APPLICATION OF TOURNIQUET IN ORTHOPAEDICS

PRESENTED BY – DR SUNIL POONIA MODERATED BY – DR. A. K. DAOLAGUPU

PGT MS ORTHOPAEDICS PROFESSOR, MS ORTHO

SMCH,SILCHAR . SMCH,SILCHAR .

Development of tourniquets

The term tourniquet was coined by petit in 1718,to describe the action of his screw device to stop hemorrhage.

lister was the first surgeon to employ it to provide blood less field for operation other than amputation. but he drained the blood of limb by elevation.

In 1873 Johann von Esmarch, Professor of surgery ,he used it to exsanguinate the limb , but prevented blood from re-entering by applying ,around the limb, heavy rubber tubing . but it is associated with nerve palsies.

Harvey cushing ,in 1904, invented pneumatic tourniquet . doveloping it from standard riva-rocci blood pressure apparatus.

he described its use in craniotomies , but soon it was used for operations on limbs.

Types of tourniquet

Non pneumatic tourniquet

Pneumatic tourniquet(non automatic , automatic)

Non pneumatic tourniquet

It is permissible only in exceptional circumstances.

Pressure exerted by them on underlying tissue is unknown.(Adult up to 900mm of Hg , children up to 1015 mm of Hg ).

Esmarch bandage can be autoclaved ( if rolled properly with cloth between each layer. Thus in sterile situation it can be used ( only a few pneumatic cuff can be autoclaved )

Pneumatic tourniquet

Are based on same principles on blood pressure cuffs but they are stronger.

Their fastening are more secure and they usually have stiff backing piece to maintain the effective width of the inflated cuff.

Non automated pneumatic tourniquet

Tourniquet consist of a pneumatic cuff & hand operated pump and pressure gauge.

There is no automatic compensation for leak in the system so regular check is required.

Hand pump is small so it is difficult to raise pressure above systolic pressure rapidly thus it can causes venous engorgement if esmarch bandage is not applied for exsanguination.

Automated 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.

Contra-indication to the use of tourniquet

Peripheral arterial disease.

Severe crush injuries.

Sickle cell disease( if tourniquet must be used , the limb must be exsanguinated thoroughly before inflation of cuff)

Severe infection

Contra-indication to expressive exsanguination

Severe infection

Malignant tumor

Proven or suspected DVT

Site for application of tourniquet.

Must only be placed around upper arm and thigh (exception – digital tourniquet). b/c these are the only site where there is sufficient bulk to distribute the pressure in the cuff evenly.

Must not be placed around forearm ,leg ,wrist ,ankle.

Width of pressure cuff

According to American Heart Association ,if width of cuff is

20% greater than the diameter of upper arm 40% of the circumference of the thigh 8 inch (20 cm) then pressure in them need only be little above

systolic pressure, to maintain bloodless field. length 10 cm in arm , 15 cm in thigh If narrow cuff is used high pressure is needed to

occlude the artery. With narrow cuff tissue immediate beneath a cuff

may be submitted to excessive damaging pressure

Exsanguination

The simplest and safest way to remove most of blood from a limb ,to elevate as vertical as possible for 4 minute.

The blood drain from the vein under gravity and this followed by reflex arteriolar constriction which makes emptying more complete.

More efficient way is to cover whole limb in envelope and then inflation of that envelope.

Or by applying esmarch bandage from the digits to the cuffs.

Tourniquet pressure

upper limb = SBP + 50 mm of Hg

Lower limb = SBP × 2 mm of Hg

Tourniquet time

Must apply for the shortest possible time.

For a healthy person safe limit is for one hour .

For difficult operation it can be used for 1 & ½ - 2 hrs. but 2 hrs is not safe for all patient.

Longer duration is safe as the minimum effective pressure is used.

Care must be taken for elderly , alcoholic , sub clinical neuropathy and unwell patient.

