquet more proximally

20.  The curved tourniquet on conical extremity ,
significantly reduces arterial occlusion
pressure than rectangle one .

21. Dangers of tourniquet
 Tourniquets are dangerous (advantage only to
surgeons)
 Major complication are rare( 1:5000 in UL,1:13000
in LL, 2:1500 due to faulty instrument).
 Can be divided into
 dangers from ischemia
 dangers from exsanguination
 danger from pressure in tourniquet cuff
 danger from bleeding after closer of wound
 danger from failing to remove tourniquet

22. Tourniquet paralysis syndrone
 Describe by moldaver in 1954
 It is caused by pressure rather than ischemia.
 c/f
 motor paralysis with hypotonia or atonia without
atrophy.
 sensory dissociation ( touch , position, vibration ,
position sense is lost/ pain sensation intact even
hyperalgesia).
 colour , temperature and sympathetic function are
normal.
peripheral pulse is normal

23.  Electrical study shows block to nerve conduction
is at the level of tourniquet.
 Excessive pressure distort the myelin sheaths
which retract from the nodes of ranvier . this
process continues as segmental demyelination.
 Axons are preserved.
 Recovery from full paralysis takes upto three
month.

24.  Couses of tourniquet paralysis
I. excessive pressure
II. insufficient pressure – congestion and
haemorrhagic infiltration of nerve
III. application for too long
IV. application without consideration of local
anatomy

25. Dangers from ischemia
 The tissue distal to cuff become anoxic , acidotic, and
loaded with metabolite.
 Klenerman found that after 3 hrs it took 40 min. for
acid base level in the limb to return to normal.
 For ischemia of more than three hrs recovery time
increases drastically.
 There is controversy in the practice advocated by
Bruner (releasing the tourniquet for 10 min after 1 hr
,if surgery require > 1 and ½ to 2 hrs)

26. Post tourniquet syndrome
 Following release of tourniquet there is
immediate swelling of tissues (reactive
hyperaemia , inc. capillary permeability ).
 Swelling is much more severe when tourniquet
time is more than 2 hrs.
 Post tourniquet syndrome probably due to
ischemia.
 Longer the period of ischemia , older the patient
increase the chance of post tourniquet
syndrome.

27. Clinical feature
 Puffiness of skin and fingers ( smoothning out of
normal skin crease)
 Stiffness of joints
 Colour change ( pale on elevation, congested when
dependent)
 Subjective sensation of numbness
 Weakness of muscle without real paralysis.

28. Prevention of post tourniquet
syndrome
 Select correct operation for each patient
 Avoid wasting of time –
Care full pre-op planning of operation
delaying the application of tourniquet.
do not extend the tourniquet time
unnecessarily
 Ensure good hoemostasis
 Elevate the limb after operation
 Encourage the patient to perform active movement

29. Dangers from exsanguination
 Exsanguination by elevation is not hazardous . but
there is risk when achieved by compression.
 Risks –
damage to skin.
damage to sub cutaneous nerve.
Injury to major vessel may remain
unrecognized
fracture
spread of infection, malignancy, DVT
cardiac overload.

30. Dangers from pressure in the
tourniquet cuff.
 Skin necrosis.
 Occasionally wall of arteries get calcified .chance of
fracture of vessel wall and permanent damage to blood
supply of limb.
 Local damage of soft tissue under the cuff.
Nerve palsy (diabetes,alcoholism,RA are more
prone)
muscle damage - Up to 3 hrs of compression ,
recovery was rapid and muscle had normal histological
appearance when examined at 24 hrs.
After 5 hrs of compression necrotic fiber were
seen three days later.

31. How to apply an esmarch bandage
for exsanguination
 Elevate the limb
 Wrap the esmarch bandage around the limb,
starting at hand or foot and working proximally.
Tips of toes and fingers and heel can be left free.
 Fully stretch each turn of esmarch bandage
before applying it to the limb.
 Overlap each turn of bandage by ½ inch or 1.25
cm.
 Extremity is wrapped till 2.5 – 5 cm to tourniquet ,
to avoid slipping of tourniquet distally

32. How to apply an esmarch bandage
as a tourniquet
 Esmarch bandage as tourniquet is not
recommended
 In special situation it can be used as
tourniquet . in those condition tourniquet time
should be minimum.
 Apply esmarch as described for
exsanguination. at the upper arm or thigh wrap
the esmarch bandage over padding 4-5 turns.
 Only first turn is applied tightly. The last 3-4
turns must only be wrapped loosely around the
limb.

