Download Intraoperative Tourniquet Use

INTRAOPERATIVE
TOURNIQUET USE
Micah Reece
*A caveat

As we’ve learned, pneumatic tourniquets play an
important role in regional/Bier blocks but such use is
outside the scope of this paper as the assigned
topic is INTRAoperative tourniquet use (particularly
with regards to orthopedic surgery)
So what is a pneumatic tourniquet?

Essentially an
inflatable compression
device of varying sizes
containing:
 Air
compressor
 Inflatable cuff
 Connective tubing
 Timer
Stryker SmartPump
How does it work?


Almost always inflated
AFTER induction or
block
Inflated to 100 mm Hg
above systolic baseline
for LE and 50 mm Hg
above baseline for UE
How does it work?

Limb can be
further
exsanguinated
via Esmarch
bandage and
elevation of
extremity.
…But it can’t stay on forever


Most machines have a timer that will alarm after 60
minutes of inflation time
Current guidelines recommend max inflation time of
120 minutes before requiring a ten minute break
for deflation of the cuff and reperfusion to the
extremity
Why use these things?

Commonly used in orthopedic/extremity surgeries to
accomplish three goals:
 Minimize
blood loss
 Maintain a bloodless field
 Aid in identifying vital structures
Anesthesia Considerations
Why do WE care?!
MANY deleterious effects of inflation



Muscle breakdown and hypoxia begin almost
immediately=cellular acidosis
Abolition of nerve conduction and somatosensory
evoked potentials to effected area
Progressive sympathetic activation often manifests
as marked hypertension, diaphoresis, and
tachycardia
You’re not done yet! (Deflation)

Following deflation,
patients will exhibit
numerous transient CV
changes:
lower core body
temperature
 decreased venous
oxygen tension
 sudden drops in arterial
and pulmonary pressures
 increased heart rate

Deflation Cont’d
Lab changes



Further hyperkalemia
and myoglobinemia
Myoglobinuria
Metabolic acidosis
 Think
of tourniquet
release as a
“metabolic washout”
Respiratory Changes


Respiratory Acidosis
Increased minute
ventilation in a
spontaneously
breathing patient
So what is our role?



Vigilant monitoring of
hemodynamic status
Cautious use of pressors
depending on when cuff
is inflated/deflated
Ensure proper padding
of limb, appropriate
tourniquet size, minimize
inflation time
Cont’d


Careful monitoring of
pertinent labs (i.e.
potassium, myoglobin,
ABG)
Assess for any
lingering postoperative pain or
parasthesias
Remember!

It’s hard to have tourniquet-induced complications if
the tourniquet isn’t being used. Coordinate with the
surgical team to keep inflation time to an absolute
minimum.
L is for “litigation”



It is very important for
the nurse anesthetist to
accurately document
inflation AND deflation
time
Make sure your times
match those of the OR
record
Also a good idea to
chart that you notified
surgeon at intervals of
time and the message
was acknowledged
Questions?
The End
References
Barash, P. G., Cullen, B. F., Stoelting, R. K., Cahalan, M. K., Stock,
M. C., & Ortega, R. (2013). Clinical Anesthesia (7th
ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Butterworth, IV, J. F., Mackey, D. C., & Wasnick, J. D. (2013).
Morgan & Mikhail’s Clinical Anesthesiology (5th ed.).
[AccessMedicine]. Retrieved from
http://www.accessmedicine.com
Davis, R., Keenan, J., Meza, A., Danaher, P., Vacchiano, C., Olson,
R. L., & Maye, J. (2002, August). Use of a simple
forearm tourniquet as an adjunct to an intravenous
regional block. AANA Journal, 295-298. Retrieved
from
http://www.aana.com/newsandjournal/Documents/fore
arm_tourniquet0802_p295-298.pdf
References Cont’d
Hoerneman, D. W. (1982, December). Orthopedic surgery:
Some anesthetic considerations. Journal of the
American Association of Nurse Anesthetists, 555-563.
Retrieved from
http://www.aana.com/newsandjournal/Documents/orth
opedic_surgery_1282_p555.pdf
Nagelhout, J. J., & Plaus, K. L. (2013). Nurse Anesthesia (5th ed.).
St. Louis, MO: Elsevier Saunders.