Tourniquet

1. Tourniquet
Dr. Syauqat

2. Definition
• A tourniquet is a device constricting or compressing device used to
control venus and arterial circulation to an extremity for a period of
time.
• Pressure is applied circumferentially upon the skin and underlying
tissues of alimb,pressure then transferred to walls of vessls,causing
temporary occlusion.
• Surgcal tourniquet prevents blood flow to a limb and enable surgeons
to work in a bloodless operative field and are frequently used in
orthopaedic surgery.
• Emergency tourniquet s are used in emergency bleeding

3. Uses
• Extremity surgery
• Intervaneous regional anesthesia
• Intervaneous regional sympathectomy
• Isolated limb perfusion
• Control bleeding
Contraindications:
-severe crush injury
-Peripheral arterial disease
-DVT
-MALIGNANCY

4. Types of tourniquet
NON-Pneumatic Tourniquet
-only in certain cases
-Unknown pressure exerted (Adult
900mmhg ,Children upto 1015mmhg
Pneumatic tourniquet
-same concept as blood pressure cuff
-consists of
1.inflatable cuff
2.Compressed gas
3. Pressure display
4.Pressure regulator
5.Connection tubing

5. Application
• Applied proximal part of the limb at the greatest circumference –best protection for the nerve
• Adequate padding should be done at the site (orthoban)
• Thickness of padding may reduce the pressure exerted
Exsanguination
-done before inflation,better in providing bloodless field
Done by limb elevation,arm at 90 degree for 5 min
Leg at 45 degree fro 5 min
Using elastic wrap or bandage –wrapped till 2.5-5cm to tourniquet
overlap eac turn of bandage 1.25cm
Result in autotrasnfusion of blood from the peripheral circulation
into the central circulation.
Malignancy,infection thrombi,fracture
-simple elevation or no wrapping
Advantages-establish clear operating field
-reducing overall blood loss
-reduce risk of microemboli
- minimize pain

7. • Width
-upper limb more than 20% of the diameter
-lower limb more than 40 % of the diameter
• Tourniquet cuff should overlap at least 3
inch but not more than 6 inches.
• Widder cuff lesser pressure is required to
provide occlusion
• Narrow cuff require higher pressure

9. Tourniquet cuff pressure
• LOP –Limb occlusion pressure
• LOP,pressure which the arterial pulse distal to the tourniquet
disappears
• Assess by Doppler probe
• LOP is usally higher than the pressure that is actually transmitted to
the extremities and is also dependant on the circumference of the
limbs.

10. • Common practice fixed pressure 250mmhg upper limb and
300mmhg lower limbs
• Inflate by a certain fixed pressure above SBP(100mmhg above SBP for
upper libs and 100-150mmhg for lower limbs).
• Disadvaantages can lead to over inflation
• AORN guidelines
-safety margin is added to cover intraoperative fluctuations in arterial
pressure
LOP is <130mmhg then 40mhg is added
LOP I 131-190mmhg,60 mmhg is added
If LOP is 190mmhg,90mmhg is added
So young,slim,normotensive adult may require cuff pressure
<200mmhg

11. Duration
• A period of 1.5 -2 hr in a healthy adult,coreesponds to the point at
which muscle ATP stores are depleted (3hr max)
• 3 fold increase in the risk of neurological complications for each 30
min exceeding tourniquet time
• Deflation for 5-10 in for every 30 min of inflation.
• Allowing metabolic waste removed and reperfusion occurs

13. • Nerve injury
-Upper limb radial ulnar  median
-lower limb sciatic nerve –most common
-large diameter nerve fibre more commonly affected
• Muscle injury – greatest beneath the tourniquet (ischemia and
defoemation)
-pressit after deflation due to microvascular congestion
-post tourniquet syndrome -weakness palsy without anasthesisa
-3 weeks usally normalize

14. • Excess bleed intra op
- Poor techinuque applied
- Calcified vessels
- -vessel bypasses the tourniquet through the medulla of the humers
or femur occur after 30 min after inflation of tourniquet-not esolved
by increasing pressure
• Tourniquet pain –

15. Post tourniquet syndrome
• Comined effect of muscle ischemia,edema and microvascular congestion
• Immediate swelling post deflation-reactive hyperaemia,increase capillary
prmeablity
• Determined by patient comorbids and duration f tourniquet
• Features:
-Puffiness of skin and fingers
-joint stiffness
-numbness
-weakness with no real paralysis