principles of tourniquet in orthopaedic surgery.pptx
1. Principles of tourniquet in
orthopaedic surgery
by
Tijani Sadiq
Moderator: Dr. Ejagwulu F. S.
Date: August 4th ,2022
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Discuss Tourniquet in orthopaedic Surgery
2. Outline
• Introduction
• Types of Tourniquet
• Indications
• Contraindications
• Principles
• Systemic Effects of Tourniquet
• Complications
• Conclusion
• References
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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
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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
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5. Types of Tourniquet
• Non Pneumatic Tourniquet
• Pneumatic Tourniquet
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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
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7. Types of non pneumatic tourniquet
• Infusion tubes
• Surgical gloves
• Esmarch bandage
• Martin sheet rubber
• Others/improvised
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8. Types of non pneumatic tourniquet
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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
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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.
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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.
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14. Uses
• Diagnostic
• Phlebotomy
• Therapeutic
• Haemostatic
• Bloodless fields and procedures
• Control haemorrhage
• Anaesthetic-Bier’s block
• Isolated Regional Chemotherapy (Isolated Limb Perfusion
Chemotherapy)
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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
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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
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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
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19. Principles
• Applied away from surgical site to
avoid contamination
• Ensure an accurate pressure
display.
• Ensure adequate padding
• Apply the ideal cuff
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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
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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
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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
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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
• Tourniquet pain
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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 CO2 decrease in arterial pH.
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25. Respiratory Effects
• Tourniquet deflation is associated with a transient increase in-end tidal
carbon dioxide tension (ETCO2) by 0.13-2.4 kPa that peaks within one
minute and returns to baseline values within 10-13 minutes.
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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.
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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.
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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.
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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.
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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
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32. Systemic complications
• Cardiac Arrest
• Cardiac Failure
• Hyperthermia
• Thrombo-embolism
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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.
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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.
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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
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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”, 1st 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
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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
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Notes de l'éditeur
Jean Louis Petit (1718) described his invention of screw tourniquet Coined word “tourniquet” from French word tourner which means “to turn”
Cuff, similar to a blood pressure cuff, which is wrapped around a patient’s limb and then inflated
Pressure gauge designed to maintain pressure in the cuff at a set value
Non-automatic-leakage is possible
Automatic-constant supply of gas
Rajpura et al. showed that application of more than two layers of padding resulted in a significant reduction in the actual transmitted pressure.
A, Straight (rectangular) tourniquets fit optimally on cylindrical limbs. B, Curved tourniquets best fit conical limbs. (From Pedowitz RA, Gershuni DH, Botte MJ, et al
Braithwaite and Klenerman’s Modification of Bruner’s Ten Rules of Pneumatic Tourniquet Use
Background: The modern arterial tourniquet is an automatic tourniquet system which contains many features that help to minimise complications and improve safety. However, the non-pneumatic tourniquet is still in use, a practice that may be commoner in resource-constrained settings. This study was conducted to investigate the types of tourniquet available and used by orthopaedic surgeons in Nigeria as well as the practical aspects and complications of their use of the tourniquet.
Materials and methods: At an Annual General Meeting/Scientific Conference of Nigerian Orthopaedic Association, a survey was conducted among orthopaedic surgeons using a pre-tested self-administered questionnaire which contained questions on types of tourniquet, practical aspects of the use of tourniquet and complications.
Results: The non-pneumatic tourniquet was usually used by 60.2% of the respondents and 58.1% of those who had both pneumatic and non-pneumatic tourniquets used the latter more commonly. In most cases, the tourniquet was applied by surgeons or surgical residents on the arm or thigh. Surgeons who had ever used the tourniquet in diabetic patients were 71.6% while 29.5% had used it in patients with sickle cell disease. Tourniquet duration was usually 1½ h and 2 h in the upper and lower limbs, respectively. The two most common complications were tourniquet palsy and tourniquet pain.
Conclusions: The non-pneumatic tourniquet was more commonly used than the pneumatic tourniquet. Application of the tourniquet on sites other than the thigh and the upper arm were uncommon. The most common complication was neurologic injury.
Keywords: Esmarch bandage; Nigeria; non-pnematic tourniquet; orthopaedic surgery; orthopaedics; pneumatic tourniquet; tourniquet.
