Recently Asked Questions

Question 1: How should an Esmarch bandage be used for best exsanguination?

Answer 1:

• When wrapping an Esmarch bandage it is very important that tension in the elastic bandage be maintained during the entire application of the bandage to the limb.

• In upper limb surgery, and especially for hand surgery, one problem area can be in the region of the patient's hand, specifically in the region of the fingers and the palm.  Generally, surgical staff will elongate the fingers and have them positioned in a "bundle" as the bandage is wound around the hand.  This results in excellent exsanguination within the fingers but produces an area of low pressure in the region of the palm.  To eliminate this low pressure region and improve exsanguination, it may be beneficial to first place a soft ball (or some other round object) in the palm of the hand and if possible wrap the fingers around the ball, then begin exsanguination of the hand with the Esmarch bandage.

• An area of concern, for lower limb surgery and upper limb surgery, is that tension in the Esmarch bandage may not be maintained uniformly around the limb as the bandage is wrapped.  Surgical staff typically pull or tension the bandage in a single direction away from the limb as they exsanguinate the patient's arm or leg. This results in a higher degree of tension and compression along one side of the limb and little to no tension and compression along the opposite side of the limb as the bandage is wrapped proximally up the limb.  This variation in compression results in poor exsanguination and exposes the soft tissues of the limb to unnecessarily high shear stresses.

• To overcome this, a better approach is to tension the bandage in "two" directions away from the limb rather than a single direction as describe above.  For example, if we were to look at the limb in cross section and using the face of a clock to assist in this description, as the bandage is wrapped around the limb tension is applied in a "3 o'clock" direction, the tension is maintain and the bandage is wrapped around the limb to the "9 o'clock" position.  The  bandage is again tensioned and the tension is maintain as the bandage is wrapped around the limb back to the "3 o'clock" position.  The two direction technique is repeated all the way up the limb resulting in a more uniform compression in the soft tissues, reduced shear stresses within the soft tissues and a superior exsanguination of the limb.

• For best exsanguination, the Esmarch bandage should be wound up to, and over, the distal edge of the tourniquet cuff.   The Esmarch bandage should remain in position until the tourniquet cuff is pressurized.  After the pressure in the cuff has reached the desired level, the bandage may be removed from the limb.

Question 2: Is there an ideal tourniquet deflation rate?

Answer 2: Venous congestion occurs when the pressure in a partially deflated cuff is below limb occlusion pressure but above venous pressure. This condition blocks venous outflow from the limb but allows arterial flow into the limb. If this period of time becomes significant due to overly slow deflation, then venous congestion will be considerable and that is hazardous. Hemorrhagic infiltration of nerves may occur if the cuff is deflated too slowly. Special considerations and precautions apply for IVRA.

Question 3: Regarding tourniquet deflation rates and deflation times associated with the use of Intravenous Regional Anesthesia (also called IVRA or Bier block anesthesia), what are the special considerations and precautions?

Answer 3: Special considerations and precautions are given in relevant excerpts (below) from the AORN 2009 Recommended Practices on Pneumatic Tourniquets, and from relevant sections of this educational website, as excerpted below. See also the cited references for more detailed information.

From 2009 AORN Recommended Practice XIII:

“Potential patient injuries and complications associated with intravenous regional anesthesia (IVRA,Bier block) should be identified and safe practices should be established.

“The tourniquet should be deflated gradually as determined by the physician to minimize the potential for an adverse reaction. As the tourniquet cuff deflates, the anesthetic agent is released into the circulatory system, causing systemic effects.

“The perioperative registered nurse circulator should be aware of the patient’s physiological status. Adverse reactions to local anesthetic agents are potential complications of IVRA. A bolus of local anesthesia entering the general circulation can occur when there is a sudden deflation of the tourniquet, from deflation soon after injection of local anesthetic, or if the bolus is released too rapidly at the end of the procedure. The sudden rush of anesthetic and metabolites into the circulatory system affects the central nervous system (eg, ringing in the ears, tingling, numbness, loss of consciousness, seizures) and the heart.”

From “Complications and Preventive Measures” elsewhere in www.tourniquets.org:

“Intraoperative Bleeding may be caused by too slow inflation and deflation, both of which allow arterial flow to enter while preventing venous return.

“Toxic Reactions to local anesthetic agents are potential complications of IVRA. Hypersensitive patients can exhibit generalized symptoms almost immediately. The greatest danger is an inadvertent bolus of local anesthetic entering the general circulation, which can affect the central nervous system and the heart. Early recognition and prompt treatment of early signs of toxicity such as dizziness, drowsiness, respiratory depression, tinnitus, and bradycardia may prevent progression to more serious complications, like grand mal seizures, coma, cardiorespiratory depression, and even cardiac arrest and death.

Causes: The major cause of adverse effects of IVRA and/or failure of the technique is technical error. A toxic reaction may result from:

• Accidental, sudden deflation of the tourniquet.
• Deflation of the tourniquet too soon after injection of local anesthetic; prior to tourniquet release, approximately 15 - 20 minutes is required to maximize tissue binding of the local anesthetic, thus removing the anesthetic from the circulatory system.
• Single release of tourniquet pressure at the end of IVRA procedures. This results in a sudden infusion of metabolic waste products and local anesthetic into the circulatory system.
• Under-inflation of the tourniquet cuff. If complete occlusion is not present, leakage of the anesthetic will occur.

Safety considerations relating to inflation/deflation rate and time during IVRA, from elsewhere in www.tourniquets.org:

1. When IVRA is used, it has been suggested in published literature that the tourniquet remain inflated for a minimum of 20 minutes from the time of injection to ensure that most of the anesthetic agent has been absorbed into the limb tissue. For a procedure requiring only a few minutes, too rapid a release of anesthetic agent can be prevented by quickly deflating and reinflating the cuff several times, or by slowly decreasing the cuff pressure.
2. Upon completion of the procedure, fully deflate the tourniquet bladder, while the surgeon elevates the limb to enhance venous return and exerts pressure over the incision to prevent bleeding and hematoma formation. Deflation to zero pressure each time is important to prevent venous distention, which leads to bleeding and hematoma formation. A short (15 - second) deflation period permits the wash of local anesthesia and anaerobic waste products back into the general circulation in small doses to minimize toxic reactions.
3. Observe the patient's mental status and cardiac monitor carefully, as this is the time when complications are most likely to occur.
4. Reinflate for 30 - 45 seconds to allow nourishment of the tissue with oxygenated blood and diffusion of the anesthetic agent and waste products back into venous circulation.
5. Apply the dressing and move the patient to the recovery area.
6. The anesthetic effect recedes within 15 - 20 minutes, and patients can be safely discharged from the post anesthesia care unit more promptly than when other anesthetic techniques are used.”