33.  Slip the remaining bandage under the last turn
so that it lines in the line of artery.
 Then unwind the distal end of the bandage
starting from fingers and tie the two end
securely to the table . To guard against the
patient leaving the theater with the tourniquet
still in place.

34. How to apply a digital tourniquet
 Fingers and toes –
clean and anesthetised the digit
wrap a layer of guaze around the base of
digit
elevate the hand for 4 min and squeeze
wrap a single layer of rubber tubing around
the guaze and pull it tight
secure the tubing with large artery clip

35. For fingers only
 Clean the hand and anasthetise the relevant
digit.
 Ease a sterile surgical gloves over the fingers
and rest of hand
 Cut a small hole in the tip of glove of the
required finger.
 Roll back the glove to the base of finger and
tie at the base of relevant finger.

36. Application of pneumatic
tourniquet
 Apply few layer of orthopaedic wool or towel at
tourniquet site.
 Choose correct size of cuff.
 Express all air from it.
 Snugly wrap the pneumatic cuff around the
limb.
 Ensure that connecting tube lies on the outer
aspect of limb pointing proximally.
 Elevate the limb for 4 min. or exsanguinate the
limb by applying the esmarch bandage .

37.  Raise the pressure of cuff rapidly to
predetermined level to prevent the filling of
superficial vein.
 Not the time and remove the esmarch
bandage.

38. PRECOUTIONS
 Use a colourless skin preparation esp. for finger
and toes.
 Do not allow skin preparation solution to collect
under the edge of the tourniquet.
 If the pressure of tourniquet fall during the
operation, remove the tourniquet completely to
relieve congestion.
 Do not allow the tissues of operative site to
become dry. (regular saline application, avoid use
of hot spot light)
 At the and of operation remove tourniquet and
check for circulation

39. BIER’S BLOCK
 Double pneumatic cuff have been introduced
as an ingenious method of reducing the pain
from tourniquet cuff in BIER’S BLOCK.
 But in double cuff , each cuff size is half of size
than normal cuff, thus high pressure is needed
to occluded the arteries. Which can damage
the underlying soft tissues.
 So it is safer to use standard cuff in bier’s
block.
 In bier’s block operating time is limited up to
40 minutes.

40. Application of bier’s block in upper
limb
 Patient should be lie supine.
 Dilute 20 ml of 0.5% plain bupivacaine HCL to a final
volume of 50 ml in NS, this will produce 0.2 %
solution .
 The maximum recommended dose of bupivacaine is
1.5 mg/ kg body weight ( lignocaine 3 mg/ kg) .
 Measure the BP of patient.
 Apply a tourniquet cuff in upper arm but do not inflate
it.
 Insert a small indwelling needle or plastic cannulla into
a suitable vein.
 Exsanguinate the upper limb by elevation or esmarch
bandage.

41.  Inflate the cuff to a pressure 50 mm of hg
higher than SBP.
 Inject the required dose of 0.2% of
bupivacaine and then gently massage the limb
to facilitate the spread of the anesthetic
solution. Patient will experience the feeling of
warmth and paraesthesia.
 Wait for analgesia to develop. This usually
takes 4 – 6 min. of time.
 If analgesia is patchy or inadequate inject a
further 5 to 10 ml of bupivacaine solution.

42.  On completion of operation deflate the cuff.
 Remove the indwelling needle. Sensation will
usually return within 8 minute.
 Allow the patient to recover under supervision.

43. WHY BUPIVACAINE HCL ?
 LOW SYSTEMIC TOXICITY.
 LONGER ACTING.
 4 TIMES MORE POTENT THAN LIGNOCAINE.
strong warning has been issued by
committee on safety of medicine that bupivacaine
should no longer be used for bier block. Serious
complication like cardiac arrest are more likely to
occur than with lignocaine.

44. THANK YOU