principles of tourniquet in orthopaedic surgery.pptx

principles guiding the use of tourniquet in orthopaedic practice

1. Principles of tourniquet in orthopaedic s urgery by Tijani Sadiq Moderator: Dr. Ejagwulu F . S. Date: August 4 th ,2022 8/4/2022 1 Discuss Tourniquet in orthopaedic Surgery

2. Outline Introduction Types of Tourniquet Indications Contraindications Principles Systemic Effects of Tourniquet Complications Conclusion References 8/4/2022 Discuss Tourniquet in orthopaedic Surgery 2

3. Introduction Constricting or compressing device used to control venous and arterial circulation to the upper or lower extremity for a period of time . Pressure is applied circumferentially upon the skin and underlying tissues of a limb; transferred to the walls of vessels, causing temporary occlusion 8/4/2022 Discuss Tourniquet in orthopaedic Surgery 3

4. Historical perspective Jean Louis Petit (1718) described his invention of screw tourniquet Joseph Lister (1860) was the first surgeon to use tourniquet to create a bloodless field for operations other than amputation Johan Friedrich August Von Esmarch;1873, introduced flat rubber tube wrapped repeatedly around the limb as tourniquet . Harvey Cushing; in 1904 introduced the pneumatic tourniquet . Dr. McEwen(1984) electronic tourniquet system 8/4/2022 Discuss Tourniquet in orthopaedic Surgery 4

5. Types of Tourniquet Non Pneumatic Tourniquet Pneumatic Tourniquet 8/4/2022 Discuss Tourniquet in orthopaedic Surgery 5

6. Non pneumatic tourniquet They were invented long before pneumatic tourniquet and are still currently in use . Pressure exerted by them on underlying tissue is unknown . The pressure is dependent on the individual applying the tourniquet 8/4/2022 Discuss Tourniquet in orthopaedic Surgery 6

7. Types of non pneumatic tourniquet Infusion tubes Surgical gloves Esmarch bandage Martin sheet rubber Others/improvised 8/4/2022 Discuss Tourniquet in orthopaedic Surgery 7

8. Types of non pneumatic tourniquet 8/4/2022 Discuss Tourniquet in orthopaedic Surgery 8

9. Pneumatic Tourniquet Are based on the same principles of blood pressure cuffs but they are stronger . Pneumatic tourniquets consist of three basic components : Cuff Compressed gas source Pressure gauge 8/4/2022 Discuss Tourniquet in orthopaedic Surgery 9

10. Pneumatic Tourniquet 8/4/2022 Discuss Tourniquet in orthopaedic Surgery 10

11. Pneumatic Tourniquet Non-automatic Automatic Discuss Tourniquet in orthopaedic Surgery 8/4/2022 11

12. Non Automatic pneumatic tourniquet There is no automatic compensation for leak in the system so regular check is required . Regular check on pressure in cuff . Hand pump is small so it is difficult to raise pressure above systolic pressure rapidly thus it can cause venous engorgement. 8/4/2022 Discuss Tourniquet in orthopaedic Surgery 12

13. Automatic 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.   8/4/2022 Discuss Tourniquet in orthopaedic Surgery 13

14. Uses Diagnostic Phlebotomy Therapeutic Haemostatic Bloodless fields and procedures Control haemorrhage Anaesthetic -Bier’s block Isolated Regional Chemotherapy (Isolated Limb Perfusion Chemotherapy) 8/4/2022 Discuss Tourniquet in orthopaedic Surgery 14

15. Indications Reduction of certain fractures Arthroscopy of knee, wrist, digits, hand or elbow Bone grafts Kirschner wire removal Traumatic or non traumatic amputations Tumour and Cyst excision 8/4/2022 Discuss Tourniquet in orthopaedic Surgery 15

16. Indications Nerve injuries Tendon Repair Replacement or revision of the joints of the knee, wrist, digits, hand or elbow Correction of a hammer toe Subcutaeneous Fasciotomy 8/4/2022 Discuss Tourniquet in orthopaedic Surgery 16

