Tourniquet Use And Care
Pneumatic tourniquet setup, use, and care and handling will be
discussed in this section. Patient safety is the primary concern
when working with a pneumatic tourniquet. Take the time to become
thoroughly familiar with the particular tourniquet used in your
Applying a pneumatic tourniquet and monitoring its use cannot
be taken lightly. Ideally, the preoperative assessment is
conducted the day before surgery is scheduled.
During the preoperative assessment, review the patient's
physical status and medical history. For example:
- Does the patient have allergies (e.g., to prep solution
containing iodine, to adhesive tape, or to drugs)?
- What medication(s) is the patient currently taking (e.g.,
- Does the patient have any preexisting disease that could
complicate tourniquet use (e.g., arterial calcification,
abnormal clotting time, diabetes, sickle cell trait,
tumor, infection, or previous vascular surgery in the
involved limb, or hypertension)?
Also during the patient assessment, measure the operative limb
for selection of the proper size tourniquet cuff. Record the
patient's blood pressure.
Efficiency in the operating room demands that all of the
necessary equipment and supplies be assembled before the patient
arrives in the room. For procedures that will require the use of
a pneumatic tourniquet, the following equipment and supplies are
- Mounting. Some types of tourniquets are mounted
on IV poles; others are mounted on portable stands or are
placed on a table top.
- Tourniquet instrument. Modern electronic
tourniquet instruments have a power cord that must be
plugged into a properly grounded power source. The more
sophisticated instruments have a backup battery which
charges automatically when the unit is plugged in, and
therefore the unit should be plugged in whenever
possible. Note that some instruments do not have a backup
battery and therefore must be plugged in at all times
Some instruments require a connection to hospital pressurized
gas supply. Ensure that the source is of the appropriate type and
pressure as specified by the tourniquet manufacturer. Other types
of tourniquet systems use a disposable pressurized canister.
Ensure that the canister is not empty or depressurized and ensure
that a spare, new canister is readily available.
- Manufacturer's guides. Keep an operating manual
readily available and attach a troubleshooting guide to
every tourniquet unit.
- Connecting tubing. Virtually all systems have a
hose and connector assembly (positive - locking or Luer)
for attaching the cuff to the tourniquet instrument.
Ensure that the connectors on the cuff and instrument
hose(s) are compatible. If a Dual Port system is being
used, ensure that the cuffs are also dual port; similarly
for single port systems ensure that the cuffs have a
single port. Do not use adapters other than those that
may be provided by the instrument manufacturer for
connecting the cuff to the instrument.
For systems requiring a hospital pressurized gas supply,
another hose attaches the tourniquet to the external pressure
source. Ensure that this hose has appropriate connectors and
- Tourniquet cuff. Be sure to select the
appropriate cuff style, width, and length as outlined in
- Limb Protection. If limb protection is to be
used between the cuff and the limb, select the
appropriate limb protection material for the selected
cuff. It has been reported that the patients skin
is most effectively protected from wrinkling and pinching
under the cuff when a stretched, two - layer tubular
stockinette limb protection sleeve matching the size
range of the selected cuff is used. Some manufacturers
supply a limb protection sleeve with the cuff or supply
the sleeve separately with a colored trim matching the
appropriate cuff. It is important to ensure that the
sleeve matches the cuff selected. If a matching sleeve is
not available for the selected cuff, use two layers of
tubular stockinette, sized such that it is stretched when
applied to the limb at the cuff location and such that
the compression applied by the stockinette is less than
venous pressure and less than the pressure of a snugly
applied cuff. The tubular material should be longer than
the width of the cuff, so that the excess length
extending beyond the distal edge of the cuff can be
folded back over the cuff.
Do not use cotton cast padding, sheet padding, Webril, or any
material that may shed loose fibers; lint from these materials
can become embedded in the hook and loop cuff fasteners and
reduce their effectiveness, possibly leading to an unexpected
release of the cuff during the procedure.
- Drape. The size of the drape depends on the
limb. It is used to protect the skin from chemical burns
and to keep the tourniquet cuff clean. In particular the
drape chosen must prevent fluids from collecting between
the patients skin and the cuff, which can cause
- Measuring tape. Use a nonstretch measuring tape
to obtain limb circumference. Preferably, the tape should
measure both inches and centimeters so the measurement
can be compared to tourniquet cuff sizes in either unit.
