Survey of tourniquet use in podiatric surgery

Improving the Safety of Tourniquet Use in a Trauma Theatre According to the British Orthopaedic Association Guidelines: A Closed Loop Audit

Introduction Tourniquets are used widely in trauma and orthopaedic surgery to reduce blood loss and facilitate better visualisation of the operative field; however, some complications can result from improper use such as pressure sores, chemical burns, compartment syndrome, and deep vein thrombosis. We audited the use of intraoperative tourniquets in our trauma theatre against the guidance published by the British Orthopaedic Association (BOA) in 2021. Methods This was a closed-loop audit evaluating 80 trauma operations that utilised tourniquets. In the first cycle, we audited 40 operations (23 upper limbs vs 17 lower limbs) over a period of two months through a review of operation notes and theatre documentation. We presented our findings and implemented changes including the addition of tourniquet use to the operation note template and labels on the tourniquet machines aiding the calculation of tourniquet pressures. A re-audit was then performed involving a further 40 operations (20 upper limbs and 20 lower limbs). Statistical analyses were performed to compare the two cycles. Results Tourniquet time was on average similar across both audit cycles (60.7 vs 70.0, p = 0.192) with compliance up to standard in 97% of cases. Post-intervention, there was an improvement in the documentation of skin status (37 vs 69%, p = 0.004), tourniquet isolation method (43% vs 74%, p = 0.003), and tourniquet pressure (71% vs 94%, p = 0.003). The difference between tourniquet pressure and systolic blood pressure was on average lower post-intervention for the upper limb (125.9 vs 99.9, p < 0.01) and lower limb operations (154.2 vs 121.7, p < 0.01). Adherence to the British Orthopaedic Association Standards for Trauma (BOAST) guidance with tourniquet pressure improved with intervention (25% vs 75%). Conclusion The introduction of tourniquet parameters in the operation note template and patient-specific calculation of tourniquet pressures improved the safe use of tourniquets within the trauma theatre.

Tourniquet Practice Among Orthopaedic Surgeons in Saudi Arabia

Introduction This study aimed to evaluate the knowledge of tourniquet use among orthopedic surgeons in Saudi Arabia and assess the practical aspects of their use of tourniquets and the complications they have experienced in their practices. Materials and methods This cross-sectional study was conducted from December 2022 to February 2023. An online questionnaire was distributed among orthopedic surgeons and trainees in Saudi Arabia, and the surgeons' knowledge of tourniquet use was assessed using 17 questions. To investigate tourniquet usage, the participants were divided into three groups: orthopedic residents, specialists, and consultants. An upper limb cuff pressure (CP) of 200 mmHg and a lower limb CP of 250 mmHg were chosen as the cut-off values, and the doctors' choices were compared against literature recommendations using these measures. Result A total of 205 participants filled out the questionnaires; 130 residents, 15 consultants, and 60 specialists, with more males (175/205) than females responding. One hundred and twenty-one surgeons placed the cuff on patients by themselves, while 50 (24.3%) surgeons asked nurses for aid; 135 (65.6%) of them work in teaching hospitals, while 50 (24.3%) work in community hospitals. The incidence of post-tourniquet syndrome was unrelated to expertise (p=0.12). Conclusion When applied properly, tourniquets prevent excessive bleeding and keep the operative field clean during limb surgeries. This study aims to inspire the orthopedic community to reconsider long-held practices, especially regarding tourniquet pressure. The addition of ligature safety education to orthopedics training and outlining the settings and procedures for applying pressure should also be considered. The orthopedic community should set CP and process criteria to avoid complications. This study showed the importance of modifying the training of orthopedic residents to raise awareness and prevent unpleasant events from occurring.

