Review Article

Safe Tourniquet Use: A Review of

the Evidence

Peter G. Fitzgibbons, MD
Christopher DiGiovanni, MD
Sayed Hares, MD
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Abstract
Due in part to an emphasis on quality and cost control within
healthcare institutions, protocols for healthcare practice are
increasingly being developed in an effort to maintain normative

guidelines and set acceptable standards. For example, the

Edward Akelman, MD Association of periOperative Registered Nurses, the National
Quality Forum, and the Association of Surgical Technologists have
made recommendations regarding tourniquet use. In the institution
of the senior authors (C.D. and E.A.), an effort to establish a
protocol for tourniquet use prompted a review of the evidence
behind standard practices and existing recommendations for safe
tourniquet use in the upper and lower extremities. Sparse evidence
exists in support of strict limits for tourniquet use, including
tourniquet duration, inflation pressure, and reperfusion periods.
However, simple principles and general guidelines regarding
tourniquet use can be extrapolated to guide safe practice.

F or hundreds of years, surgeons

From the Hand and Upper Extremity
Service, Department of Orthopedic
Surgery, Brigham & Women’s
Hospital, Boston, MA
(Dr. Fitzgibbons) and the
Department of Orthopaedics,
Warren Alpert School of Medicine of
Brown University, Providence, RI
(Dr. DiGiovanni, Dr. Hares, and
Dr. Akelman).
J Am Acad Orthop Surg 2012;20:
310-319
http://dx.doi.org/10.5435/
JAAOS-20-05-310
Copyright 2012 by the American
Academy of Orthopaedic Surgeons.
have used tourniquets to afford a
bloodless surgical field in extremity
surgery. The tourniquet may be used
to minimize blood loss and improve
visualization within the surgical
field.
The decision to use a tourniquet is
based on many factors, including the
technical demands of the procedure,
the location and duration of the pro-
cedure, and the anticipated blood
loss. Efforts to minimize or amelio-
rate blood loss using pharmacologic
or other methods (eg, tranexamic
acid, hypotensive anesthesia, intra-
operative blood salvage) may affect
this decision. In every case, the bene-
fits of tourniquet use must be
weighed against the risks.
The deleterious effects of pro-
longed tourniquet use are well estab-
lished. Published and anecdotal rec-
ommendations abound regarding
appropriate pressure, design, dura-
tion of inflation, and number of ac-
ceptable reinflations for any given
patient in a single surgical setting. In-
creased emphasis on quality and cost
control in healthcare institutions has
led to the development of protocols
for acceptable practice standards, in-
cluding protocols for tourniquet use.
In the institution of the senior au-
thors (C.D. and E.A.), an effort to
establish a policy for tourniquet use
involved a detailed review of the lit-
erature. Published protocols advo-
cate a range of practices, and the
strength of the evidence is variable1-3
(Table 1). These standards have med-
ical, financial, and legal implications;
as such, they must be grounded in a
solid understanding of medical facts.
Animal and human studies of tour-
niquet use are summarized in Table 2
and Table 3, respectively. These stud-
ies present information on the ac-
ceptable limits of tourniquet dura-
tion, pressure, and design. Other

310 Journal of the American Academy of Orthopaedic Surgeons

 Peter G. Fitzgibbons, MD, et al

Table 1
Published Recommendations on Tourniquet Use
Organization/Study Pressure Duration (min) Reperfusion Interval

Association of Surgical Upper extremity, 50 mm Hg above SBP; Upper extremity, 60; 15 min
Technologists3 lower extremity, 100 mm Hg above SBP lower extremity, 90
Association of periOperative 40 mm Hg above LOP for LOP <130 Upper extremity, 60; 15 min deflation after every 1 h
Registered Nurses1 mm Hg; 60 mm Hg above LOP for LOP lower extremity, 90 of tourniquet time
<131–190 mm Hg; 80 mm Hg above
LOP for LOP >190 mm Hg
Wakai et al2 General recommendation, 50–75 mm Hg 120 30 min at 2-h point in surgery
above LOP; upper extremity, 50–75 lasting >3 h
mm Hg above SBP; lower extremity,
90–150 mm Hg above SBP
Kam et al4 50–150 mm Hg above SBP, using the 120 10 min at the 2-h point for
lower end of the range for the upper surgery lasting >2 h
extremity and the higher end for the
lower extremity
Noordin et al5 Use LOP. No margin specified. 120 NR

