Evidence for Safe Tourniquet Use in 500 Consecutive Upper Extremity Procedures

Abstract

Background Although pneumatic tourniquets are widely used in upper extremity surgery, further evidence is needed to support their safe use. Excessive pressure and prolonged ischemic time can cause soft-tissue injury. The purpose of this study was to determine the safety of tourniquet use in a yearlong, consecutive series of patients. Methods A retrospective review of all patients who underwent upper extremity surgery by two board-certified hand surgeons over a 1-year period was performed. Demographic variables, comorbidities, and complications were noted along with tourniquet parameters, including application site, ischemic pressure, and time. Results A total 505 patients were included in the study because a tourniquet was used during their operation. Patients ranged in age from 3 months to 90 years old (mean 40.1 years). More than half of the population was overweight (mean body mass index (BMI) 27.1), and 77.1 % of adults had at least one cardiac risk factor. No immediate or delayed tourniquetrelated injuries were identified. The average operative time was 35.9 min, with an average tourniquet time of 33.1 min.Tourniquet inflation pressure of 250 or 225 mmHg was utilized in 78 and 21 % of adult patients, respectively; no patients had a pressure setting exceeding 275 mmHg. Conclusion In this series of more than 500 operations, there were no immediate or delayed tourniquet-related events using parameters determined perioperatively by the attending surgeon. Tourniquet pressures of 250 mmHg or less in adult patients with less than 2 h of ischemic time appear to be safe, even in the elderly and patients with multiple medical comorbidities.

Tourniquet pressure settings based on limb occlusion pressure determination or arterial occlusion pressure estimation in total knee arthroplasty? A prospective, randomized, double blind trial

“… 1 , 2 , 3 , 4 Thus, the use of a minimal effective tourniquet inflation pressure which provides a bloodless surgical field is desired. 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 Although, clinical efforts and advances in tourniquet technology have resulted in the use of lower inflation pressures, there is still a lack of standard practice and consensus regarding minimal effective tourniquet inflation pressures. 16 , 17 , 18 Most of the orthopedic surgeons even routinely apply fixed tourniquet pressure of 250–300 mmHg or add fixed amount of pressure above SAP (SAP + 100–150 mm Hg) in lower extremity surgery based on individual experiences and accept these pressures as safe, in spite of reported adverse effects due to unnecessarily high tourniquet pressures.…”

Association of intraoperative cerebral and muscular tissue oxygen saturation with postoperative complications and length of hospital stay after major spine surgery: an observational study

“…The complexity of tissue oxygenation can be further demonstrated by the fact that different organs have different tolerance for ischaemia and hypoxia. The muscle can tolerate one to two h of ischaemia without clinically overt injury, 12 while the brain can be permanently injured even if ischaemia only lasts for a few min. As a vital organ, the brain is prioritized during haemodynamic derangement.…”

Understanding and Optimizing Tourniquet Use During Extremity Surgery

“…Nerve injuries range from paresthesia to paralysis of the extremity . LOP measured by absent arterial pulses distal to the tourniquet using a Doppler is the recommended minimal pressure for tourniquets.…”

“…In upper‐extremity surgery, many surgeons choose tourniquet pressures 50 to 100 mm Hg above the systolic blood pressure and often use lower pressures for more distal tourniquets to avoid neurovascular injury, protecting the deeper vital structures when less subcutaneous tissue is present. The use of tourniquet pressures of 250 mm Hg or less for fewer than two hours of tourniquet time seems to be safe for adult patients, including older adult patients and patients with multiple medical comorbidities . Like upper‐extremity surgery, lower‐extremity surgery also relies on lower tourniquet pressures distally.…”

“…A review of the evidence conducted in 2012 suggests a reperfusion interval at two hours for procedures lasting more than 150 minutes, although the amount of breathing time is unspecified . Based on a retrospective review, Drolet concluded that up to two hours of inflation time, with a 15‐minute breathing time for longer periods, was safe for tourniquet pressures approximately 100 mm Hg above systolic blood pressure for upper‐extremity procedures. Derner and Buckholz recommend a 10‐minute breathing time after a maximum cuff time of two hours for lower‐extremity procedures.…”