Care Of Patients Undergoing Pneumatic Tourniquet-Assisted Procedures

Publication Date: May 11, 2020
Last Updated: March 14, 2022



  • During the preoperative briefing, discuss plans for use of a pneumatic tourniquet.
  • Preoperatively assess the patient’s:
    • circulation in the extremity (eg, pulses, temperature, capillary refill)
    • skin condition under and distal to the planned cuff site
    • sensory and motor responses of the operative extremity compared to the contralateral extremity
  • Assess the patient preoperatively for factors that may increase his or her risk of developing complications from pneumatic tourniquet use.
  • Use pneumatic tourniquets with caution for patients who:
    • are older adults
    • have low preoperative hemoglobin
    • have an increased risk for venous thromboembolism (VTE)
    • have a high body mass index
  • Assess the patient for potential systemic contraindications to tourniquet use, including:
    • arteriovenous grafts or fistulas
    • diabetic neuropathy
    • peripheral vascular disease
    • previous revascularization
    • sickle cell anemia
    • severe infection
    • VTE or a history of VTE
  • Notify the prescriber (ie, the surgeon or anesthesia professional) of any identified contraindications.
  • Assess the surgical site for potential contraindications to tourniquet use, including:
    • malignancy
    • open fracture
    • severe crushing injuries
    • severe scar tissue at the cuff location
    • thigh circumference larger than 100 cm


  • Verify the surgical site, including laterality, before

tourniquet application.

  • Select the tourniquet cuff size to maintain pressure, fit, and field visibility according to the manufacturer’s instructions for use (IFU).
  • Apply the tourniquet at the optimal location of the extremity based on the procedure.
  • Use a contoured tourniquet cuff for extremities in which there is a tapering of the extremity between the upper and lower edge of the cuff.
  • Use a sterile tourniquet cuff if the tourniquet will be positioned close to the surgical site.
  • If a cuff position change is necessary, remove and reapply the cuff to reduce skin friction and shearing.
  • Apply a low-linting, soft padding (eg, limb protection sleeve, two layers of stockinette) around the limb under the tourniquet cuff according to the cuff manufacturer’s IFU.
  • Verify that the padding is wrinkle-free and the tourniquet cuff does not pinch the skin.
  • Use a physical barrier (eg, an impervious adhesive drape) to prevent fluid accumulation (eg, skin antiseptic, irrigation) under the cuff and contamination of the tourniquet cuff.
  • Position the cuff tubing on or near the lateral aspect of the extremity, facing away from the sterile field.
  • Use tourniquet tubing and connectors that are incompatible with other tubing (eg, IV tubing) or are labeled to clearly identify that they are part of the tourniquet system.


  • Time prophylactic antibiotic administration to achieve optimal tissue concentration.
  • Notify the OR team before the extremity is exsanguinated.
  • Exsanguinate the extremity before inflation of the tourniquet.
  • Elevate the extremity for exsanguination if indicated and based on an assessment of the benefits versus potential harms.
  • Use an elastic wrap for exsanguination if applicable and not contraindicated (eg, by extended immobilization, infection, fracture, malignancy) and based on an assessment of the benefits versus potential harms.
  • Do not use a hand-over-hand exsanguination technique.
  • Keep tourniquet inflation pressure to a minimum based on the individual patient’s needs.
  • Measure the limb occlusion pressure (LOP) to determine initial tourniquet pressure.
  • Take the baseline systolic blood pressure or LOP measurement when the patient’s blood pressure is stabilized to the level expected during surgery.
  • Add a safety margin to the LOP based on the manufacturer’s IFU when available.
  • Consider increasing inflation pressure for limbs with larger circumferences.
  • Inflate the tourniquet cuff in coordination with the surgeon and the anesthesia professional after verifying the pressure and position of the extremity.
  • Monitor the patient for:
    • normothermia
    • respiratory acidosis (for pediatric patients)
    • pain tolerance (for regional and local anesthesia procedures)
  • Ensure activation indicators and pressure displays are visible to the entire OR team, and adjust audible alarms so they can be heard above other sounds in the OR.
  • Inform the surgeon of the tourniquet inflation time at regular, established intervals.
  • When using multiple tourniquet cuffs on the same extremity, confirm whether:
    • a dual-bladder tourniquet cuff and extra connective tubing will be used
    • a higher pressure is planned to compensate for the narrow size of each cuff bladder
    • the planned location on the extremity is wide enough to accommodate the additional width of the dual- bladder tourniquet cuff
  • When using a dual-bladder cuff or when using two single-bladder cuffs together, identify the cuff location, respective tubing, and equipment, and clearly communicate the inflation sequence.


