tourniquets in orhopedics

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TOURNIQUETS IN ORTHOPEDICS : 

TOURNIQUETS IN ORTHOPEDICS DR. NAVEED AHMED FCPS-II STUDENT JPMC WARD-26

OVER VIEW : 

OVER VIEW History Types Clinical use Pathophysiology Tourniquet time Contraindications Complications Recommendations

HISTORY OF TOURNIQUETS : 

HISTORY OF TOURNIQUETS

HISTORY : 

HISTORY Early Roman Reduce blood loss during amputations Materials: Narrow bands of cloth Fillet

HISTORY : 

HISTORY Ambrose pere (1510-1590) Recommended the operative use of a tourniquet

HISTORY : 

HISTORY Jean Louis Petit (1718) Screw Coined word “tourniquet” from French word tourner which means “to turn”

HISTORY : 

HISTORY Johann Frederic August von Esmarch (1873) Flat rubber bandage

HISTORY : 

HISTORY Harvey Cushing (1904) Pneumatic tourniquet Bloodless limb surgery

TYPES OF TOURNIQUETS : 

TYPES OF TOURNIQUETS

TYPES OF TOURNIQUETS : 

TYPES OF TOURNIQUETS Surgical tourniquets Esmarch Tourniquet Pneumatic Tourniquet Automated manual

TYPES OF TOURNIQUETS : 

TYPES OF TOURNIQUETS Battle field/ Trauma scene Tourniquet Improvised Tourniquets Commercially available tourniquets Combat application tourniquet Emergency military tourniquets Ranger Ratchet tourniquets

CLINCAL USE OF TOURNIQUETS : 

CLINCAL USE OF TOURNIQUETS

Clinical Use of tourniquets : 

Clinical Use of tourniquets Anesthetic use Prevention of blood loss at trauma scene Facilitate surgery

Tourniquet use for anesthesia : 

Tourniquet use for anesthesia Intravenous regional anesthesia Bier block

Tourniquet time for IVRA : 

Tourniquet time for IVRA Minimum 15 to 25 minutes have been recommended. The goal is to minimize systemic toxicity.

IVRA deflation : 

IVRA deflation Generally an inverse relationship between tourniquet time and peak plasma level. Deflate over 10 seconds Arm movement post release - Increases drug levels; therefore keep movement to a minimum.

LA toxicity with IVRA : 

LA toxicity with IVRA Release of toxic LA dose into circulation Common factors in these cases include Automatic tourniquets Bupivacaine Block monitored by non anaesthetist

Tourniquet used to prevent blood loss at the scene of trauma : 

Tourniquet used to prevent blood loss at the scene of trauma One of the leading preventable cause of death after trauma is bleeding from an extremity Attempts should be made to stop the massive bleeding as soon as possible as it falls under “C” of ATLS protocols.

How to prevent blood loss? : 

How to prevent blood loss? Manual pressure and limb elevation Pressure dressing with elastic or non elastic bandages Tourniquets are the last resort

Use of tourniquet in setting of trauma : 

Use of tourniquet in setting of trauma Only used on an arm, forearm, thigh, or leg Used when there is no time to control bleeding Used on an amputation of the arm, forearm, thigh, or leg

Recommendations: : 

Recommendations: Never cover Write “Tourniquet” on the medical tag Conscious patient should tell everyone he has one applied In place for > 6 hrs = dead limb

TOURNIQUETS TO FACILITATE SURGERY : 

TOURNIQUETS TO FACILITATE SURGERY Bloodless surgical field Reduces blood loss Facilitates identification of structures Reduces operating time Reduces surgical complications

Esmarch Tourniquet : 

Esmarch Tourniquet Rubber band wrapped around the limb High pressures generated in excess of 1000 mmHg. Higher incidence of complications Twisting and stretching of skin during application Greater occurrence of nerve injury

Pneumatic Tourniquet : 

Pneumatic Tourniquet Source of pressurised gas connected to an inflatable cuff Cuff is wrapped and secured around the limb Even compression is applied around circumference of the limb Occludes arteries and prevents blood flow into the limb distal to the cuff Controllable pressures Complications are few

Principles of tourniquet application : 

Principles of tourniquet application The pressure and time of application should be recorded The tourniquet width and position must be checked by the operating surgeon. Esmarch rubber bandages used must be applied with care by an experienced technician Disinfectant must not be allowed to run under the tourniquets. The anesthetists should remind the surgeon ’tourniquet time’ at half-hourly intervals. The surgeon records the total duration of the tourniquet time in the surgical operating note.

APPLYING THE TOURNIQUET : 

APPLYING THE TOURNIQUET Exanguination of the limb Tissue compression Elevation of limb for two minutes Pneumatic air splint Padding application applied closely and snugly to the padding to avoid skin trauma Inflation Inflate rapidly to prevent blood from being trapped in the limb

Relative contraindications to exsanguination : 

Relative contraindications to exsanguination Traumatized limb. Poor cardiac reserve (especially leg). Serious limb infection

TOURNIQUET PRESSURE : 

TOURNIQUET PRESSURE Aim is to produce a bloodless field Cuff pressure needs to be high enough to prevent arterial and venous blood flow The lowest pressure that safely assures haemostasis and arterial occlusion is the goal Minimum tourniquet pressure will depend on Limb size Cuff type and cuff width Peripheral vascular disease Intraoperative systolic blood pressure range

SAFE APPROACH : 

SAFE APPROACH Measure the patient's SBP preoperatively and look at chart to note usual range. Inflate the tourniquet an additional 50 to 75 mmHg for the arm and 75 to 100 mmHg for the leg above the baseline SBP.

