Proposed Clinical Guidelines for
Large-Circumference Thighs
For large and obese thighs,
conventional tourniquet cuffs may not
work: (1) the shape of the limb may be
too tapered or conical for a cuff
designed to encircle a cylindrical limb;
(2) the presence of large amounts of
fatty tissue may seriously impair the
ability of the cuff to stop blood flow
when inflated to typical tourniquet
pressures; and (3) the limb circumference
may be sufficiently large so that the
largest standard cuff may not encircle
the thigh.
For conical and tapered thighs typical
of certain obese patients, alternative
cuffs are available if the best standard
tourniquet cuffs, such as Zimmer A.T.S.
Cylindrical Cuffs, do not fit well. For
example, "Low Pressure" Thigh
Cuffs are available from Delfi Medical (www.delfimedical.com).
These specialty cuffs may provide a
better fit to the highly tapered limbs of
some obese patients, and thus produce a
better tourniquet effect when inflated.
Also, the Delfi Low Pressure Cuffs are
wider than standard tourniquet cuffs and
the extra width may allow a lower
pressure to be used to occlude blood
flow.
A figure of the extended cuff is shown
here.
To minimize the pressure required in a
tourniquet cuff applied to an obese
thigh, a specialized technique of cuff
application may be worthy of
consideration. Krakow, in a 1982 paper in
Clinical Orthopedics and Related Research
(Vol 168) describes how best to apply a
tourniquet cuff to the thigh of an obese
patient. In essence, Krakow’s
technique involves the following: (1) the
cuff is applied loosely on the proximal
thigh by a first person; (2) a second
person grips the fatty tissue distal to
the thigh and retracts it distally; (3)
while the tissue is being retracted by
the second person, the first person
increases the snugness of cuff
application (typically, in Zimmer and
Delfi cuffs, by pulling on the ribbon tie
straps with one hand and the velcro
securing strap with the other hand); and
(4) the second person releases the
retracted tissue after the cuff has been
secured snugly around the limb. This
technique usually results in a cuff that
stays fixed at the applied location, and
that transfers pressure well from the
inflated cuff to underlying, non-fatty
tissue, thus reducing the pressure
required to stop blood flow past the cuff
in the obese thigh.
To download a copy of Krakow's paper,
click on the following icon:
To estimate the minimum effective
pressure required to stop blood flow past
a cuff applied to an obese thigh of an
individual patient, the use of a
technique based on the measurement of the
individual patient’s "limb
occlusion pressure (LOP)" is
recommended. A summary of this technique,
together with pertinent references from
the clinical literature, is given here. The
surgeon may wish to have the LOP measured
prior to surgery if desired.
For some extremely obese patients
having fatty thighs up to 58 inches (147
cm) in circumference, special
"extended cuffs" are available
from Delfi Medical; these cuffs will
encircle large-circumference thighs, but
may not occlude blood flow in all cases.
Whenever such a cuff is used, is it
strongly recommended that LOP be measured
by the surgeon prior to surgery, to
determine whether blood flow can be
occluded by the cuff, and if so to
provide the basis for the surgeon’s
determination of the tourniquet pressure
setting to be used.
|
A Manoever for Improved
Positioning of a Tourniquet in
the Obese Patient