- Pressure display testing equipment. A
calibration kit is available from many manufacturers; a
mercury manometer adapted for the testing of the
tourniquet display may also be used.
- Elastic bandage. A tensor (e.g. Ace Wrap) or
other elastic bandage should be available for
exsanguination; in some cases, gravity exsanguination
alone will be sufficient and the bandage will not be
- Gas canister or tank. If required, ensure that
appropriate canisters are sufficiently full and readily
Calibrating and Testing
It is important to test the pneumatic tourniquet and inspect
all of the other components before every patient use. Patient
safety demands that all tourniquet parts be functioning properly
before the procedure.
Calibrating the Pressure Display
Some pneumatic tourniquets, particularly older non-electronic
types, can be subject to large and dangerous discrepancies
between the pressure indicated on the display and that exerted by
the cuff bladder. Such discrepancies can result in over
pressurization or under pressurization of the cuff and underlying
soft tissue. The perioperative nurse can minimize potentially
hazardous pressure variations by learning how to perform the
manufacturers recommended calibration tests. Some
manufacturers of older, non - electronic tourniquets recommend
that calibration be checked before each patient use.
As an accessory, most manufacturers make available a
calibration kit with a gauge specifically designed for
calibrating the pressure display. If a calibration kit is not
provided, a mercury manometer can be used. For a preoperative
calibration check, a T - shaped connector can be fitted between
the pneumatic tourniquet instrument and the cuff. A manometer is
then attached to the T connector. When the cuff is inflated, the
pressure display should equal that of the mercury manometer. The
display should also be checked for pressure changes (drift) by
ensuring that the pressures remain equal over several minutes. If
a substantial difference or drift is observed, the tourniquet
instrument should not be used and should be sent for repair.
Most modern electronic tourniquet instruments have a self -
test mode that is activated when the power switch is turned on.
The self - test rapidly verifies all alarm systems and the
pressure accuracy of the display. A manual calibration check is
normally unnecessary for these units, and if required is
performed by appropriately trained biomedical engineering or
If either a manual calibration test or the computerized self -
test indicates that the tourniquet display is in error, do not
use the unit. Immediately remove the equipment from service and
send it to biomedical engineering for repair.
Testing Other Parts
Before each use, inspect the tourniquet instrument and
mounting, connecting tubing, gas source (if used), and cuff. Make
sure that all connections are in good condition and are securely
fastened according to the manufacturer's written instructions. To
guard against accidental deflation, connect the cuff to a
tourniquet instrument, wrap the cuff onto itself, secure all
fasteners, and inflate the cuff. Check to make sure that there
are no leaks in the cuff, tubing, or connectors. If gas tanks or
canisters are used, check the gas level before the procedure
A reusable tourniquet cuff is subject to wear and deteriorates
with use. When inspecting the cuff before each use, give special
attention to the following questions:
- Is there any physical damage (rips, tears, holes, etc.)
to the cuff? If the cuff is not completely intact, it may
leak or burst, causing an unexpected loss of pressure.
- Is (are) the connector(s) bent, broken or worn?
- If there is a ribbon tie, is it torn or the ribbon
- Is the contact closure torn or is any of the strap
- After cleaning, is more than 25% of the contact closure
embedded with fibers that cannot be removed?
- Is there any other physical change or damage to the cuff
that would compromise the cuff's ability to maintain
occlusion during the surgical procedure?
- Have permanent kinks or ridges formed in the stiff
structure inside the cuff (palpable through the cuff
outer material), particularly along the inner surface
facing the patients limb?
If any of the above conditions are present, do not use that
particular cuff. Use of a damaged cuff could result in one or
more of the following unwanted events:
- Loss of cuff pressure.
- Release of the cuff from around the patient's limb.
- Movement of the cuff on the patient's limb.
- Excessive leakage of cuff pressure.
- Pinching of tissue under the cuff leading to injury.
Some of these failures could cause catastrophic injury,
including death, to the patient by releasing blood into the
surgical site or releasing a bolus of anesthetic into other parts
of the body.
The physician is responsible for determining the appropriate
tourniquet cuff pressure. The objective is to maintain a cuff
pressure that is high enough to completely suppress arterial
circulation and produce a bloodless field, yet low enough to
minimize the risk of neuromuscular injury. Lower pressures have
also been shown to reduce postoperative pain associated with
tourniquet use. Calculation of this "minimum effective
pressure" is not always straightforward. The surgeon must
take into account the following factors:
- Blood pressure.
