Care Of Patients Undergoing Pneumatic Tourniquet-Assisted Procedures

• 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