Tourniquet: surgical

A tourniquet is a mechanical device used for the temporary control of the circulation of blood. 

Tourniquets are used during surgery of the extremeties to restrict blood flow, thus creating a 'bloodless' field of vision for the surgeon (Rothrock, 2014).

All staff involved in the use of tourniquets must know:

  • the anatomy and physiology of the extremity (Rationale 1)
  • the potential risks to the patient 

Potential risks associated with tourniquets include:

  • local skin damage under a poorly applied cuff
  • local tissue/nerve damage from over inflation
  • compromised circulation caused by extended use 
  • peripheral nerve and vessel damage

Prior to use

The tourniquet should be checked prior to use, ensuring that the cuff is not leaking, connections are not loose, tubing is not worn and the equipment is clean (Rationales 2 and 3).

Worn or damaged parts/equipment must not be used (Rationales 2 and 3).

Worn or damaged parts must be removed from the area and replaced or repaired as soon as possible (Rationale 2 and 3).

The widest possible size of cuff should be selected for use (Association for Perioperative Practice (AfPP), 2011)(Rationale 4).

The cuff should not overlap more than 15cm (AfPP, 2011)(Rationale 5).

Application of the tourniquet cuff

Apply under cuff padding to the point of the limb, which offers the greatest amount of soft tissue ie not over a boney prominence (Rothrock, 2014)(Rationales 6 and 7).

Ensure that the under cuff padding is the same width as the tourniquet cuff (Rationale 8).

The cuff should be positioned on the point of the limb, which offers the largest amount of soft tissue ie not over a boney prominence (AfPP, 2011) (Rationale 9).

Ensure that the cuff is placed over the under cuff padding and does not obscure the site of surgical incision (Rationale 10).

On male patients it is essential to check that genitalia are not caught in the tourniquet cuff when it is placed high on the leg (Rationale 11).

A minimum of two people must always be available when applying a tourniquet cuff and the under cuff padding (AfPP, 2011)(Rationale 12).

The patient's skin should be protected from prep solutions accumulating under the tourniquet cuff by the application of an occlusion dressing or holding the limb horizontally to the patient's body while prep solutions are applied and until the sterile drapes are applied (Rationale 13).

The use of an adhesive occlusive dressing should not be used on children suffering from epidermolysis bullosa (Rationale 14).

Avoid over prepping of the required surgical area (Rationale 13).

If the limb is elevated during prepping ensure any excess prep solution that comes in contact with the tourniquet is dried prior to draping (Rationale 13).

Attach the tubing to the correct pressure regulator on the tourniquet machine, ie the left inflation tubing from the left cuff is attached to the left pressure regulator.

Exsanguinate the limb by using one of the following methods (Rationale 15):

  • an Esmarch bandage
  • a roll cylinder
  • limb elevation prior to inflation (AfPP, 2011)

If an Esmarch bandage is to be used it should be applied from the extremity tip towards the tourniquet cuff. The bandage should overlap by 2.5 cm (1 inch) and continuous pressure must be applied during application (AfPP, 2011)(Rationale 16).

An Esmarch bandage should not be used on children suffering from epidermolysis bullosa, the limb should be elevated instead (Rationale 14).

During use

Tourniquet pressure will be selected depending on the patient’s systolic blood pressure, patient age and limb size (Rothrock, 2014)(Rationale 17).

It is the surgeon’s responsibility to approve the tourniquet pressure setting (AfPP, 2011)(Rationale 18).

Inflate the cuff to the required pressure (Rationale 19).

Ensure that the cuff has inflated.

Remove the Esmarch bandage, or roll cylinder, or lower the limb.

Activate the tourniquet clock.

The duration of use should be kept to a minimum (Rothrock, 2014)(Rationale 20).

The tourniquet machine should be visible during the procedure and not occluded by sterile drapes (AfPP, 2011).

Circulating staff should record the time inflation occurred on the theatre count board (Rationale 21).

The scrub practitioner should inform the surgeon once the tourniquet has been inflated for one hour (Rationale 20)(AfPP, 2011).

