TOURNIQUETS IN ORTHOPEDICS : TOURNIQUETS IN ORTHOPEDICS DR. NAVEED AHMED
JPMC WARD-26 OVER VIEW : OVER VIEW History
Recommendations HISTORY OF TOURNIQUETS : HISTORY OF TOURNIQUETS HISTORY : HISTORY Early Roman
Reduce blood loss during amputations
Narrow bands of cloth
Fillet HISTORY : HISTORY Ambrose pere (1510-1590) Recommended the operative use of a tourniquet HISTORY : HISTORY Jean Louis Petit (1718)
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)
Bloodless limb surgery TYPES OF TOURNIQUETS : TYPES OF TOURNIQUETS TYPES OF TOURNIQUETS : TYPES OF TOURNIQUETS Surgical tourniquets
manual TYPES OF TOURNIQUETS : TYPES OF TOURNIQUETS Battle field/ Trauma scene Tourniquet
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
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
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
Elevation of limb for two minutes
Pneumatic air splint
applied closely and snugly to the padding to avoid skin trauma
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
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
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
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
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
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
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.
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).
Develops in up to 66% of patients COMPLICATIONS : COMPLICATIONS Arterial 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.
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