Tourniquet Use During Open Reduction and Internal Fixation of Ankle Fractures - A Systematic Review and Meta-Analysis

The intra-operative use of tourniquet in open reduction and internal fixation (ORIF) of ankle fractures remains a topic of debate. The purpose of this study was to perform a systematic review and meta-analysis of randomized control trials (RCTs) comparing clinical outcomes of patients undergoing ankle ORIF with tourniquet use versus a control group where no tourniquet was used. A systematic review was performed with reference to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines of the Pubmed, Scopus, Embase, and Cochrane Library databases. Studies were included if they were an RCT comparing tourniquet and no-tourniquet in ankle ORIF. Meta-analysis was performed using RevMan, and p-value <.05 was considered to be statistically significant. On completion of the literature search, a total of 4 RCTs including 350 ankles (52.6% males), with a mean age of 47.1 ± 5.7 years were included. There were 173 patients in the tourniquet group (T), versus 177 patients in the no tourniquet control group (NT), with nonsignificant differences between the groups for age, gender and body mass index demographics (all p > .05). There were significantly shorter duration of surgery, with significantly higher patient-reported rates of pain levels at day 2 postoperatively (both p < .001) in the T group. Additionally, there were significantly greater ranges of ankle motion at 6 weeks postoperatively (p = .03), with nonsignificant differences reported incidence of wound infections and deep vein thrombosis (p = .056 and p = .130 respectively) between the groups. In conclusion, current evidence suggests that although intraoperative tourniquet usage in cases of ankle ORIF results in significant reductions in duration of surgery, this may be at the expense of higher patient-reported pain scores and reduced range of motion postoperatively.

A comparison of thrombosis in total knee arthroplasty with and without a tourniquet: a meta-analysis of randomized controlled trials

Background

Tourniquets are widely used in total knee arthroplasty (TKA), but the issue of their safety remains controversial. Previous studies have focused on TKA blood loss, duration of surgery, and hemostatic drugs. The purpose of this meta-analysis was to analyze the effect of tourniquet use on postoperative deep venous thrombosis (DVT).

Methods

PubMed, SCOPUS, Web of Science, Embase, and the Cochrane Library were searched for randomized clinical trials published before April 17, 2020, that compared the effect of tourniquet use on postoperative DVT, knee circumference, D-dimers, and pain measured using the visual analog scale (VAS).

Results

Fourteen clinical trials that included 1321 unique participants were included in the meta-analysis. Among the total, 721 and 600 participants were randomized to the tourniquet and non-tourniquet groups, respectively. The incidence of postoperative thrombosis in the tourniquet group was significantly higher than in the non-tourniquet group (RR 2.30, 95% CI 1.51–3.49, P < 0.0001, I² = 0%). On the 1st, 3rd, and 5th to 21st days, and 3 to 6 weeks after surgery, the knee circumference difference of the tourniquet group was significantly larger than that of the non-tourniquet group (P < 0.05). However, 4 to 6 months after the surgery, no significant difference in knee circumference was found between the two groups (MD 0.14, 95% CI −0.02–0.31, P = 0.09, I² = 0%). The VAS score of the tourniquet group was higher than the non-tourniquet group on the 3rd and 5th days after surgery (P < 0.05). However, this difference was not significant (MD 0.31, 95% CI −0.05–0.66, P = 0.09, I² = 89%).

Conclusion

Results of this meta-analysis indicate that tourniquet application could increase the incidence of postoperative DVT and aggravate postoperative pain and swelling in the short term.

Level of evidence

Level III

The risks associated with tourniquet use in lower limb trauma surgery: a systematic review and meta-analysis

Purpose

Tourniquet use in lower limb fracture surgery may reduce intra-operative bleeding, improve surgical field of view and reduce length of procedure. However, tourniquets may result in pain and the production of harmful metabolites cause complications or affect functional outcomes. This systematic review aimed to compare outcomes following lower limb fracture surgery performed with or without tourniquet.

Methods

We searched databases for RCTs comparing lower limb fracture surgery performed with versus without tourniquet reporting on outcomes pain, physical function, health-related quality of life, complications, cognitive function, blood loss, length of stay, length of procedure, swelling, time to union, surgical field of view, volume of anaesthetic agent, biochemical markers of inflammation and injury, and electrolyte and acid–base balance. Random-effects meta-analysis was performed. PROSPERO ID CRD42020209310.