- Cuff design, fit, and snugness of application.
- Limb circumference.
- State of the tissue.
- Vascular status.
The patient's systolic blood pressure is an important
criterion for determining the minimum amount of cuff pressure
required to suppress arterial circulation. It is important to
- The patient's systolic blood pressure measured
immediately prior to the induction of anesthesia.
- The maximum anticipated rise in systolic pressure during
the surgical procedure (due to anesthesia or
- Potential for movement of the limb during surgery, which
can cause transient drops in cuff pressure. The set
pressure must be high enough to prevent blood seepage
during such movement.
- The presence of hypertension, which demands a higher
tourniquet cuff pressure.
Cuff Design, Fit, and Snugness of Application
Tourniquet cuff design also affects the minimum cuff pressure
needed to occlude arterial flow. With dual bladder cuffs, a
higher pressure is often required to achieve occlusion and ensure
a bloodless operative field because the individual bladders are
narrower. It has been reported that curved and wider tourniquet
cuffs occlude blood flow at a lower inflation pressure than
straight or narrow cuffs. If a cylindrical cuff is used on a
significantly tapered limb, the effective width of the bladder is
reduced due to the loose distal portion of the cuff and the
required pressure may be higher than normal. Similarly, if a cuff
of any design is applied too loosely or applied over a thick
layer of loose padding, higher pressures may be required to
occlude the limb.
The circumference of the limb at the site of cuff application
also affects the cuff pressure required to suppress circulation.
Circumference is an external indicator of the depth of soft
tissue through which tourniquet cuff pressure must be exerted.
Research has demonstrated that soft tissue pressure is lower than
tourniquet cuff pressure, and decreases with the depth of the
tissue. For a slender, thin limb, the cuff pressure indicated on
the pressure display is very close to the pressure actually
exerted on the deep artery. However, for limbs with a large mass
of fatty or muscular subcutaneous tissue, a higher tourniquet
cuff pressure is required to ensure sufficient pressure to
occlude arterial circulation.
Similarly, the lower extremities have a higher tissue mass
than the upper extremities; therefore, a higher tourniquet
pressure is necessary to transmit sufficient pressure through the
tissue to occlude the deep vessels.
State of the Tissue
The state of the tissue (its flaccidity or tenseness) at the
site of cuff application also has an effect on the pressure
exerted. Folds and puckers in underlying flaccid tissue can cause
skin injury and uneven pressure on vessels. Tense, strong muscle
resists pressure more readily than soft muscle.
Usually, the presence of atherosclerotic vascular disease or
similar diseases that occlude the artery demands a higher
tourniquet cuff pressure. Atherosclerotic vascular disease is a
common condition in older patients. It makes arteries resistant
to tourniquet - exerted pressure.
Limb Occlusion Pressure and optimum cuff
Clinical and laboratory studies have shown that the minimum
effective pressure cannot be reliably predicted using a standard
pressure or a simple formula based on the factors listed above.
For each individual limb, cuff, and cuff application there is a
unique cuff pressure required to occlude arterial flow in the
limb, known as the Limb Occlusion Pressure (LOP). These studies
have demonstrated that the best way to optimize cuff pressure is
to apply the cuff and, after induction of anesthesia and prior to
cuff inflation, measure the LOP with the applied cuff. Cuff
pressure is then set to the LOP plus a predetermined safety
margin which allows for changing conditions during the procedure.
To measure the LOP, use the following procedure:
- Select the cuff to be used in the procedure
- Apply the cuff over the appropriate limb
- Using a Doppler stethoscope, locate an arterial
pulse distal to the cuff. Normally the radial
artery is used on the arm, and the posterior
tibial artery is used in the leg. The dorsalis
pedis artery may also be used for the leg (see
- Slowly increase cuff pressure until the arterial
pulse stops and remains stopped for several
- Note the cuff pressure: This is the LOP
- Deflate the cuff and confirm that the distal
- Prior to cuff inflation, adjust the cuff pressure
setting to the noted LOP plus a safety margin.
|Figure 11. A manual Limb Occlusion
Pressure (LOP) measurement with a Doppler
stethoscope and lower leg cuff
A safety margin of the LOP plus 40 - 100 mmHg have been
suggested in the literature, and typically the margin required is
lower for lower LOP levels and higher for higher LOP. A higher
margin may be selected if a considerable amount of manipulation
of the limb and/or large blood pressure rises are expected to
occur during the procedure. One cuff pressure setting method that
has been used successfully in clinical studies is LOP + 40 mmHg
for LOP levels less than 130 mmHg, LOP + 60 mmHg for LOP levels
between 131 - 190 mmHg, and LOP + 80 mmHg for LOP levels greater
than 190 mmHg.
