tourniquet in orthopedics

this slide was presented to department of Orthopedics,
Shree Birendra Army Hospital , Nepal

1. Tourniquet in Orthopaedics Dr. ELIZ ACHHAMI INTERN NAIHS-TU,NEPAL

2. Definition A tourniquet is a constricting or compressing device used to control venous and arterial circulation to an extremity for a period of time. Pressure is applied circumferentially upon the skin and underlying tissues of a limb; this pressure is transferred to the walls of vessels, causing them to become temporarily occluded.

3. History Jean Louis Petit coined the word “Tourniquet” from theFrench word tourner (to turn) in 1718 when he used them for lower limb amputations to reduce blood loss. In 1873 , Johan friedrich august von esmarch introduced flat rubber tube wrapped repeatedly around the limb as tourniquet In 1904 Harvey cushing introduced pneumatic tourniquet to limb surgery Johan friedrich august von esmarch

4. Esmarch Pneumatic – microprocessor controlled Pneumatic manual Petit original

5. TOURNIQUET SURGICAL EMERGENCY TOURNIQUET TOURNIQUET Surgical Tourniquets prevent blood flow to a limb and enable surgeons to work in a bloodless operative field and are frequently used in orthopaedic surgery. Emergency Tourniquets are used in emergency bleeding control to prevent severe blood loss from limb trauma.

6. Uses in Orthopedics Reduction of certain fractures. Kirschner wire removal. Replacement or revision of the joints of the knee, wrist, digits, hand, or elbow. Arthroscopy of the knee, elbow, wrist, hand, or digits . Repair of traumatic nerve damage .

7. Cont’d Bone grafts. Graft and repair of lacerated tendons . Subcutaneous fasciotomy . Carpal tunnel release. Traumatic or non traumatic amputation. Correction of a hammer toe .

8. Parts of tourniquet Inflatable cuff Gas source ( nitrogen or air ) Pressure display Pressure regulator (within 2-6 mmHg) Connection tubing

9. Proper application should be applied very carefully to the proximal part of the limb at the greatest circumference. Adequate padding should be done at that site but no loose cotton . 3 inches to 6 inches overlap.

10. Exsanguination Exsanguination before inflation of the tourniquet improves the quality of the bloodless field and minimizes pain. Normally done by limb elevation, maximal exsanguination can be achieved by elevation of the arm or leg for 5 min at 90◦and 45◦ respectively, without mechanical compression . or using an elastic wrap of the extremity. Malignancy, infection thrombi, fracture – simple elevation or nothing – no wrapping

11. Tourniquet Cuff Pressure LOP can be defined as the minimum pressure required to stop the flow of arterial blood into the limb distal to the cuff.( limb occlusion pressure) Not well defined Preop LOP Safety in kids - ??

12. Inflation or occlusion time One hour Not yet defined but may be up to three hours 10 minute deflation interval every one hour Pediatric patients – better less than 75 minutes

13. Tourniquet related complications

14. Local Normal physiological conduction block in fifteen minutes Nerve injuries – 0.37% The radial nerve, followed by the ulnar and median nerves in the upper limb. The sciatic nerve in the lower limb are most commonly involved. L arge diameter nerve fibers are more commonly affected.

15. Muscle injury T ends to be greatest beneath the tourniquet because of the combination of ischaemia and mechanical deformation. M ay persist after tourniquet deflation as a result of micro- vascular congestion Post tourniquet syndrome – weakness palsy without anesthesia Three weeks – usually normalize.

16. Excess bleeds intra op under-pressurized cuff, insufficient exsanguination, improper cuff selection, loosely applied cuff, calcified vessels or too slow inflation or deflation . Bleeding may occur despite a properly applied and inflated tourniquet, in a patient with noncalcified vessels. ( the phenomenon of tourniquet ooze .)

17. Vessel bypasses the tourniquet through the medulla of the humerus or femur. It typically starts about 30 minutes after tourniquet inflation Increasing the tourniquet pressure does not help

18. Tourniquet pain The smaller unmyelinated C-fibers are more resistant to LA induced conduction block as compared A-fibers C-fibers start conducting impulses before the A-fibers, resulting in a Dull aching poorly localized tight pain. Increased HR and BP ( tourniquet hypertension) Difficult to prevent and treat this – even in spinal and dense blocks

19. Tourniquet pain Eutectic mixture of local anesthetic (EMLA) cream application , LAs given via the neuraxial route with or without opioids have been used to attenuate tourniquet-induced pain. Adjuvants – Magnesium sulfate , ketamine, ketorolac and clonidine Alternative techniques like electro puncture and meditation.

20. Pre-application precautions The pressure source, cuff, regulator, tubing, and connectors need to be checked before use as wide a cuff as possible should be used . The cuff should not directly overlie bony prominences. The cuff should overlap at least 3 inches, but not more than 6 inches as it may cause generation of high pressures.

21. The extremity should be exsanguinated before inflation of the tourniquet. Tourniquet inflation pressure should be kept to the minimum effective pressure.

22. Bruner's ten rules for the safe use

23. C ontraindications Peripheral vascular disease Arteriovenous (AV) fistula Peripheral neuropathy DVT in the limb Severe infection of the limb Severe trauma to the limb Poor skin condition of the limb Sickle cell haemoglobinopathy

24. Conclusion Tourniquets are useful aids for limb procedures. Pre-determination of LOP and inflating tourniquets accordingly can help reduce the complications. Proper patient monitoring and care after deflation for neurological deficit postoperatively can minimize the complications.