PEDIATRIC TOURNIQUETS:

ANALYSIS OF CUFF/LIMB INTERFACE,
CURRENT PRACTICE, and GUIDELINE FOR USE

Stephen J. Tredwell MD FRCSC^1,3, Michael Wilmink MD^1,3,
Kevin Inkpen M.A.Sc.², James A. McEwen Ph.D. P. Eng.^2,3

¹Div. of Pediatric Orthopaedics, ²Western Clinical Engineering Ltd., ³ Dept. of Orthopaedics, University of British Columbia, Vancouver Canada V6H 3Z6

Abstract: There are few clear guidelines on the proper use of tourniquets in pediatric surgery, and in particular on how to set the tourniquet pressure, how to select the most appropriate cuff, and whether to use some type of soft padding beneath the cuff for limb protection. We could find only one published study specifically addressing pediatric cuff pressures, and no studies that show what types of cuff and/or padding create the smoothest skin surface under the cuff.  Of 46 pediatric orthopedic surgeons we surveyed, 44 use a tourniquet 4.6 times per week on average and 2 have discontinued their use due to complications. To set cuff pressure, 13/44 use a standard value, 14/44 base pressure on age, extremity, and size, and 17/44 base cuff pressure on blood pressure. 34/44 use skin protection under the cuff yet damage to the skin is common, accounting for 21 of the 67 reported complications. Nerve (15/67) and muscle (8/67) complications, related to both pressure and tourniquet time, were also reported.

Using a molding and digital measurement technique, we compared the maximum wrinkle heights and the sums of all wrinkle heights in the skin surface under 4 different cuff/padding configurations. In a total of 44 trials on the upper arms and thighs of 2 healthy child volunteers, one type of pediatric cuff with matching limb protection sleeve designed and recommended by the manufacturer (Delfi) produced significantly fewer, less severe pinches and wrinkles in the skin surface than a second type of tourniquet cuff (Zimmer) with or without 2 layers cast padding, and a third type (Kidde) with padding (P < 0.01). With the second type of cuff, using cast padding reduced skin wrinkling compared to applying the same cuff on unprotected skin (P < 0.05). In view of the survey, clinical literature, and results of this study, a guideline for use of pediatric tourniquets is proposed.

Key words: tourniquet, survey, guideline, injury, hazard, pressure.

The Surgical Technologist 34(8) (Aug 2002)6 – 15.:

TOURNIQUET SAFETY:

PREVENTING SKIN INJURIES.

James A. McEwen PhD, PEng¹, Kevin Inkpen MASc²

¹ Dept. of Orthopaedics, University of British Columbia, Vancouver BC Canada, ²Western Clinical Engineering Ltd. Vancouver BC Canada.

Summary: No published studies show what type of padding eliminates pinching and wrinkling of the skin under a tourniquet cuff most effectively on adults, and neither present nursing guidelines nor cuff manufacturers’ recommendations specify the best limb protection technique. Using a molding and digital measurement technique, we compared pinching and wrinkling of the skin at the cuff-skin interface with 3 types of cuff and 3 padding techniques in a total of 55 trials on the upper arms and thighs of 5 healthy adults in the laboratory setting. Stretched sleeves made of 2 layer tubular elastic material and matched to specific tourniquet cuffs produced significantly fewer, less severe pinches and wrinkles than all other padding types tested, including 4 layers of loose fitting stockinette (maximum P < 0.01). With a typical disposable cuff, 2 layers of cotton cast padding gave a slight reduction in maximum wrinkle or pinch height (P < 0.05) but did not reduce the overall amount of wrinkling significantly (P > 0.05) compared to applying the same cuff on bare skin. A disposable cuff with built-in gel padding created greater maximum wrinkle and pinch heights than the typical disposable cuff when both were applied on the bare skin (P = 0.05) and was also worse than the typical disposable cuff applied over cast padding (P = 0.01). The gel cuff did not reduce the overall amount of wrinkling significantly in either case (both P > 0.05). Based on existing clinical literature and guidelines along with the current results, an updated guideline is proposed for tourniquet use at arm and thigh locations on adults, including specific limb protection technique recommendations.