Results

Six RCTs enabled inclusion of 552 procedures. Pooled analysis demonstrated that tourniquet use reduced length of procedure by 6 minutes (95% CI −10.12 to −1.87; p < 0.010). We were unable to exclude increased harms from tourniquet use. Pooled analysis showed post-operative pain score was higher in tourniquet group by 12.88 on 100-point scale (95% CI −1.25–27.02; p = 0.070). Risk differences for wound infection, deep venous thrombosis and re-operation were 0.06 (95% CI −0.00–0.12; p = 0.070), 0.05 (95% CI −0.02–0.11; p = 0.150) and 0.03 (95% CI -0.03–0.09; p = 0.340).

Conclusion

Tourniquet use was associated with a reduced length of procedure. It is possible that tourniquets also increase incidence of important complications, but the data are too sparse to draw firm conclusions. Methodological weaknesses of the included RCTs prevent any solid conclusions being drawn for outcomes investigated. Further studies are required to address these limitations.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00590-021-02957-7.

Understanding and Optimizing Tourniquet Use During Extremity Surgery

Tourniquet use during extremity surgery is commonplace and a relatively safe practice. The surgical team's knowledge of the patient history, proper assessment, and indications and contraindications for and risks of tourniquet use can prevent unwanted outcomes. Exploration of these critical areas reinforces perioperative nurses' awareness and understanding of safe tourniquet use. Additionally, a review of the physiological effect of tourniquets on the skin, the body's response to local compression, the risk of vascular compromise, and the effect of the tourniquet on postoperative pain and swelling provides insight into AORN recommended practice guidelines. This article summarizes the indications and assessments for and risks of tourniquet use for patients during extremity surgery. An understanding of these topics can improve surgical outcomes and promote safe perioperative care.

Survey research in podiatric medicine: An analysis of the reporting of response rates and non-response bias

BACKGROUND

Survey research is common practice in podiatry literature and many other health-related fields. An important component of the reporting of survey results is the provision of sufficient information to permit readers to understand the validity and representativeness of the results presented. However, the quality of survey reporting measures in the body of podiatry literature has not been systematically reviewed.

OBJECTIVE

To examine the reporting of response rates and nonresponse bias within survey research articles published in the podiatric literature in order to provide a foundation with regard to the development of appropriate research reporting standards within the profession.

METHODS

This study reports on a secondary analysis of survey research published in the Journal of the American Podiatric Medical Association, the Foot, and the Journal of Foot and Ankle Research. 98 surveys published from 2000 to 2018 were reviewed and data abstracted regarding the report of response rates and non-response bias.

RESULTS

67 surveys (68.4%) report a response rate while only 36 articles (36.7%) mention non-response bias in any capacity.

CONCLUSIONS

The findings suggest that there is room for improvement in the quality of reporting response rates and nonresponse in the body of podiatric literature involving survey research. Both nonresponse and response rate should be reported to assess survey quality. This is particularly problematic for studies that contribute to best practices.

Blood Flow Restriction Therapy After Knee Surgery: Indications, Safety Considerations, and Postoperative Protocol

Blood flow restriction (BFR) training involves occluding venous outflow while maintaining arterial inflow by the application of an extremity tourniquet after surgery. BFR ultimately reduces oxygen delivery to muscle cells, similar to an anaerobic environment, and allows patients to exercise with low resistance and stimulates muscle hypertrophy and strength using heavy resistance. Thus orthopaedic surgeons and physical therapists are incorporating this type of training into their postoperative rehabilitation protocols, particularly after injuries or surgical procedures about the knee joint. The purpose of this Technical Note is to describe a BFR clinical application technique and to report on the indications, safety considerations, and postoperative knee surgery rehabilitation protocols for BFR.

Use of Tourniquets in Limb Trauma Surgery

Although tourniquets are commonly used in patients with limb trauma patients, both in the acute and elective settings, no set protocols exist for their indications, contraindications, or proper use. This article addresses the current literature on optimal pressure, timing, cuff design, and complications of tourniquets in trauma patients. General issues are discussed, followed by those specific to upper and lower extremities. Lastly, serious complications, such as pulmonary embolism, are described.

