You are on page 1of 47

LE GARROT EN CHIRURGIE DE LA

MAIN
TOURNIQUET USE IN HAND SURGERY

Professeur Christian Dumontier, MD, PhD
Centre de la Main, Guadeloupe
www.diuchirurgiemain.org

A TOURNIQUET IS USEFUL
TO STOP BLEEDING !

Using a tourniquet on war
operation theater is useful AND
not detrimental

However, after two hours of use,
the risk of fasciotomy is increased

Kragh JF Jr, Walters TJ, Baer DG, Fox CJ, Wade CE, Salinas J, Holcomb JB. Practical use of emergency tourniquets to
stop bleeding in major limb trauma. J Trauma. 2008 Feb;64(2 Suppl):S38-49

WE NEED A TOURNIQUET IN HAND
SURGERY !

« Could a jeweler repair a watch
immersed in ink ? » (Sterling
Bunnell)

A tourniquet helps in the precise
identification of anatomical
structures, decreases the need for
transfusion and shortens operating
time.

But it does not substitute for a
precise surgical hemostasis +++

HOWEVER, THE USE OF A TOURNIQUET
IS NOT WITHOUT CONSEQUENCES

1. It always leads to postoperative changes that may
interfere with healing and/or functional recovery
2. It may lead to complications that you are
responsible for +++

FUNCTIONAL CHANGES

Carpal tunnel release w/w° tourniquet and EMG study
at 3 weeks post surgery ☛ 77% of patients presented
with denervation elsewhere than thenar eminence !

Prospective randomized study of 54 patients with closed
ankle fractures (26 w/ 28w°) ☛ increase post-operative
swelling and pain in patients with tourniquet use

KONRAD, G., MARKMILLER, M., LENICH, A., MAYR, E., RUTTER, A.TOURNIQUETS MAY INCREASE
POSTOPERATIVE SWELLING AND PAIN AFTER INTERNAL FIXATION OF ANKLE FRACTURES. CLINICAL
ORTHOPAEDICS AND RELATED RESEARCH 2005; 433, 189–194.

COMPLICATIONS FOR TOURNIQUET USE

Complications rate 1/5000 à 1/8000

1/5000 (upper limb) to 1/13000 (lower limb) - Australia-1970

63484 surgical interventions with tourniquet use: 26
complications (1/2442) due to the tourniquet including 15
neurological (3 Up-limb 1/6155; 12 Lo-limb 1/3752) of which
two were definitive

ODINSSON A, FINSEN V. TOURNIQUET USE AND ITS COMPLICATIONS IN NORWAY. JBJS BR. 2006
AUG;88(8):1090-2.
PALMER AK: COMPLICATIONS FROM TOURNIQUET USE. HAND CLINICS 1986;2:301-305.
GUERRA JB: EQUIPEMENT MALFUNCTION. HAND CLINICS 1994;10:45-52.

PATIENT SAFETY REPORT OF PENNSYLVANIA

140 complications due to tourniquet in 5 years

41% redness, swelling, oedema,...➔ excessive pressure

19% phlyctenulae ➔ poor application of the tourniquet

14% unexpectd bleeding ➔ Poor control of the tourniquet / Blood
pressure

8% were left in place more than 2 hours

…poorly positioned, wrong site,…
Pa Patient Saf Advis 2010 Sep;7[3]:97-101.

COMPLICATIONS OF TOURNIQUET USE ARE NOT
ANECDOTICAL AND YOU ARE RESPONSIBLE FOR

You need to know how it should be used

You should be able to teach the room nurses

You should verify, from time to time, that everyone has well
understood

HISTORICAL


…Heliodoris (roman surgeon used it for
amputations)
JP Petit, 1718 introduce the name tourniquet
JF Von Esmach, 1873, used his suspenders to
stop bleeding in an amputee

HISTORICAL

Harvey Cushing, 1904,
introduced the pneumatic
tourniquet

Mc Ewen, 80’s, introduced the
modern device with electronic
control: more efficient and safe
(+ 49% hysteresis in pressure of +/200 mmHg)

CONTRA-INDICATIONS ?
The following Recommended Standards of
Practice were researched and written by
the AST Education and Professional
Standards Committee and have been
approved by the AST Board of Directors.
They are effective April 13, 2007.

CONTRA-INDICATIONS ?

Open fractures (difficult to analyse the vitality of tissues. Leaving necrotic tissues
increases postoperative infection rate)

Intramedullary nailing (Increases the risk of fatty embolism)

Severe arteriopathy (increases the risk of distal emboli)

Severe crush injury, compartment syndrome

Severe hyper blood pressure

Skin graft under the tourniquet

Malignant tumors

Y

S
E

SHOULD WE PAD THE SKIN UNDER THE
TOURNIQUET ?

