Pediatric Tourniquets: Analysis of Cuff and Limb Interface, Current Practice, and Guidelines for Use

Clinical Issues‐December 2013

“…The orthopedic specialists who are designated to develop a facility's policy or revise an existing policy to identify safe parameters for tourniquet inflation pressure also should develop procedures for using a wide contoured thigh cuff for patients who are older than 18 years of age 10,14 and for determining the inflation pressure by adding a safety margin to the LOP or the systolic blood pressure. The procedures should guide perioperative team members to use the tourniquet equipment according to the manufacturer's instructions for use; collaborate with each other to ensure that the baseline systolic blood pressure or LOP measurement is taken at a time when the patient's blood pressure is stabilized to the level expected during surgery; determine a minimum effective tourniquet cuff pressure that is based on LOP or systolic blood pressure by using a tourniquet system that is designed to determine LOP and automatically add a safety margin to allow for fluctuations in blood pressure intraoperatively; calculating the LOP manually and specifying safety margins to be added, such as for patients who are older than 18 years, add 40 mm Hg to 50 mm Hg for LOP less than 130 mm Hg, 10,14 add 60 mm Hg to 75 mm Hg for LOP between 131 mm Hg and 190 mm Hg, 10,14 and add 80 mm Hg to 100 mm Hg for LOP greater than 190 mm Hg 10,14,15 or for patients who are younger than 18 years, add 50 mm Hg to the LOP 16 ; or identifying a stable systolic blood pressure to which a higher safety margin (ie, when compared with the safety margin added to the LOP) can be added to compensate for intraoperative fluctuations in blood pressure; and confirm the tourniquet cuff pressure setting to be used before inflating the cuff.The perioperative RN should use the procedures to monitor team member compliance with safe tourniquet practices.…”

Tourniquet cuff pressures in pediatric patients: urgent need to device guidelines?

“…A number of different tourniquet‐related injuries and hazards have been reported in the literature including over pressurization that may cause pain at the tourniquet cuff site (3–5), muscle weakness (6), compression injuries to blood vessels, nerve, muscle, or skin (7–10), or extremity paralysis. A recent study showed that setting tourniquet cuff pressures to a level equal to limb occlusion pressure plus a predetermined margin of safety maintains a similar quality of bloodless surgical field (11).…”

“…Tourniquet cuff pressures in pediatric patients are commonly set at standard pressures based on experience or on heuristic formulations such as systolic blood pressure plus a standard margin or multiple. In comparison to adults, there are no standard guidelines on the proper use of tourniquets in pediatric patients (8,10). Because the mass of the muscle and other soft tissues is considerably less in children, which varies with age, the extrapolation of technique used in adults may not be appropriate.…”

Educational Opportunities

“…For pediatric patients, the cuff pressure setting should be adjusted by adding 50 mm Hg to the LOP 10 . If the surgical team did not determine LOP, a standard setting for tourniquet pressure may be used: 300 to 350 mm Hg in lower limbs and 200 to 250 mm Hg in upper limbs 11 …”