LOP measurement should be made when the blood pressure is
approximately stabilized to the level expected during surgery.
Depending on the anesthetic technique, the LOP measurement may
therefore occur before or after induction of anesthetic. Blood
pressure at the time of LOP measurement should be noted.
Applying the Tourniquet
After the patient is brought into the OR, apply the tourniquet
at the proper location on the limb, for an appropriate period of
time, and within the appropriate pressure range. Take the
- If the patient is to be awake during the
procedure, explain any tourniquet alarm sounds
that may be heard during the procedure. This is
particularly applicable for microprocessor -
controlled tourniquet systems.
- If general anesthesia is planned, record the
patient's blood pressure prior to induction.
- The cuff location should be selected such that as
much tissue as possible lies between the cuff and
any nerves or vascular structures that could be
subject to damage:
- Place an arm cuff midway between the
shoulder and elbow.
- Place a thigh cuff on the proximal third
of the thigh.
- Position a lower leg cuff so the distal
edge of the cuff is at least 2 inches (5
cm) proximal to the ankle malleoli and
the proximal edge is at least 2 inches
distal to the head of the fibula.
Normally the proximal edge of the cuff
will lie in the mid range of the calf
near the point of maximum calf
- Apply the appropriate limb protection material to
the limb in the area selected for the cuff,
unless the selected cuff is specifically
recommended to be used without limb protection.
- Make sure that the limb protection material (if
used) and the skin under the cuff are wrinkle -
free. Position the cuff so that the hose
connections are accessible under the drapes and
the tubing will not be kinked or in the surgical
field when the limb is positioned for surgery,
then smoothly wrap the cuff around the limb and
pull snug by grasping the tie ribbon with one
hand and pulling the strap end of the cuff snug
with the other hand. Pull in a direction roughly
along (tangent to) the circumference of the limb,
not away from the limb.
- Press the hook and loop (VelcroTM type) fasteners
on the cuff strap and outer surface together
firmly along their entire length.
- Make sure that the cuff fits snugly. The deflated
cuff should not be tight enough to impede venous
return of blood from the extremity. In general a
snug fit allows two fingers under the cuff. If
only one finger fits under the cuff, the cuff is
too tight; if three fingers fit, it is too loose.
- Tie the ribbon to prevent strap or cuff movement
during the procedure if the limb is manipulated.
- Connect the cuff to the tourniquet instrument,
using the hose assembly. For procedures that
require a dual - bladder cuff or two single -
bladder cuffs, use two hose assemblies and make
sure all OR personnel who may be operating the
tourniquet clearly understand which bladder or
cuff is connected to the first and second cuff
channels on the tourniquet instrument. If a dual
cuff control valve is being used with a single
channel tourniquet instrument, make sure
personnel are fully familiar with the valve
operation. Ensure that all connections are
- If a limb protection sleeve or stockinette
material is being used, fold the portion
extending beyond the distal cuff edge back over
the cuff (see Figure 12). This may help prevent
the cuff from sliding distally off the limb
- To prevent antimicrobial skin prep solutions and
other fluids from running under the cuff, cover
the tourniquet cuff with a plastic drape, with
the drape's adhesive edge placed over the distal
edge of the cuff.
- If your tourniquet system has an elapsed time
display and alarm function, set the elapsed time
to zero and set the time alarm to the desired
period, normally 60 to 90 minutes depending on
the surgical procedure.
- If possible, measure the Limb Occlusion Pressure
(LOP) using the applied tourniquet cuff. As
outlined above, the LOP reading may occur before
or after induction of anesthetic, depending on
the anesthetic technique. The physician may use
the LOP plus a safety margin to determine the
desired cuff pressure.
- Exsanguinate the limb. Careful and complete
exsanguination reportedly prolongs pain - free
tourniquet time; however, partial exsanguination
may be desirable in certain cases where residual
blood flow will aid in visualization and
identification of vascular structures. Elevate
the limb for a minimum of 2 minutes and, if the
surgeon indicates, wrap an elastic bandage around
the limb beginning at the distal end and ending
about 1 inch (2.5 cm) distal to the cuff (to
prevent the cuff from slipping distally and to
maintain cuff effectiveness). Do not use an
elastic bandage for exsanguination in cases where
bacteria, exotoxins, or malignant cells could be
spread to the general circulation, or where it
could dislodge thrombi that may have formed in
the vessels. Instead, accomplish exsanguination
by elevating the limb for 3 - 5 minutes.