LOP = limb occlusion pressure, NR = no recommendation, SBP = systolic blood pressure

important factors include skin pro-
tection under the tourniquet, blood
loss, and techniques for attenuating
metabolic changes.
Complications of
Tourniquet Use
Tourniquet-related pathogenesis is
related to ischemia and compression.
The metabolic effects are related to
the sequelae of ischemic tissue,
whereas nerve and muscle damage
are more likely a function of direct
compression beneath the tourniquet
itself. Controversy exists regarding
the influence of tourniquet design on
compressive damage to the soft tis-
sues. Tourniquet width is of particu-
lar interest.
Muscle Injury
Skeletal muscle injury is reasonably
well documented. Studies have mea-
sured tourniquet-induced changes in
technetium-99m pyrophosphate
( 99m
Tc PYP) uptake in muscle, con-
tractile function, and histology. In a
rabbit model, 99mTc PYP uptake was
found to be elevated following use of
a thigh tourniquet for 2 hours at 200
or 350 mm Hg of pressure and for 4
hours at pressure as low as 125 mm
Hg.48 Uptake was greatest at the site
of compression in the thigh, which is
indicative of particular vulnerability
to compression.
Tourniquet use impairs muscle
contractile function, with com-
pressed muscle experiencing greater
dysfunction than the more distal is-
chemic muscle.12 In a rabbit model,
quadriceps musculature compressed
at 350 mm Hg of pressure for 2
hours demonstrated markedly de-
creased function at 2 days postopera-
tively (21% of normal).49 However,
the muscle demonstrated restoration
to 83% of normal at 3 weeks. Lower
leg muscles experienced a milder dec-
rement initially than did the quadri-
ceps, with variable recovery to near
normal levels.
Multiple studies have documented
tourniquet-induced muscle injury at
a histologic level.11 In a canine study,
early signs of muscle damage, includ-
ing granular degeneration, inflam-
matory reaction, and edema, were
found following 1 to 2 hours of com-
pression at 350 mm Hg.6 In a rabbit

Dr. DiGiovanni or an immediate family member has received royalties from Extremity Medical; is a member of a speakers’ bureau or
has made paid presentations on behalf of BioMimetic Therapeutics and Extremity Medical; serves as a paid consultant to or is an
employee of BioMimetic Therapeutics and Extremity Medical; has received research or institutional support from BioMimetic
Therapeutics; has stock or stock options held in BioMimetic Therapeutics and Extremity Medical; and has received nonincome
support (such as equipment or services), commercially derived honoraria, or other non–research-related funding (such as paid travel)
from CuraMedix and Performance Medical Group. Dr. Akelman or an immediate family member has received royalties from Integra
LifeSciences; is a member of a speakers’ bureau or has made paid presentations on behalf of Auxilium Pharmaceuticals; serves as a
paid consultant to or is an employee of BioMimetic Therapeutics; has received research or institutional support from Auxilium
Pharmaceuticals; has stock or stock options held in BioMimetic Therapeutics and OsteoSpring Medical; and serves as a board
member, owner, officer, or committee member of the American Society for Surgery of the Hand. Neither of the following authors nor
any immediate family member has received anything of value from or owns stock in a commercial company or institution related
directly or indirectly to the subject of this article: Dr. Fitzgibbons and Dr. Hares.

May 2012, Vol 20, No 5 311

Safe Tourniquet Use: A Review of the Evidence

Table 2
Findings of Animal Model Tourniquet Studies
Pressure
Study (mm Hg) Duration Findings Model

Bushell et al15 300 4h Endothelial dysfunction, increase in Rabbit

neutrophil sequestration and increased
oxygen free radicals after 1 h of reperfu-
sion
Chiu et al16 300 1, 2, or 3 h CPK elevations in 2- and 3-h groups with Dog
clinical weakness in several after 2 and
3 h; all walked normally at 1 wk
Concannon et al17 250 Nine groups with vari- Reperfusion breaks may increase damage Rabbit
able periods of is- to the ischemic limb
chemia and 20-min
reperfusion breaks
Dillon et al18 NA 2.5 h After 12 h increased myeloperoxidase Rat
activity, impaired muscle twitch, and
titanic contractions
Duarte et al19 NA 1, 1.5, or 2 h Short periods of ischemia are sufficient Mouse
to induce functional alteration in the
endothelial cells
Fish et al20 300–400 1, 2, 3, and 4 h Duration of inflation affected contractile Rat
function of ischemic muscle at 2 wk
Gardner et al21 NA 2h Excitation contraction coupling mechanism Guinea pig
of fast muscle fibers is more sensitive to
ischemia than slow muscle fibers
Gersoff et al22 200 1h Increased tourniquet pressure negatively Cat
affects quadriceps contracture force and
fatigue time at 14 d
Heppenstall et al6 350 1, 2, and 3 h Blood gas and pH normal within 20 min for Dog
all, CPK elevated for all
Heppenstall et al23 350 3h pH, ATP, phosphocreatinine normalized in Dog
15 min. Significant cellular degeneration
in three of five specimens.
Jacobson et al24 350 1, 2, and 4 h Significant neuromuscular deficit after 2 Rabbit
and 4 h
Klenerman et al7 300 1, 2, 3, 4, and 5 h Subjects with tourniquet periods of 2, 3, Monkey
and 4 h returned to normal pH within
40 min. No evidence of nerve palsy in
any specimen.
Mohler et al25 125 and 350 2h No difference in muscle function at Rabbit
2 wk
Mohler et al26 350 4 h: 10-min interval after Nerve palsies in all groups. No benefit to Rabbit
2 h,10-min interval reperfusion.
after each hour there-
after
Nitz and Matulionis8 300 30 min–3 h Few nerve changes at 30 min. Progressive Rat
ultrastructural nerve changes from 1–3 h.
Nitz et al9 200, 300, and 400 1–3 h 400 mm Hg for a duration of 2 h Rat
produced the most severe gross motor
deficit with weak toe grip until 5 wk. EMG
changes persisted in all groups for 6 wk
after tourniquet application.