American College of Foot and Ankle Surgeons® Clinical Consensus Statement: Perioperative Management

A wide range of factors contribute to the complexity of the management plan for an individual patient, and it is the surgeon's responsibility to consider the clinical variables and to guide the patient through the perioperative period. In an effort to address a number of important variables, the American College of Foot and Ankle Surgeons convened a panel of experts to derive a clinical consensus statement to address selected issues associated with the perioperative management of foot and ankle surgical patients.

Use of peripheral blocks and tourniquets in foot surgery: A survey of Australian orthopaedic foot and ankle surgeons

BACKGROUND

The most common reasons for unplanned admission to the hospital from outpatient surgery have the potential to be minimised or eliminated by peripheral nerve blocks (PNB). Tourniquets are commonly used in elective extremity surgery but it's use is mostly guided by personal preferences and does no correlate with the existing literature. Our aim was to explore the current practice of PNB and tourniquet use by foot and ankle surgeons in Australia.

METHODS

The Australian Orthopaedic Foot and Ankle Surgery Society (AOFAS) annual meeting was held in Adelaide in 2011. Members were asked to complete an electronic survey on their current use of peripheral nerve blocks and tourniquets. Two specific elective case scenarios were included for comment, one pertaining to forefoot pathology, the other hindfoot pathology.

RESULTS

Twenty-three AOFAS members replied to the survey, an overall response rate of 76.6%. Of these, only two surgeons did not use ankle blocks in elective surgery and none were prepared to operate without a tourniquet. Most Australian foot and ankle surgeons were reluctant to use local anaesthetic techniques without an accompanying GA.

CONCLUSIONS

While the literature suggests that GA may add to complications without any benefit for the procedure and that distally based tourniquets may add benefit, these are not the favoured techniques in Australian foot and ankle surgeons.

Pneumatic tourniquet use in foot and ankle surgery--is padding necessary?

BACKGROUND

The majority of foot and ankle surgery is carried out in a bloodless field achieved by the use of a pneumatic tourniquet. The risks of tourniquet use may be divided into those resulting from direct mechanical pressure from the cuff and those secondary to prolonged limb ischaemia. Current peri-operative guidelines advise the use of padding beneath the cuff, in particular to reduce skin complication.

OBJECTIVES

To assess the complication rate of tourniquet use when the cuff is applied directly to the skin.

METHOD

Patients undergoing foot and ankle surgery under tourniquet control without use of padding were assessed pre and post operatively for soft tissue complication, neurological deficit and post-tourniquet syndrome.

RESULTS

We recorded findings for 97 patients, 47 thigh and 50 ankle tourniquets. We found a complication rate of 0%. There were no cases of skin blistering, abrasion, bruising, laceration or burn.

CONCLUSIONS

These findings are contrary to published RCTs supporting the use of padding. Our study demonstrates the safe use of pneumatic tourniquets without padding in foot and ankle surgery.

Meta-analysis on the efficacy of tourniquet on ankle trauma surgery

BACKGROUND

In our study, we used meta-analysis to study the efficacy of the tourniquet on ankle trauma surgery. Postoperative infection rate, deep venous thrombosis incidence, hospital stay, and joint range of motion were studied to compare the tourniquet and non-tourniquet groups and provide certain references for clinical decision.

METHODS

We searched PubMed, MEDLINE, EMBASE, and the Cochrane controlled trials register for all publications about the efficacy of tourniquet published before November 2012. The quality of included studies was evaluated by two estimators. I2-test and Q-statistic were used for heterogeneity analysis. When there was heterogeneity between studies, the random effects model analysis was applied or else the fixed effects model analysis was used.

RESULTS

Three studies were included with 166 patients suffering from ankle trauma surgery. There was no statistical difference (P >0.05) between the tourniquet and non-tourniquet groups on operation time (mean difference (MD) -5.45, 95% confidence intervals (CI): (-13.98, 3.09)), postoperative infection rate (relative risk (RR) 1.83, 95% CI: (0.65, 5.12)), and deep venous thrombosis incidence (RR 4.13, 95% CI: (0.47, 36.17)). But statistical significances were observed on hospital stays (MD 3.17, 95% CI: (1.39, 4.95)) and joint range of motion (MD - 5.25, 95% CI: (-9.61, -0.89)).