The scrub practitioner should then inform the surgeon every thirty minutes, following the first hour (AfPP, 2011).

The ultimate responsibility for the application and release of the tourniquet is that of the operating surgeon (AfPP, 2011)(Rationales 22 and 23).

The following information should be recorded in the patient perioperative care record (Rationale 24):

  • unit number of the tourniquet machine
  • limb - arm/leg
  • side - right/left
  • pressure
  • time of inflation
  • time of deflation

Any compromise to the integrity of the skin underlying the tourniquet cuff must be reported to the surgeon, an incident form completed and a record of the incident record in the patient’s health care record (Rationale 24).

An explanation of the incident should be given to the child and their family at the earliest opportunity (AfPP, 2011)(Rationale 25).

Decontamination and maintenance

The cuff, tubing and tourniquet unit should be checked for damage between uses.

The cuff, tubing and tourniquet unit should be checked for soiling and should be cleaned between uses with sanitising wipes (Rationale 26).

All equipment must be dried with a clean disposable cloth following decontamination (Rationale 27).

The tourniquet unit must be checked annually by the Biomedical Engineering department.

Rationale

Rationale 1: To minimise the risk of damage to the patient.
Rationale 2: To meet manufacturer’s recommendations.
Rationale 3: To avoid potential damage to the patient.
Rationale 4: Distribution of pressure avoids post-operative complications (AfPP, 2011).
Rationale 5: Too much overlap causes rolling or wrinkling of the underlying tissue and increases pressure in the area of the overlap.
Rationale 6: To reduce skin wrinkling under the tourniquet cuff, thus preventing tissue damage.
Rationale 7: This will provide natural padding for the nerves and vessels, thus helping to prevent peripheral nerve and vessel damage (Rothrock, 2014).
Rationale 8: To provide maximum protection against tissue damage.
Rationale 9: To provide natural padding for the nerves and vessels, thus helping to prevent peripheral nerve and vessel damage (Rothrock, 2014).
Rationale 10: To facilitate optimal operating conditions for the surgery.
Rationale 11: To prevent injury to the patient.
Rationale 12: To ensure adequate application of the cuff, elevation and exsanguination of the limb.
Rationale 13: To prevent the patient suffering from a chemical burn (Rothrock, 2014).
Rationale 14: To minimise damage to skin tissue.
Rationale 15: To facilitate the venous return of blood from the limb and aid in the prevention of blood pooling in the veins.
Rationale 16: To facilitate the process of exsanguination.
Rationale 17: To minimise the potential for tissue, nerve and vessel damage.
Rationale 18: To prevent injury or inadequate use of tourniquet.
Rationale 19: Over-inflation will cause injury and under-inflation will not provide a bloodless operating field.
Rationale 20: To minimise the risk of damage to the patient’s circulation.
Rationale 21: To comply with AfPP standards (AfPP, 2011).
Rationale 22: Release of toxins on deflation of the cuff may produce a drop in systemic blood pressure.
Rationale 23: If the cuff remains on the limb venous blood return may be compromised or obstructed. (Rothrock, 2014).
Rationale 24: To provide accurate documentation in accordance with Trust policy.
Rationale 25: In accordance with trust policy and to facilitate risk management process.
Rationale 26: To prevent cross infection.
Rationale 27: Water trapped in this environment can promote bacterial growth. 

References

Reference 1:
Rothrock J (2014) Alexander's care of the patient in surgery. New York, Elsever.

Reference 2:
Association for Perioperative Practice (AfPP) (2011) Standards and Recommendations for Safe Perioperative Practice. 3rd Edition. Harrogate, Association for Perioperative Practice.

Document control information

Lead Author(s)

Julie Plumridge, Team Leader, Theatres

Additional Author(s)

Anthony Baker, Assistant Practice Educator, Theatres

Document owner(s)

Anthony Baker, Assistant Practice Educator, Theatres

Approved by

Clinical Practice Committee

Reviewing and Versioning

First introduced: 
30 June 2003
Date approved: 
17 July 2015
Review schedule: 
Three years
Next review: 
17 July 2018
Document version: 
3.3
Previous version: 
3.2