Braithwaite and Klenerman's Modification of Bruner's Ten Rules

Application - Apply only to a healthy limb or with caution to an unhealthy limb

Size of tourniquet - Arm, 10 cm; leg, 15 cm or wider in large legs

Site of application - Upper arm; mid/upper thigh ideally

Padding - At least two layers of orthopaedic wool

Skin preparation - Occlude to prevent soaking of wool. 50– 100 mm Hg above systolic for the arm; double systolic for the thigh; or arm 200–250 mm Hg, leg 250–350 mm Hg (large cuffs are recommended for larger limbs instead of increasing pressure)

Time - Absolute maximum 3 hr (recovers in 5–7 days) generally not to exceed 2 hr

Temperature - Avoid heating (e.g., hot lights), cool if feasible, and keep tissues moist

Documentation calibration and maintenance - Duration and pressure at least weekly against mercury manometer or test gauge; 3-monthly maintenance

Application of more than 2 layer of padding result in significant decrease in pressor transmission to underlying tissue

For obese pt – assistant grasp flesh just distal to level of extremity – pull this loose tissue distally until padding and tourniquet applied – greater protection of subcutaneous tissue and push tourniquet more proximally

The curved tourniquet on conical extremity , significantly reduces arterial occlusion pressure than rectangle one .

Dangers of tourniquet

Tourniquets are dangerous (advantage only to surgeons)

Major complication are rare( 1:5000 in UL,1:13000 in LL, 2:1500 due to faulty instrument).

Can be divided into dangers from ischemia dangers from exsanguination danger from pressure in tourniquet cuff danger from bleeding after closer of wound danger from failing to remove tourniquet

Tourniquet paralysis syndrone

Describe by moldaver in 1954

It is caused by pressure rather than ischemia.

c/f motor paralysis with hypotonia or atonia without

atrophy. sensory dissociation ( touch , position, vibration ,

position sense is lost/ pain sensation intact even hyperalgesia).

colour , temperature and sympathetic function are normal.

peripheral pulse is normal

Electrical study shows block to nerve conduction is at the level of tourniquet.

Excessive pressure distort the myelin sheaths which retract from the nodes of ranvier . this process continues as segmental demyelination.

Axons are preserved. Recovery from full paralysis takes upto

three month.

Couses of tourniquet paralysisI. excessive pressureII. insufficient pressure – congestion

and haemorrhagic infiltration of nerveIII. application for too long IV. application without consideration of

local anatomy

Dangers from ischemia

The tissue distal to cuff become anoxic , acidotic, and loaded with metabolite.

Klenerman found that after 3 hrs it took 40 min. for acid base level in the limb to return to normal.

For ischemia of more than three hrs recovery time increases drastically.

There is controversy in the practice advocated by Bruner (releasing the tourniquet for 10 min after 1 hr ,if surgery require > 1 and ½ to 2 hrs)

Post tourniquet syndrome

Following release of tourniquet there is immediate swelling of tissues (reactive hyperaemia , inc. capillary permeability ).

Swelling is much more severe when tourniquet time is more than 2 hrs.

Post tourniquet syndrome probably due to ischemia.

Longer the period of ischemia , older the patient increase the chance of post tourniquet syndrome.

Clinical feature

Puffiness of skin and fingers ( smoothning out of normal skin crease)

Stiffness of joints

Colour change ( pale on elevation, congested when dependent)

Subjective sensation of numbness

Weakness of muscle without real paralysis.

Prevention of post tourniquet syndrome

Select correct operation for each patient Avoid wasting of time – Care full pre-op planning of operation delaying the application of tourniquet. do not extend the tourniquet time unnecessarily Ensure good hoemostasis Elevate the limb after operation Encourage the patient to perform active

movement

Dangers from exsanguination

Exsanguination by elevation is not hazardous . but there is risk when achieved by compression.

Risks – damage to skin. damage to sub cutaneous nerve. Injury to major vessel may remain

unrecognized fracture spread of infection, malignancy, DVT cardiac overload.

Dangers from pressure in the tourniquet cuff.

Skin necrosis. Occasionally wall of arteries get calcified .chance of fracture

of vessel wall and permanent damage to blood supply of limb.

Local damage of soft tissue under the cuff.

Nerve palsy (diabetes,alcoholism,RA are more prone) muscle damage - Up to 3 hrs of compression ,

recovery was rapid and muscle had normal histological appearance when examined at 24 hrs.

After 5 hrs of compression necrotic fiber were seen three days later.

How to apply an esmarch bandage for exsanguination

Elevate the limb Wrap the esmarch bandage around the

limb, starting at hand or foot and working proximally. Tips of toes and fingers and heel can be left free.