CONCLUSIONS

In general, the efficacy of the tourniquet group is comparable to that of the non-tourniquet group. The non-tourniquet group achieved greater benefits for the joint range of motion and reduced the hospital stay. However, a larger number of primary studies is still required for future evaluation of tourniquet efficacy on ankle trauma surgery.

Silicone ring versus pneumatic cuff tourniquet: a comparative quantitative study in healthy individuals

INTRODUCTION

The aim of the present study was to compare a new silicone ring tourniquet (SRT) with a classic pneumatic cuff tourniquet (PT) in terms of tolerance and recovery time following their use in healthy volunteers.

METHODS

Both tourniquets were applied in the arm and thigh of 15 healthy unmedicated volunteers. PT pressure was kept at 100 mmHg above the systolic blood pressure. The appropriate model of the SRT was used according to the systolic blood pressure. Pain was assessed by visual analogue scale and arterial blood pressure, pulse rate and oxygen saturation were monitored in all volunteers.

RESULTS

There was no statistically significant difference in tolerance time between SRT and PT in the arm (19.13 vs. 18.25 min) and thigh (21.52 vs. 21.39 min) nor in recovery time between the two devices.

CONCLUSION

The SRT performed similarly to the classic PT in terms of tolerance and recovery time when applied in the arm and thigh of unmedicated healthy volunteers.

Automated cuff occlusion pressure effect on quality of operative fields in foot and ankle surgery: a randomized prospective study

BACKGROUND

Limb occlusion pressure, which is present when blood flow ceases, has not had a practical method described for attainment. An automated tourniquet system was modified to set tourniquet pressure based on measurement of limb occlusion pressure (LOP). In this single surgeon randomized prospective study, the effectiveness of this system was assessed on patients undergoing foot and ankle surgery.

MATERIALS AND METHODS

Two hundred forty-four patients were randomized to the study group of automated pressure (n = 112) or to the control group (n = 132). The primary outcome measure was tourniquet pressure used for either group. Secondary measures included the time to set the pressure and number of patients failing LOP measurement. The tourniquet field was assessed intraoperatively and postoperatively in a blinded manner.

RESULTS

The tourniquet pressure was significantly lower in the study group at 198.5 ± 20.2 mmHg compared to 259.6 ± 4.4 in the control group (p < 0.001). The time to measure the LOP was 20 ± 6 seconds. Six patients failed to be measured. The quality of the surgical field was judged to be better in the study group based on all three methods of assessment.

CONCLUSION

LOP measurement was a practical way of setting tourniquet pressures for limb surgery. The automated pressure averages were lower than those routinely used by most surgeons for thigh tourniquets.

Understanding of intra-operative tourniquets amongst orthopaedic surgeons and theatre staff--a questionnaire study

INTRODUCTION

Pneumatic tourniquets are used frequently in orthopaedic theatres to provide a bloodless field whilst operating on the extremities. Their use has given rise to complications and preventable damage due to over-pressurisation and prolonged application. We designed a questionnaire to assess the knowledge on tourniquet use among operating department assistants (ODAs) and specialist registrars (SpRs) in orthopaedic surgery.

SUBJECTS AND METHODS

A questionnaire was constructed using set guidelines from the Association of periOperative Registered Nurses (AORN) for recommended practice of tourniquet application. This was distributed to orthopaedic registrars with varying levels of experience and ODAs from five different NHS hospitals. The unpaired, two tailed t-test was used to test for statistical significance of results.

RESULTS

A total of 54 completed questionnaires were collected for analysis. The study population included 29 orthopaedic SpRs and 25 ODAs. The mean score for the orthopaedic SpRs as a group was 41.3% (SD 6.85; range, 29.0-54.8%). The mean score for the ODAs was 46.7% (SD 9.64; range, 23.3-62.9%) with a P-value of 0.024.

CONCLUSIONS

Most surgeons are taught how to use pneumatic tourniquets by their senior colleagues as no formal teaching is given. Most of the complications are infrequent and preventable. However, their consequences can be devastating to the patient with medicolegal implications. Our results show suboptimal knowledge of tourniquets and their use among SpRs and ODAs. This study highlights the need for amendments in training to improve the knowledge and awareness of medical practitioners on the application and use of tourniquets to prevent adverse events and improve patient safety.