17. Contraindications Absolute Peripheral vascular disease Arterio -venous fistula Previous vascular surgery Malignancy Infection/Sepsis Relative Sickle cell disease Thrombo -embolism Diabetes Mellitus Obesity Rheumatoid Arthritis 8/4/2022 Discuss Tourniquet in orthopaedic Surgery 17

18. Principles Conduct an adequate pre-operative patient assessment Know when and who to exsanguinate e.g. Tumors, Infection ? SCD Who ever apply should be the one to remove Prophylactic antibiotics should be given 10 minutes before applying a tourniquet Do not cover tourniquet 8/4/2022 Discuss Tourniquet in orthopaedic Surgery 18

19. Principles Applied away from surgical site to avoid contamination Ensure an accurate pressure display . Ensure adequate padding Apply the ideal cuff 8/4/2022 Discuss Tourniquet in orthopaedic Surgery 19

20. Principles Adequate tourniquet pressure should be used; Reid et al . proposed a tourniquet pressures of 135 to 255 mm Hg for the upper extremity and 175 to 305 mm Hg for the lower extremity were satisfactory for maintaining hemostasis. The tourniquet time for upper limbs is 60-90 minutes while the tourniquet time for lower limb is 90-120 minutes. Periodic deflation for about 10-15 min followed by re-inflation can permit more prolonged use 8/4/2022 Discuss Tourniquet in orthopaedic Surgery 20

21. Principles Inform the surgeon regularly of elapsed tourniquet time every 30 minutes Release Tourniquet before wound closure Re-assess and document circulation, motor and sensation The length of time before permanent damage Muscle 4 ; Nerve 8; Fat 13; Skin 24 hrs ; Bone 4 days 8/4/2022 Discuss Tourniquet in orthopaedic Surgery 21

22. Systemic effects of tourniquet use Systemic effects are related to the inflation or deflation of the tourniquet . Cardiovascular Effects Metabolic Changes Respiratory Effects Central nervous system Hematological Effects Temperature changes 8/4/2022 Discuss Tourniquet in orthopaedic Surgery 22

23. Cardiovascular Effects Circulating Blood volume and vascular resistance increases. After tourniquet inflation for 30-60 minutes patients may develop an increase in heart rate, systolic and diastolic pressure that persists until tourniquet deflation T ourniquet pain 8/4/2022 Discuss Tourniquet in orthopaedic Surgery 23

24. Metabolic Changes After 1-2 hours of ischaemia , arterial serum potassium and lactate concentrations increase by 0.28-0.32 mmol/L and by 2.13 mmol/L respectively for about 30 minutes after deflation. Lactic acid from the ischaemic limb increase in arterial partial pressure of CO 2 decrease in arterial pH. 8/4/2022 Discuss Tourniquet in orthopaedic Surgery 24

25. Respiratory Effects Tourniquet deflation is associated with a transient increase in-end tidal carbon dioxide tension (E T CO 2 ) by 0.13-2.4 kPa that peaks within one minute and returns to baseline values within 10-13 minutes. 8/4/2022 Discuss Tourniquet in orthopaedic Surgery 25

26. Cerebral Circulatory Changes Multi-trauma patients with severe head injuries can suffer marked intracranial pressure increases when lower limb tourniquets are released. The resultant increased cerebral blood volume can contribute to secondary brain injury. Normocapnia maintained by hyperventilation following tourniquet deflation can prevent the increase in intracranial pressure. 8/4/2022 Discuss Tourniquet in orthopaedic Surgery 26

27. Hematological Effects Pain caused by the tourniquet and surgery provide the release of catecholamines, which promote platelet aggregation and may initially result in systemic hypercoagulability However , limb tissue ischaemia following tourniquet inflation promotes tissue plasminogen activator release, activating the antithrombin III and thrombomodulin -protein-C anticoagulant systems in the occluded limb and causing systemic thrombolysis when the tourniquet is deflated. 8/4/2022 Discuss Tourniquet in orthopaedic Surgery 27