- Rapidly inflate the tourniquet to the set
pressure specified by the physician. (Rapid
inflation of the cuff occludes arteries and veins
simultaneously, avoiding return of blood into the
limb, thus preventing the filling of superficial
veins before occlusion of the arterial blood
flow.) Make sure that the pressure display is
clearly visible. IMPORTANT: Record the time of
inflation, the tourniquet pressure, and the
patient's blood pressure at time of inflation.
- If used, remove the bandage used for
- Before the surgical procedure begins, verify full
occlusion by arterial palpation and/or
auscultation. This ensures that the pressure
setting and cuff application for that patient is
correct and successful.
- Prepare the skin according to standard procedure
and drape the operative site in preparation for
- In the event that arterial blood flow is observed
past the tourniquet cuff, the surgeon may request
that tourniquet pressure be increased. One
commonly used method is to increase pressure in
25 mmHg increments until blood flow stops.
|Figure 12.Cuff with limb
protection sleeve folded back over distal edge
Intraoperative monitoring of tourniquet safety parameters
reduces the risk of complications. During the procedure, it is
important to monitor the patient's blood pressure, tourniquet
pressure, and tourniquet time.
Monitor the patient's blood pressure for fluctuations and
relate this information to the surgeon.
Adjust the tourniquet pressure at the physician's request.
Monitor the cuff pressure display during surgery and immediately
report any changes to the surgeon. Any sudden loss of cuff
pressure intraoperatively is a cause for serious concern. If the
tourniquet cuff fails for any reason, deflate it fully, and re -
exsanguinate the limb before re - inflation. Re - inflation over
blood - filled vasculature may lead to intravascular thrombosis.
It is the physician's responsibility to determine when the
tourniquet is to be inflated, at what pressure, for how long, and
at what point in the procedure the tourniquet should be released.
It is customary to prominently note the time of cuff inflation
and to notify the physician after a certain time has elapsed and
at pre - established intervals thereafter. Modern electronic
tourniquet systems have an elapsed time display and an alarm
which can be set to sound after a predetermined amount of
tourniquet inflation time.
There is no clearcut rule as to how long a tourniquet may be
inflated safely, although various investigators have addressed
effects of ischemia on muscle and nerve to define a relatively
"safe" period of tourniquet hemostasis. In practice,
safe tourniquet inflation time depends greatly on the patient's
anatomy, age, physical status, and the vascular supply to the
extremity. Unless instructed otherwise, report to the surgeon
when 60 minutes of tourniquet time has elapsed. There is general
agreement that for reasonably healthy adults, 90 minutes should
not be exceeded without releasing the tourniquet for a short
Releasing the tourniquet allows for removal of metabolic waste
products from the limb and nourishment of the tissue with
oxygenated blood. During this time, elevate the limb 60 degrees
to encourage venous return and apply steady pressure to the
incision with a sterile dressing. Tissue aeration periods should
last at least 10 and preferably 15 minutes the first time and 15
- 20 minutes subsequently. To proceed with the surgery, re -
exsanguinate the limb before reinflating the cuff. Take care
during this procedure to maintain the sterility of the operative
field. No known safe limit to the number of aeration intervals
during prolonged tourniquet time has been established.
Deflating the Tourniquet
At the surgeons request, deflate the tourniquet cuff by
taking the following steps:
- Apply pressure dressings over the incision to protect the
wound from blood resurgence. Ideally, the final bandage
is applied and pressure is exerted over the incision
prior to tourniquet cuff deflation, to prevent blood
resurgence. Sometimes, however, the tourniquet is
deflated before incisional closure in order to better
identify and control bleeding.
- If necessary to prevent blood resurgence, elevate the
limb 45 - 60 degrees. Transient pain upon tourniquet
release can also be lessened by elevating the limb.
- Deflate the tourniquet cuff rapidly to establish
immediate venous return and prevent engorgement.
- Record the time of deflation.
- Immediately remove the deflated cuff and any underlying
limb protection following cuff deflation. Even the
slightest impedance of venous return by the deflated cuff
or padding may lead to congestion and pooling of blood in
the operative field.