Yes / No

Why ? Explain !

YES - WE SHOULD PAD THE SKIN UNDER
THE TOURNIQUET

Guo S. Is Velband still a safe and cost effective skin protection beneath the
tourniquet in hand surgery? Hand Surg. 2011;16(1):5-8.

Din, R., Geddes, T., 2004. Skin protection beneath the tourniquet, a prospective
randomised trial. Annual New Zealand Journal of Surgery 74, 721–722.

Olivecrona, C., Tidermaaark, J., Hamberg, P., Ponzer, S., Cedferfjall, C., 2006. Skin
protection underneath the pneumatic tourniquet during total knee arthroplasty.
Acta Orthopaedica 77 (3), 519–523.

Saleh KJ. An elastic stockinette under a pneumatic tourniquet protected against
the development of blisters during total knee arthroplasty. J Bone Joint Surg Am.
2007 Feb;89(2):459.

A stockinette, an elastic
stockinette, A Velpeau
crepe bandage,….

better distribute pressure,
avoid skin blistering, ….

WHERE TO PLACE THE
TOURNIQUET ?

On the diaphysis, where the
muscular mass is thicker

Arm or Forearm:

Same tolerance (Edwards) or
even superior at the forearm
(+45% if < 30 mn)

Surgeons are less satisfied at
the forearm ( Odinsson)

Well tolerated if < 20’

Edwards SA, Harper GD, Giddins GE. Efficacy of forearm versus upper arm tourniquet for local anaesthetic
surgery of the hand.J Hand Surg Br. 2000 Dec;25(6):573-4.
Odinsson A, Finsen V. The position of the tourniquet on the upper limb. JBJS Br 2002; 84-B; 202-204

WHICH SIZE SHOULD YOU
CHOOSE ?

O

e
n

?
la l
s
t
fi
e
is z

TOURNIQUET SIZE

The largest the best ☛ stops the blood flow for a
lesser pressure ; ☛ diminishes deep pressure
under the cuff

The tourniquet cuff should be longer of 7-15 cm
☛ too short, it will fail; ☛ too long, it increases
pressure under the cuff and the risk of skin blisters

Obese patients have conical shape (use a curved
tourniquet or make the limb cylindrical)
Width of the tourniquet = 1/2 limb diameter
Moore MR, Garfin SR, Hargens AR. Wide tourniquets eliminate blood flow at low inflation
pressures. J Hand Surg Am. 1987 Nov;12(6):1006-11.

HOW DO YOU EXSANGUINATE THE LIMB ?

Elevation for a few minutes

Hand-over-hand technique

Velpeau bandage

Elastic bandage (Biflex,

Esmach bandage

DO NOT USE ESMACH BANDAGE !

The more you turn around
the limb, the higher the
pressure on the soft-tissues

Deadly pulmonary
embolism have been
described (5 cases in
traumatology, 1 during
Knee replacement,…)
Darmanis: Injury 2000

DO NOT TRY TO EMPTY THE LIMB !

Hand-over-hand technique has proven efficient in 92% of cases

Not emptying a limb:

allows for a better visualization of vessels (Tourniquets do
not replace hemostasis ++)

Maintain a level of NO that protect agains free radicals
during re-perfusion of the limb

Itar et al. Does the method of expression of venous blood affect ischaemia/reperfusion damage in tourniquet
use? An experimental study on rabbits. Injury 2013; 44:1493-1497

WHICH PRESSURE ?

Over 150 surgeons, lower extremity
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 (recommended
values)

Levy O, David Y, Heim M, Eldar I, Chetrit A, Engel J. Minimal tourniquet pressure to maintain arterial closure in upper
limb surgery. J Hand Surg Br. 1993 Apr;18(2):204-6.
Tejwani NC1, Immerman I, Achan P, Egol KA, McLaurin T. Tourniquet cuff pressure: The gulf between science and
practice. J Trauma. 2006 Dec;61(6):1415-8.

TOURNIQUET PRESSURE

We need 50-100 mm Hg
> Systolic BP (usually
250-300 mmHg)

Using Doppler control: 190
+/- 24 mm Hg
Higher pressure increases
tourniquet
« dangerousity » without
any benefit

Current guidelines:

Safety margin of 40 mmHg
for LOP < 130 mmHG

60 mmHG if
131<LOP<190 mmHg

80 mmHG if > 190 mmHG

In children, add 50 mmHg

HOW LONG ?

HOW LONG SHOULD WE KEEP IN PLACE A
TOURNIQUET ?