Fully stretch each turn of esmarch bandage before applying it to the limb.

Overlap each turn of bandage by ½ inch or 1.25 cm.

Extremity is wrapped till 2.5 – 5 cm to tourniquet , to avoid slipping of tourniquet distally

How to apply an esmarch bandage as a tourniquet

Esmarch bandage as tourniquet is not recommended

In special situation it can be used as tourniquet . in those condition tourniquet time should be minimum.

Apply esmarch as described for exsanguination. at the upper arm or thigh wrap the esmarch bandage over padding 4-5 turns.

Only first turn is applied tightly. The last 3-4 turns must only be wrapped loosely around the limb.

Slip the remaining bandage under the last turn so that it lines in the line of artery.

Then unwind the distal end of the bandage starting from fingers and tie the two end securely to the table . To guard against the patient leaving the theater with the tourniquet still in place.

How to apply a digital tourniquet

Fingers and toes – clean and anesthetised the digit wrap a layer of guaze around the base

of digit elevate the hand for 4 min and

squeeze wrap a single layer of rubber tubing

around the guaze and pull it tight secure the tubing with large artery

clip

For fingers only

Clean the hand and anasthetise the relevant digit.

Ease a sterile surgical gloves over the fingers and rest of hand

Cut a small hole in the tip of glove of the required finger.

Roll back the glove to the base of finger and tie at the base of relevant finger.

Application of pneumatic tourniquet

Apply few layer of orthopaedic wool or towel at tourniquet site.

Choose correct size of cuff. Express all air from it. Snugly wrap the pneumatic cuff around the

limb. Ensure that connecting tube lies on the

outer aspect of limb pointing proximally. Elevate the limb for 4 min. or exsanguinate

the limb by applying the esmarch bandage .

Raise the pressure of cuff rapidly to predetermined level to prevent the filling of superficial vein.

Not the time and remove the esmarch bandage.

PRECOUTIONS

Use a colourless skin preparation esp. for finger and toes.

Do not allow skin preparation solution to collect under the edge of the tourniquet.

If the pressure of tourniquet fall during the operation, remove the tourniquet completely to relieve congestion.

Do not allow the tissues of operative site to become dry. (regular saline application, avoid use of hot spot light)

At the and of operation remove tourniquet and check for circulation

BIER’S BLOCK

Double pneumatic cuff have been introduced as an ingenious method of reducing the pain from tourniquet cuff in BIER’S BLOCK.

But in double cuff , each cuff size is half of size than normal cuff, thus high pressure is needed to occluded the arteries. Which can damage the underlying soft tissues.

So it is safer to use standard cuff in bier’s block.

In bier’s block operating time is limited up to 40 minutes.

Application of bier’s block in upper limb

Patient should be lie supine. Dilute 20 ml of 0.5% plain bupivacaine HCL to a final

volume of 50 ml in NS, this will produce 0.2 % solution . The maximum recommended dose of bupivacaine is

1.5 mg/ kg body weight ( lignocaine 3 mg/ kg) . Measure the BP of patient. Apply a tourniquet cuff in upper arm but do not inflate

it. Insert a small indwelling needle or plastic cannulla into

a suitable vein. Exsanguinate the upper limb by elevation or esmarch

bandage.

Inflate the cuff to a pressure 50 mm of hg higher than SBP.

Inject the required dose of 0.2% of bupivacaine and then gently massage the limb to facilitate the spread of the anesthetic solution. Patient will experience the feeling of warmth and paraesthesia.

Wait for analgesia to develop. This usually takes 4 – 6 min. of time.

If analgesia is patchy or inadequate inject a further 5 to 10 ml of bupivacaine solution.

On completion of operation deflate the cuff.

Remove the indwelling needle. Sensation will usually return within 8 minute.

Allow the patient to recover under supervision.

WHY BUPIVACAINE HCL ?

LOW SYSTEMIC TOXICITY.

LONGER ACTING.

4 TIMES MORE POTENT THAN LIGNOCAINE. strong warning has been issued by

committee on safety of medicine that bupivacaine should no longer be used for bier block. Serious complication like cardiac arrest are more likely to occur than with lignocaine.

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