- Record the time of cuff removal.
- Check the circulation of the limb. Note the return of
color to the limb and any abnormalities. If full color
does not return within 3 - 4 minutes after release, place
the limb slightly below body level.
- Inspect the cuff site and note any signs of soft tissue
Additional care must be taken in bilateral procedures
involving tourniquet control on two limbs, as the risk of
complications and the effects of tourniquet use may be increased.
Exsanguinating and inflating the cuff on both limbs in rapid
succession may cause a more pronounced blood pressure rise due to
the sudden decrease in effective circulation system volume. In
studies, clotting time decreases and more pronounced blood
pressure decreases were found after second cuff deflation. In
children, body temperature rise during surgery has been shown to
be significantly greater with bilateral tourniquets compared to
unilateral, and more pronounced pH drops (greater lactate
increases) were found when bilateral cuffs were deflated
simultaneously. If possible, bilateral tourniquet deflations
should be staggered by 30 to 45 minutes.
It is particularly important in the bilateral case to confirm
that the first tourniquet cuff has been completely deflated (and
the cuff and limb protection removed if possible) and that
circulation in the first limb has been restored, because any
related problems could go unnoticed throughout the second limb
Documenting Tourniquet Use
Documentation of tourniquet use is always a nursing
responsibility. Documentation provides information for continuity
of care, retrospective review, and research. Careful records
become particularly important if a patient sustains an injury and
a lawsuit is filed. Record only observable facts, rather than any
Information is usually entered on a special record. Such
records include, at minimum, the following items:
- Identification/serial number and model of the tourniquet.
- Identification of the person who applied the cuff.
- Location of the cuff.
- Times of inflation and deflation of the tourniquet.
- Length of tissue aeration periods, if applicable.
- Original tourniquet pressure.
- Initial systolic blood pressure.
- Subsequent systolic blood pressures.
- The fact that the surgeon was informed of elapsed
tourniquet time and any alterations in systolic blood
- Skin and tissue integrity under the cuff before use of
the pneumatic tourniquet and when the patient is sent to
- Any abnormal or adverse occurrences.
If an abnormal event occurs, note the time any symptoms began
and ended. Enter adverse reactions on the appropriate record, as
dictated by institutional policy. If a malfunction in the
pneumatic tourniquet causes serious injury, or contributes to the
death of a patient or other individual, this information should
be reported to the manufacturer and to the U.S. Food and Drug
Administration, in accordance with the Safe Medical Devices Act
Table 3 provides a checklist that could be used to document
pneumatic tourniquet testing and use. The actual testing method
and criteria used are established by institutional policy. This
checklist is designed to serve as a general guideline only.
Table 3. Checklist for use of pneumatic tourniquet
|Last Service Date:
|Pounds of Pressure
||Type of Gas
||Microprocessor - controlled
self - check (no further testing required)
||Requires check prior to each
use (all non - computerized systems)
of Display Testing
||Average % above set pressure
||Average % below set pressure
|Maximum cuff pressure _______
|% Drift =
||Right Lower Leg
||Left lower leg
|(Limb circumference + 3 - 6
in (7.5 - 15 cm) = _______ in/cm
||Single - Bladder
||Dual - Bladder
||Wide, Contoured (Low
||Matching sleeve supplied
Intravenous Regional Anesthesia (IVRA)
IMPORTANT: Tourniquet users must be familiar
with the inflation - deflation sequence when using a dual -
bladder cuff or when using two single - bladder cuffs together
for IVRA. If the wrong bladder or cuff is released inadvertently
due to user error, it could cause severe injury or death to the
patient. In addition, the users must be familiar with operation
of the tourniquet instrument and any auxiliary pneumatic valves
connected to the cuffs. Some more sophisticated tourniquet
systems incorporate safety functions to help reduce the risk of
accidental deflation of both cuffs during an IVRA procedure. To
further reduce risks, users must be fully aware of which cuff is
proximal, which cuff is distal, and the inflation/deflation
status of each at all times.
The tourniquet procedure for IVRA is similar to other
tourniquet procedures, with the following important differences:
- When conducting a preoperative assessment prior to IVRA,
it is very important to note any allergies to local
- A dual - bladder tourniquet and extra connective tubing
- A wider placement site is needed because of the dual -
- A higher pressure is generally required because each cuff
bladder is narrower.
Tourniquet Application for IVRA
- The patient will be awake for the procedure; to alleviate
any fears related to the procedure, explain the
equipment, alarms, or other unfamiliar items.