PATHOPHYSIOLOGY : 

PATHOPHYSIOLOGY

What Happens when A Tourniquet is Placed? systemic effects : 

What Happens when A Tourniquet is Placed? systemic effects Cardiovascular ↑ circulating volume (limb exanguination) ↑ systemic vascular resistance Transient ↑central venous & systolic pressure 30 – 60 min after ↑ diastolic BP & HR “tourniquet pain”

What Happens when A Tourniquet is Placed? systemic : 

What Happens when A Tourniquet is Placed? systemic Hematological: Coagulation system activation in limb Catecholamine release Temperature: Transient ↑ in body temperature

Slide 34: 

Shaw-Wilgis - Biochemical (Venous pH, pO2, pCO2 in the arm) (J Bone Joint Surg. 1997 ; 53-A ; 1343) What Happens when A Tourniquet is Placed? Blood Biochemistry

What Happens when A Tourniquet is Placed? Local effects : 

Nerve injury Neuropraxia ‐> paresthesias to paralysis Most likely: Radial in UE Sciatic in LE Permanent damage rare What Happens when A Tourniquet is Placed? Local effects

What Happens when A Tourniquet is Placed? Local effects : 

Muscle Injury: Ischemia & mechanical damage Microvascular congestion within muscle Intracellular changes: Cell Becomes more acidotic Depletes energy stores Increased lactate / CO2 production What Happens when A Tourniquet is Placed? Local effects

What Happens when A Tourniquet is Placed? Local effects : 

Arterial injury rare Plaque rupture in an artheromatous vessel Thrombosis Skin Pressure necrosis Friction burns What Happens when A Tourniquet is Placed? Local effects

TOURNIQUET TIME : 

TOURNIQUET TIME Absolute limits for tourniquet ischemia and nerve compression have not been established or agreed upon Maximum safe duration recommended on literature review ranges from 1 to 3 hours, most commonly 1.5 to 2 hours Corresponding to the fatigue point of muscle Histological studies show muscle changes at > 1 hour Muscle degeneration and cell necrosis occurs at 2 to 3 hours EMG abnormalities and more subtle functional changes have been demonstrated with times < 1 HOUR.

Duration to Damage : 

Duration to Damage The length of time before permanent damage in an animal model: Muscle 4 hours Nerve 8 hours Fat 13 hours Skin 24 hours Bone 4 days

SAFE TOURNIQUET TIME : 

Factors to consider include: the patient's general health nutritional status tourniquet pressure limb trauma neuropathy PVD SAFE TOURNIQUET TIME

REPERFUSION : 

REPERFUSION Reperfusion periods should be used when prolonged use is needed Allows for correction of metabolic abnormalities in the limb and restoration of depleted energy stores. Studies suggest reperfusion times of between 5 and 20 minutes after the first 2 hours.

DEFLATING THE TOURNIQUET : 

DEFLATING THE TOURNIQUET Deflating a tourniquet leads to the release of blood with low pH and pO2 plus high pCO2, lactate, and K+. Transient fall in central venous oxygen tension (SvO2) Mean decreases in SBP of 14-19 mmHg. Mean increases in HR of 6-12 bpm. Transient fall in core temperature of 0.7C within 90 seconds of deflation of a leg tourniquet. Changes peak at approximately 3 minutes and return to baseline by 30 minutes. These changes are generally mild and well tolerated.

RELATIVE CONTRAINDICATIONS : 

RELATIVE CONTRAINDICATIONS Peripheral Vascular Disease Severely Injured or Traumatized Limb. Peripheral Neuropathy. Severe Infection in the Limb. DVT in the Involved Limb. Severe Arthritic Changes / Bony Spurs. Poor Skin Condition of the Involved Limb. Sickle Cell Haemoglobinopathy.

COMPLICATIONS : 

COMPLICATIONS

COMPLICATIONS : 

COMPLICATIONS Pulmonary Embolus pulmonary emboli secondary to limb exsanguination and tourniquet inflation have been reported. (Anesth Analg, 1984;63:371) Pre op evaluation for venous thrombosis is therefore important Tourniquet Failure (inadequate Heamostasis) Inadequate tourniquet pressure - Arterial and venous leakage. Calcified, incompressible arteries (<1% VASA, 1971;3;160). Inadequate exsanguination. Tourniquet Pain Develops in up to 66% of patients

COMPLICATIONS : 

COMPLICATIONS Arterial Injury Muscle Injury Tissue Changes - Oedema, Compartment Syndrome Post tourniquet Syndrome Swollen, stiff, pale limb with weakness but no paralysis. Duration 1-6 weeks. Postoperative oedema is the main aetiology. Haematoma, Bleeding Pharmacologic Effect Drug Injection after tourniquet inflation leads to higher plasma levels and a shorter elimination half-life. Nerve injury

Recommendations: : 

Recommendations: Always check the tourniquet as part of the equipment check. Use only proper pneumatic tourniquets. Size should be appropriate for limb size. Wider cuffs minimize pressure. Use lowest tourniquet pressure that provides adequate haemostasis safely. Continuously monitor tourniquet pressure. Carefully watch volume status in patients with limited cardiac reserve when exsanguinations

Recommendations: : 

Shortest possible tourniquet time is important Apply tourniquet where the nerves are best protected by muscles. Once the tourniquet has been deflated, immediate removal of the cuff and padding helps decrease oedema When prolonged tourniquet times are necessary use a double tourniquet and intermittent reperfusion periods. Do not allow prep solution to pass under the cuff. Recommendations:

QESTIONS : 

QESTIONS

SUMMARY : 

SUMMARY Use tourniquets tracks back from roman civilizations Used to prevent blood loss and aid during surgery Exerts significant systemic and local effects Expertise and caution is needed to avoid complications