Neurological injuries (moderate) were observed
after 5 hours in cats, and severe after 8 hours
(Korthals et al. J Neurol 1965)

Between 30 mn and 4 hours….no evidence

90-120 mn seems a reasonable maximum

AND IF WE NEED MORE TIME ?

Deflating the tourniquet to allow repercussion ?

No scientific evidence supports this practice.

Tissues lose structural features, making dissection
difficult,

Edema makes wound closure arduous.

WHAT ARE THE COMPLICATIONS OF
TOURNIQUET USE ?

Neurological deficit ☛ Pressure

Post-tourniquet syndrome ☛ Time

Compartment syndrome ☛ Predisposition

Burns and skin damages ☛ Surgical mistakes

Hemorrhage ☛ Surgical mistakes (poor hemostasis, time)

Embolism, ischemia, gangrene ☛ predisposing factors, wrong
indication

NEUROLOGICAL INJURIES ARE DUE TO
TOURNIQUET PRESSURE

Ischemia leads to a conduction block within 30 to 90 mn with complete
recovery if ischemia is less than 6 h - While pressure leads to definitive
nerve injuries at the proximal edge of the tourniquet within 2 hours

Radial > Ulnar > Median (1/750 to 1/11000 cases)

Experimental studies:

Nerves are 1/2 to 1/4 of its diameter - De-myelinisation, loss of
endoneural proteins, squeezing o Ranvier’s nodes,…

More severe at the edges of the tourniquet

RISK FACTORS OF
NEUROLOGICAL INJURIES

Young age

High pressure (> 400 mmHg)

Longer time (Odd Ratio of 2,8 for every 30 mn
after 2 hours of tourniquet)

POST-TOURNIQUET SYNDROME

Give 4 consequences of a prolonged ischemia ?

Acidosis, hyperkaliemia, and byproducts of muscle
breakdown (myoglobin) are released into the
systemic stream.

POST-TOURNIQUET SYNDROME




Ischemia

Limb oedema
Stiffness
Hyperhemia
Inflammation
Palor, ischemia
Muscular weakness
Bleeding
Oedema
• ⬊ Muscular contractility
• ➚ post-op amyotrophy
• ➜ Muscular necrosis
Paresthesiae
Hyperhemia
usually resolve within 1 month

POST-TOURNIQUET SYNDROME

➚ 10% of limb volume after tourniquet release

More important in the absence of hemostasis and if the dressing is made before releasing the
tourniquet

Release tourniquet before closure ?

Post-op dressing increases limb pressures during 3 hours but limits the limb edema (bandage =
cast). Small-caliber vessels that cause “a prolonged ooze” are difficult to control

Studies on total knee arthroplasty have shown decreased blood loss with tourniquet release
after wound closure

Three studies comparing tourniquet release before/after skin closure. No differences in
complications like pain or ecchymosis

Hemostasis was better controlled if tourniquet was release AFTER, and operative time was
decreased

Sharma JP, Salhotra R. Tourniquets in orthopedic surgery. Ind J Ortho 2012; 46(4):377-383

COMPARTMENT SYNDROME

Rare

Ischemia > 2 hours

Predisposing factor +++ (Mc Ardle syndrome)

BURNS / PRESSURE SORES / BLISTERS /
SKIN DAMAGE

Too high pressure

Highly concentrated alcohol /
P-Iodine

Wrinkles under the tourniquet

Maceration in a wet
environment (do not « paint »
under the cuff)

BLEEDING UNDER THE TOURNIQUET

With a tourniquer, endo-medulalry
flow is < 1% of normal blood flow

If, after one hour, the patient bleeds
while the tourniquet is correctly
inflated

Revascularisation of the limb
through the humerus (anterior
circumflex artery)

ISCHEMIA, GANGRENE,
EMBOLISM

Predisposing factors (arteriosclerotic patients,
arterial prostheses,…)

PAIN UNDER THE TOURNIQUET

Either the tourniquet is in a nonanesthetized area

Local circular anesthesia
Place the tourniquet more distal

Most often pathophysiology is poorly
understood (smaller un-myelinated C-fibers
are more resistant to local anesthetic)

TOURNIQUET AND PREVIOUS LYMPH
NODE DISSECTION FOR BREAST CANCER

A. We must not operate on a patient who
previously had an axillary node dissection
B. We may operate, but without a tourniquet
C. We do as usual

Two groups of carpal tunnel syndrome operated
with Bier’s block

15 lymph node dissection (7 lymphoedema) - 0
complications

302 w/o node dissection: 3,6% superficial infections,
31 complications including 13 Reflex dystrophies
Dawson WJ, Elenz DR, Winchester DP, Feldman JL. Elective hand
surgery in the breast cancer patient with prior ipsilateral axillary
dissection.Ann Surg Oncol. 1995 Mar;2(2):132-7.

online review

58% of hand surgeons believe that there is no c/i;
30% of gynecologists; 10% of educational nurses

79% of hand surgeons and 58% of gynecologists
would use a tourniquet

Fulford D, Dalal S, Winstanley J, Hayton MJ. Hand surgery after axillary lymph node clearance for breast
cancer: contra-indication to surgery? Ann R Coll Surg Engl. 2010 Oct;92(7):573-6.