- Cannulate a vein in the distal portion of the limb. (An
angiocath is preferred to a butterfly needle because it
is less likely to be moved out of position during
application of the elastic bandage.)
- Apply limb protection (if used) to the limb.
- Apply the dual - bladder tourniquet smoothly and snugly,
individually fitting each bladder to the shape and
circumference of the patient's limb.
- Connect each bladder of the dual - bladder cuff to the
tourniquet instrument. (Consult the tourniquet instrument
instruction manual for more information on this
connection. If a dual cuff control valve is used between
the tourniquet instrument and the cuff ensure that you
are familiar with the connection and operation of the
- Fold the distal portion of the limb protection sleeve
back over the distal edge of the cuff. Place the
protective plastic drape around the tourniquet and limb.
- Elevate the limb and wrap with the elastic bandage to
exsanguinate the limb.
- Inflate the proximal bladder to its set - point.
(Generally, the proximal bladder is inflated first, but
sometimes the distal bladder is the first one inflated in
order to complete exsanguination). Limb Occlusion
Pressure (LOP) is particularly useful in setting the cuff
pressure in IVRA procedures due to the importance of
maintaining occlusion and the generally higher pressures
required due to the narrow width of each bladder.
- Remove the elastic bandage.
- Verify full occlusion by palpation and/or auscultation.
Induction of Anesthesia
After tourniquet placement, the following steps may be taken
to induce IVRA. This procedure is presented as a general
guideline and may differ in your institution:
- A predetermined amount of local anesthetic is slowly
injected into the cannulated vein via syringe or drip
method (usually the responsibility of the
anesthesiologist). Care must be exercised not to over
distend the vein by rapid infusion.
- Immediately begin to observe the patient's physiological
status for any sign or symptom of a toxic reaction to the
local anesthetic. (The presence of an anesthesiologist in
this instance does not release the nurse from noting any
adverse or toxic reactions to the anesthetic agent.)
- The angiocath may or may not be removed.
- The anesthetic agent circulates throughout the veins and
venules distal to the tourniquet and perfuses the sensory
and motor nerve trunks and endings.
- In about 3 minutes, the limb should be anesthetized.
During this time the limb may be prepped and draped for
the surgical procedure.
- About 20 - 30 minutes following the onset of anesthesia,
if the patient feels pain from the cuff, inflate the
distal tourniquet over the anesthetized limb and deflate
the proximal tourniquet. The patient should feel more
comfortable since the tissue under the distal bladder has
been anesthetized. NOTE: Tourniquet users must be
familiar with the inflation - deflation sequence
described below when using a dual - bladder cuff.
Deflating the Tourniquet
NOTE: Tourniquet users must be familiar with
the inflation - deflation sequence when using a dual - bladder
cuff or using two single - bladder cuffs together. If the wrong
bladder or cuff is released accidentally, it could cause severe
injury or death to the patient.. Never leave the patient
unattended for any reason during intermittent deflation.
- 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.
- 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.
- Observe the patient's mental status and cardiac monitor
carefully, as this is the time when complications are
most likely to occur.
- 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
- Apply the dressing and move the patient to the recovery
- 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.
Care and Handling of Pneumatic
Handle tourniquet cuffs carefully. Never puncture the cuff.
Handle towel clips used near the cuff with care. Avoid excessive
compression of the cuff by a leg holder.
Various types of microorganisms are commonly found on contact
closure - covered tourniquets and on Penrose drains. The
tourniquet cuff, which is placed near the patient's axilla or
groin, may be a source of pathogenic microorganisms. After each
use, it is important to decontaminate the tourniquet components,
by following the manufacturers recommended cleaning
procedures. The following cleaning procedure is presented as an
- If the tourniquet cuff is adequately protected during
surgery, hand washing of the cuff and bladder in lukewarm
water is the only decontamination procedure indicated. If
the bladder and plastic liner are removable, wash them as
separate items. Do not immerse the bladder unless the
connectors are sealed; if fluid enters the bladder,
mildew may form, or subsequent deflation of a wet bladder
during use may cause minute droplets of water to be
forced back into the tourniquet regulating mechanism.
Prevent rapid deterioration, shrinkage, and fading of the
cuff fabric by avoiding hot water, harsh detergents, or
- If blood or other body fluid comes in contact with these
items, add an enzymatic detergent to the wash water to
remove blood components from the fabric and rubber.