  • Coordinate the timing of the tourniquet deflation based on the surgical procedure and the anesthesia plan of care.
  • When using tourniquets on two extremities, confirm the sequence and timing of the deflation of each of the tourniquets.
  • When using multiple or dual-bladder tourniquet cuffs, confirm the sequence and timing of the deflation of each of the cuffs.
  • Postoperatively assess the patient’s:
    • circulation in the extremity (eg, pulses, temperature, capillary refill)
    • skin condition under and distal to the cuff site
    • sensory and motor response of the operative extremity compared to the contralateral extremity
  • Monitor the patient’s vital signs after tourniquet deflation.
  • Monitor the patient for normothermia after tourniquet deflation.
  • Assess the patient for tourniquet-associated pain after tourniquet deflation.
  • Report the preoperative assessment, tourniquet intervention, and postoperative evaluation during the hand over to the recovery team.


  • Verify that the tourniquet and accessories are complete, clean or sterile, and functioning according to the manufacturer’s IFU:
    • confirm that the battery is fully charged, if applicable
    • inspect the cuff, tubing, connectors, and closure systems for damage or flaws
    • test the tourniquet for integrity and function
    • use a pneumatic tourniquet regulator that is compatible with all associated components and secure the connections
  • Maintain records of tourniquet maintenance, including:
    • biomedical equipment identification number or serial number
    • date of inspection
    • preventive maintenance
  • When there is evidence of complications or adverse events related to the use of a pneumatic tourniquet:
    • notify the OR team
    • obtain functioning equipment and supplies
    • replace faulty equipment and supplies under the direction of the operator
    • document the actions taken
  • Report to the US Food and Drug Administration and the manufacturer when a pneumatic tourniquet is suspected to have contributed to a death or serious injury, and report to other regulatory bodies as defined by state or local regulations.
  • When a patient injury occurs as a result of pneumatic tourniquet use:
    • remove the tourniquet supplies and equipment from service
    • retain all supplies if possible
    • report the adverse event details, including device identification and maintenance and service information, according to the health care organization’s policy and procedures


  • Document the following:
    • initial assessment of operative extremity:
      • skin condition
      • peripheral vasculature
      • neuromuscular and sensory responses
    • tourniquet cuff size and location
    • the person who applied the tourniquet
    • skin protection measures taken
    • cuff pressure settings
    • times of inflation and deflation
    • total time inflated
    • reperfusion time, if applicable
    • postoperative assessment of the operative extremity:
      • skin condition
      • peripheral vasculature
      • neuromuscular and sensory responses
    • systemic reactions to ischemia and reperfusion
    • communication of concerns (ie, to whom, what, and when
    • system identification information

Recommendation Grading




Care Of Patients Undergoing Pneumatic Tourniquet-Assisted Procedures

Authoring Organization

Publication Month/Year

May 11, 2020

Last Updated Month/Year

January 5, 2023

Document Type


External Publication Status


Country of Publication


Inclusion Criteria

Female, Male, Adolescent, Adult, Child, Older adult

Health Care Settings

Hospital, Operating and recovery room

Intended Users

Surgical technologist, nurse, medical techologist technician, nurse practitioner, physician, physician assistant



Diseases/Conditions (MeSH)

D014111 - Tourniquets, D061214 - Patient Safety, D048228 - Intermittent Pneumatic Compression Devices


perioperative nurse, tourniquet, patient safety, intravenous regional anesthesia, pneumatic tourniquet