FINGER TOURNIQUET

Two problems:

Forget to remove the
tourniquet

Which pressure is
delivered ?

Sequelae +++

Pain (mainly due to cold),
dysesthesiae, allodiny; articular
stiffness

Trophic disturbances and
cosmetic sequelae are constant
(thin finger,…)
MALLARD F, SAINT-CAST Y, RICHOU J, LE NEN D. RÉSULTATS
FONCTIONNELS À LONG TERME D’ISCHÉMIES DIGITALES
SOUS GARROT : À PROPOS DE TROIS OBSERVATIONS.
CHIRURGIE DE LA MAIN 31 (2012) 358–363

WHICH PRESSURE IS DELIVERED ?

Penrose’ tube: 727 mmHg

Finger glove with a clamp: 439 mmHG

Rolled finger glove: 267 mm HG

Tourni-cot(r) : 246 mm HG

T-Ring (r): 151 mmHG

Lahham S, Tu K, Ni M, Tran V, Lotfipour S, Anderson CL, Fox JC. Comparison of pressures applied by digital
tourniquets in the emergency department.West J Emerg Med. 2011 May;12(2):242-9.
Hixson FP et al. Digital tourniquets: a pressure study with clinical relevance. J Hand Surg Am 1986; 11(6):
865-868.

WHAT I USE

A 8,5 glove wrapped around the wrist (110-260 mm Hg)

A small size glove with on finger rolled over (it has been shown
that if the glove used is the same size as the patient’s hand the
mean pressure generated was 355 mmHg, and uniformly less
than 500 mmHg independent of the operator’s experience of
the technique)

CONCLUSION = PREVENTION
Strategies for Pneumatic Tourniquet Use
Failure or misuse of pneumatic tourniquets can lead to muscle ischemia, nerve damage,
convulsions, and coma. Addressing cuff availability and educating staff about cuff selection,
application, and inflation pressure are fundamental strategies to avoid complications.

Before Patient Use
Maintain an adequate selection of cuffs.
—Contoured cuffs are desirable for excessively tapered limbs.
—Do NOT reuse single-use cuffs.
Ensure electronic controllers are connected to line power and/or have adequate battery capacity; perform self-test.
Select the proper size cuff, and look for cracked tubing and loose connectors.
Keep tubing off the floor and routed to avoid accidental contact by personnel.
Apply a soft padding uniformly to the operative limb cuff site.

After Applying a Tourniquet Cuff
Do not allow prepping solution to migrate under cuff.
Determine minimum limb occlusion pressure (LOP).
—Place a Doppler stethoscope on a distal arterial pulse.
—Increase cuff pressure until the pulse stops.
Set cuff inflation pressure for adult patients at LOP plus:
—40 mm Hg if LOP is less than 130 mm Hg,
—60 mm Hg if LOP is between 131 and 190 mm Hg, or
—80 mm Hg if LOP is greater than 190 mm Hg.
Set cuff inflation pressure for pediatric patients at LOP
plus 50 mm Hg.
Minimize cuff inflation time.

Notify the surgical team of elapsed inflation
time at regular intervals.
Monitor cuff pressure during the procedure,
especially when repositioning the limb.
Remove cuff and padding immediately
after completing procedure.
Indicate the following in patient record:
—Times of inflation and deflation
—Inflation pressure(s)
—Site of cuff placement
—Controller ID number

Include Tourniquet Controllers in the Facility’s Technology Management Program
MS10432

Inventory tourniquet controllers so that they can be identified and located in the event of hazard and recall notices.
Schedule units for routine inspection and preventive maintenance.
For more information, visit http://www.patientsafetyauthority.org.
Source: Association of periOperative Registered Nurses (AORN). Recommended practices for the use of the pneumatic tourniquet.
In: Perioperative standards and recommended practices. 2007 ed. Denver (CO): AORN Inc; 2009:3753-85.

An independent agency of the Commonwealth of Pennsylvania

This poster accompanies
Strategies for avoiding problems with the use of pneumatic tourniquets. Pa Patient Saf Advis [online]. 2010 Sep [cited 2010 Sep 1].
Available from Internet: http://www.patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2010/Sep7(3)/Pages/97.aspx.
© 2010 Pennsylvania Patient Safety Authority