- If necessary, use a hand brush to remove encrusted
- If loose fibers are present in the contact closure
straps, it may be possible to remove them using a
nonmetallic brush or a comb in a side - to - side manner.
If this is not effective the cuff must be replaced. This
problem is often caused by using non - woven cast padding
type materials under the cuff.
- Rinse the cuff and bladder thoroughly; detergent residue
increases the chances for allergic reactions and may
decrease the life of the cuff.
- Carefully follow manufacturer's instructions for drying.
As a rule, air - dry the cuff and bladder flat, at room
temperature, in their original shapes. Drip drying over a
rack may stretch the cuff over time.
- Clean the exterior of the cuff hoses using a mild
detergent solution, or a disinfectant that is not
deleterious to rubber or polyethylene.
- After each use, decontaminate the exterior of the
tourniquet instrument by wiping it with a cloth that has
been dampened (not dripping) with a mild detergent.
- Avoid storing the cuff tightly rolled up to a small
diameter as this may cause permanent kinking and ridging
of the stiffened inner structure of the cuff. If possible
store the cuff rolled loosely to approximately its normal
in - use diameter.
Most modern reusable tourniquet cuffs are not recommended for
sterilization. Always follow the manufacturer's written
instructions regarding the ability to sterilize any cuff. If a
sterile cuff is required use a sterile disposable tourniquet
cuff. Under no circumstances should a tourniquet cuff be steam
sterilized unless specifically recommended by the manufacturer.
Any exposure to steam sterilization will render most cuffs
Maintenance and Storage
A comprehensive pneumatic tourniquet management program helps
identify equipment problems that may adversely affect patient
safety. Regular maintenance checks by the biomedical engineering
department should include calibration of the pressure regulator
and display with a calibrated pressure standard and regular
inspection of the regulator on every mechanical tourniquet. Refer
to the tourniquet controller operator's manual for information on
the appropriate frequency, method, and criteria for pneumatic
tourniquet testing. Document the date of inspection, preventive
maintenance performed, and status of all equipment. Review
records of equipment failure and preventive maintenance to help
identify equipment performance problems or hazards.
It is the nurse's responsibility to calibrate a mechanical
tourniquet prior to each patient use. If the pressure indicated
by the mercury manometer is different from the set pressure by
more than 10%, pull it out of service and send it to biomedical
Store pneumatic tourniquet components as a unit in an
environment that is dust - free, clean, and cool; cover with a
reusable or disposable fabric. Along with the equipment, store
the manufacturer's guide to troubleshooting and use. Prominently
display the manufacturer's name, model number, and serial number.
Depending on hospital policy, tagging each tourniquet with the
date of its most recent maintenance check may be required.
Notation of date of most recent use is valuable for facilitating
rotation among stored units.
Tourniquets that use battery power may have additional storage
requirements, such as leaving the tourniquets electrical
power cord plugged into an electrical outlet. Refer to your
tourniquet systems operating manual for specific storage
Table 4 provides sample troubleshooting guidelines. Many of
these problems are device - specific, and may not apply to your
tourniquet system. This is particularly true for computerized,
digital systems. Read the manufacturer's operating manual
carefully for troubleshooting guidelines specific to your system.
Table 4. Troubleshooting Guide
|Malfunctioning pressure regulator
||None, especially for non - computerized units
||Calibrate regularly by biomedical
|Malfunctioning pressure display
||Fails to return to 0 on complete depressurization
||Pull out of service and send for repair.
|Malfunctioning pressure display
||Error of 10% or more when checked with mercury
||Have serviced regularly by biomedical engineering.
|Malfunctioning pressure display
||Computerized system indicates a calibration error
||Have serviced by biomedical engineering.
|Bladder or connecting tubing leaks
||Gradual deflation of bladder; feel or hear leak
through or around cuff, computerized system indicates low
pressure or leak alarm
||Tighten all connectors; replace cuffs or tubing if
|Kinking of tubing
||Failure of bladder to inflate; excess venting of gas
through pressure release valve, computerized system
indicates occlusion alarm
||Turn connecting device to unkink tubing.
|Failure to operate
||Loss of electrical power receptacle.
||Make sure plug is securely in
|Failure to operate
||Loss of battery power
||Recharge or replace battery.
|Deterioration of component parts
||Chronic malfunctioning and problems
||Check for deterioration each time used; follow
regular preventive maintenance schedule; replace parts if