28. Hematological Effects Reports of fatal pulmonary emboli associated with lower limb exsanguination, tourniquet inflation and deflation suggest that tourniquets are contraindicated in patients at high risk of deep vein thrombosis. 8/4/2022 Discuss Tourniquet in orthopaedic Surgery 28

29. Temperature changes A rise in the temperature of the body core occurs during the inflation of arterial tourniquets because of reduced metabolic heat transfer from the central compartment to the peripheral compartment, and also from decreased heat loss from distal skin. 8/4/2022 Discuss Tourniquet in orthopaedic Surgery 29

30. Complications Local Systemic 8/4/2022 Discuss Tourniquet in orthopaedic Surgery 30

31. Local complications Skin; Pressure necrosis, Blisters Tourniquet palsy; Neurapraxia , Parasthesias Tourniquet Ischaemic Injury ; Plaque rupture in an artheromatous vessel, Arterial Spasm Post Tourniquet Syndrome Compartment syndrome Gangrene 8/4/2022 Discuss Tourniquet in orthopaedic Surgery 31

32. Systemic complications Cardiac Arrest Cardiac Failure Hyperthermia Thrombo -embolism 8/4/2022 Discuss Tourniquet in orthopaedic Surgery 32

33. Local experience A survey of the use of tourniquet among orthopaedic surgeons in Nigeria Adesina Ajibade   Olusegun Michael Oladipo     Ya'u Zakari Lawal   Kehinde Sunday Oluwadiya Nigerian Postgraduate Medical Journal Actions 2021 Apr-Jun;28(2):133-138. 8/4/2022 Discuss Tourniquet in orthopaedic Surgery 33

34. Future trends Prolonged Tourniquet Ischeamia can be prevented by local hypothermia. This suggests a possible future development in clinical work. Two simple practical suggestions for keeping the limb with a tourniquet cool are the frequent irrigation of the operative field with cold saline and the avoidance of hot spotlights. 8/4/2022 Discuss Tourniquet in orthopaedic Surgery 34

35. Conclusion Tourniquets are useful devices to provide a bloodless surgical field and reduce the chance of iatrogenic damage. Patient factors and the anticipated surgical time should be carefully considered. The optimal pressure should be applied for the minimum duration 8/4/2022 Discuss Tourniquet in orthopaedic Surgery 35

36. Thank you for listening 8/4/2022 Discuss Tourniquet in orthopaedic Surgery 36

37. References Apley’s system of Orthopaedics and fractures ninth edition by Louis S, David W, Selvadurai N. L.K Almas, G. Andrew “Tourniquet Uses and Precautions” Surgery volume 29(2), 2011, Page 73-75 D.Patrick , “The Tourniquet Manual-Principles and Practice”, 1 st Edn ; British Journal of Anaesthesia , Volume 93, August 2004, Page 311 A.Rowse , “The pathophysiology of the arterial tourniquet: a review” Southern African Journal of Anaesthesia and Analgesia, November 2002, Page 22-24 August 4, 2022 Discuss Tourniquet in Surgery 37

38. References … A survey of the use of tourniquet among orthopaedic surgeons in Nigeria by Adesina Ajibade   ,  Olusegun Michael Oladipo   ,   Ya'u Zakari Lawal   ,   Kehinde Sunday Oluwadiya   J.F.Kragh Jr, K.G.Swan , R.L.Mabry , L.H.Blackbourne , “Historical review of emergency tourniquet use to stop bleeding” The American Journal of Surgery(2012) Page 203, 242-252 Kumar K, Railton C, Tawfic Q. Tourniquet application during anesthesia: “What we need to know?”. J Anaesthesiol Clin Pharmacol 2016;32:424-30. P.C.A. Kam, R.Kavanaugh , F.F.Y. Yoong . “The arterial tourniquet: Pathophysiological consequences and anaesthetic implications” Anaesthesia 2001 56 Page 534-545 August 4, 2022 Discuss Tourniquet in Surgery 38