The efficacy of the tourniquet in foot and ankle surgery? A systematic review and meta-analysis

Tourniquets are commonly used during foot and ankle surgery. The purpose of this study was to compare the peri- and post-operative outcomes of tourniquet-assisted to non-tourniquet-assisted ankle and foot surgery. A systematic review was undertaken assessing the electronic databases Medline, CINAHL, AMED and EMBASE, in addition to a review of unpublished material and a hand search of pertinent orthopaedic journals. The evidence-base was critically appraised using the Cochrane Bone, Joint and Muscle Trauma Group quality assessment tool. Study heterogeneity was measured using chi(2) and I(2) statistics. Where appropriate, a random-effects meta-analysis was undertaken to pool results of primary studies, assessing mean difference or relative risk of each outcome. A total of four studies were identified. The findings of this study would suggest that hospital length of stay was significantly shorter, and that the post-operative period was less painful, with reduced swelling from the fifth post-operative day, in surgeries undertaken without a tourniquet, compared to tourniquet-assisted procedures. There may be a greater incidence of wound infection and deep vein thrombosis in tourniquet-assisted foot and ankle procedures. The methodological quality of the evidence base is limited. Further study is required to address these limitations, after which we may be able to determine whether a tourniquet should be used during ankle or foot procedures.

Pneumatic tourniquet use in the perioperative environment

Pneumatic tourniquets are routinely used in operating theatres worldwide. Generally, tourniquets are viewed as a relatively safe instrument with minimal complications. Nevertheless, Klenerman (2003) and Golder et al (2000) both suggest that caution should be exercised in tourniquet use. Furthermore Phillips (2004, p532) claims that, 'a tourniquet is dangerous to apply, to leave on and to remove'. This article will inform perioperative practitioners of the current research pertaining to the routine procedure of using pneumatic tourniquets to achieve a bloodless surgical field.

Tourniquet cuff pressure: The gulf between science and practice

Tourniquet use is effective in producing a bloodless field. It is recommended that the least effective pressures be used to minimize tissue microstructure and biochemical damage from tourniquet application. When applied at the thigh, the minimum effective tourniquet pressure is 90 to 100 mm Hg above systolic BP, and in a normotensive, nonobese patient, pressure of 250 mm Hg is sufficient. Similarly, an arm tourniquet pressure of 200 mm Hg is recommended. The purpose of this survey was to assess the tourniquet pressures used by orthopaedic surgeons, both academic and community based, and their familiarity with associated literature.

MATERIALS

A Website-based survey was distributed to a random sample of academic and community-based surgeons. Respondents were asked the upper and lower-extremity tourniquet pressures they routinely use. They were asked if they were able to cite or were aware of literature to support their answer. They were also asked to specify their practice setting and years in practice. Results were statistically analyzed utilizing Fisher's exact test and Mann-Whitney test.

RESULTS

A total of 199 survey responses were collected. Out of these, 151 (76%) were complete for the lower extremity, and 141 (71%) were complete for upper extremity. The average years in practice were 12.6 years (range, 1-30). The median LE pressure was 300 mm (range, 150-400), and the median UE pressure was 250 mm (range, 150-300). Less than 20% of respondents routinely used pressures of 250 mm or less for the lower extremity. For upper extremity, only 11.3% used pressures at or below 200 mm. Surgeons in academic practice were more likely to use lower tourniquet pressures, and less likely to choose "don't know" as the option for literature support, but the difference was not statistically significant. Although 60% of respondents thought that they were aware of literature supporting their answers, only 25% of these for the lower extremity and 11% for the upper used the correct pressures.

CONCLUSION

This survey demonstrates the existing gulf between tourniquet use and supporting literature. Tourniquet use is not benign and the correct pressure usage allows the least morbidity. We hope this survey will raise awareness of the correct tourniquet pressures and change practice patterns based on "that's how we have always done it".

Survey of tourniquet use in orthopaedic foot and ankle surgery

BACKGROUND

Tourniquet technique varies among foot and ankle surgeons, and to establish a standard practice guideline the current standard of care should be examined.

METHODS

One hundred and forty responses were received after 253 surveys were mailed to American Orthopaedic Foot and Ankle Society (AOFAS) members, concerning type of tourniquets, location, and pressures used.

RESULTS

Cuff pressures most commonly used were 301 to 350 mmHg for thigh cuffs (49% of thigh cuff users) and 201 to 250 mmHG for calf and ankle cuffs (52% of calf cuff users, 66% of ankle cuff users). A substantial number of foot and ankle surgeons who use calf and ankle cuffs frequently use pressures above 250 mmHg (41% of calf cuff users, 19% of ankle cuff users). Only 9% use limb occlusion pressure when determining cuff pressure.

CONCLUSION

Based on the existing evidence-based literature these pressures may be higher than necessary for many patients, and increased adoption of optimal pressure setting techniques as reported in the literature may help reduce tourniquet pressures used and risk of tourniquet injury. Respondents reported experiencing or hearing reports of breakthrough bleeding, nerve injury, and skin injuries under the cuff.

Wide contoured thigh cuffs and automated limb occlusion measurement allow lower tourniquet pressures

We examined the amount of thigh tourniquet pressure that can be reduced from the typical 300 to 350 mm Hg by using a new automated plethysmographic limb occlusion pressure measurement technique. We also examined how much pressure could be reduced by using a wide contoured cuff compared with a standard cuff and if limb occlusion and systolic blood pressures were well correlated. Patients having surgery with a thigh tourniquet were randomized into two groups, one group having surgery with a standard cuff and the other with a wide cuff. Pressure was set at the automatically measured limb occlusion pressure plus a safety margin. Systolic blood pressure and quality of the bloodless field were recorded. The standard cuff maintained an acceptable bloodless field for 18 of 20 patients at an average pressure of 242 mm Hg, and the wide cuff was acceptable for 19 of 20 patients at an average of 202 mm Hg. One patient in each group had a poor bloodless surgical field at the initial pressure, and one patient in each group had a poor bloodless surgical field after a sharp rise in blood pressure during surgery. Systolic blood pressure was not correlated well enough to limb occlusion pressure to be used alone to set the optimum cuff pressure. The automated limb occlusion pressure technique and the wide contoured cuff reduced average pressure by 33-42% from typical pressures.

Acceptability of ankle tourniquet use in midfoot and forefoot surgery: audit of 1000 cases

BACKGROUND

While use of a thigh tourniquet with general anesthesia is widely accepted, use of an ankle tourniquet in the awake patient is more controversial. In particular, it is not clear how long patients tolerate this device or what the consequences are of intraoperative tourniquet pain.

METHOD

A prospective audit was done of 1000 patients undergoing midfoot and forefoot surgery using an ankle block. We examined the intraoperative problems associated with the use of an ankle tourniquet, particularly the role and consequences of intraoperative tourniquet pain. Risk factors for tourniquet pain were statistically examined, and patient acceptance was gauged through followup questions.

RESULTS

With correct application and the option of sedation, 3.1% of patients complained of tourniquet pain. In 0.4% of patients tourniquet pain necessitated a conversion to general anesthesia. A significant association was found between tourniquet pain and both age and tourniquet time. We found that for patients younger than 70 years of age, the tourniquet can be applied comfortably for up to 30 minutes in over 97%. For each 11 minutes beyond this, another 1% of patients reported tourniquet pain. However, patients 70 years or older had an average 3.5 times increase in tourniquet pain. In this age group the tourniquet can be applied comfortably for up to 30 min in 91%. For each 3.2 minutes beyond this, another 1% reported tourniquet pain. When questioned, 97.2% of our patients reported that they would have surgery again with an ankle tourniquet.

CONCLUSIONS

Our audit shows that with correct application and the option of sedation the ankle tourniquet is well tolerated by most patients. However, clinicians need to be mindful that patients 70 years of age or older are at greater risk of tourniquet pain and that in all patients the risk of tourniquet pain gradually increases when application times exceed 30 min.