312 Journal of the American Academy of Orthopaedic Surgeons

 Peter G. Fitzgibbons, MD, et al

Table 2 (continued)
Findings of Animal Model Tourniquet Studies
Pressure
Study (mm Hg) Duration Findings Model

Ochoa et al10 1,000 1–3 h Displacement of nodes of Ranvier followed Baboon

by demyelination
250 2h No persistent conduction block or delay, no
demyelination
Pedowitz27 125, 200, and 350 1, 2, and 4 h Compressed thigh muscle histologic findings Rabbit
include: 125 mm Hg for 2 h, few abnormal-
ities and no necrosis; 350 mm Hg for 2 h,
marked abnormalities and some regional
necrosis
350 and 1,000 2h NCV decreased at 350 mm Hg and absent
at 1,000 mm Hg
Patterson and 300 3 and 5 h Muscle compressed for 3 h appeared histo- Monkey
Klenerman11 logically normal at 24 h. Muscle com-
pressed for 5 h had many necrotic fibers at
3 d.
Patterson et al12 300 3 and 5 h At 6 d postinflation, 3 h tourniquet time re- Monkey
duced compressed muscle tension to
80%–84% of control and ischemic muscle
tension to 64%–112%. 5 h of tourniquet
time reduced values to 61% and 2%, re-
spectively.
Rorabeck13 250 and 500 1, 2, or 3 h 250 mm Hg at 3 h: nerve conduction block Dog
resolved in 90 min. 500 mm Hg at 3 h:
nerve conduction block did not resolve by
150 min.
Sapega et al14 350 3 × 1 h (5- and 15-min No significant difference between 5 and 15 Dog
reperfusion interval); min of reperfusion as measured by meta-
2 × 1.5 h (5- and 15- bolic derangement or histologic muscle
min reperfusion inter- changes. Longest single inflation time was
val); 2 h + 1 h (5- and the most significant factor contributing to
15-min reperfusion in- muscle ultrastructure damage.
terval)

ATP = adenosine triphosphate, CPK = creatine phosphokinase, EMG = electromyography, NA = not available, NCV = nerve conduction
velocity

model, notable focal and regional ne-
crosis was noted in the thigh 2 days
after a 4-hour tourniquet time at 350
mm Hg of pressure.48 Cellular infil-
tration and milder necrosis were
noted in the leg. Marked but less se-
vere changes were seen with tourni-
quet pressure measuring 350 mm Hg
for a duration of 2 to 3 hours.
Nerve Injury
Nerve injury caused by tourniquet
use has been documented on histo-
logic examination, electromyography
(EMG), and nerve conduction veloc-
ity (NCV) studies. Compared with
skeletal muscle, nerve tissue seems to
be less vulnerable to acute injury, al-
though the effects of injury appear to
be longer-lasting in nerve tissue fol-
lowing mild to moderate insult.
In one histologic study, rat sciatic
nerve structure was evaluated with
electron microscopy 14 days after
application of a tourniquet at 300
mm Hg of pressure for periods of 30
minutes to 3 hours.8 Damage ranged
from no change to mild change at 30
minutes to complete myelin dissolu-
tion and Schwann cell hypertrophy
at 3 hours. Myelin sheath rupture
appeared after 2 hours; this finding
has been confirmed in other stud-
ies.10 Similar findings have been
noted in light microscopy studies,
with mild changes at 2 hours pro-
gressing to significant edema with
prolonged times at tourniquet pres-
sure of 350 mm Hg.50 As with skele-
tal muscle studies, damage was
worse in compressed tissue than in
ischemic tissue.

May 2012, Vol 20, No 5 313

Safe Tourniquet Use: A Review of the Evidence

Table 3
Findings of Clinical Tourniquet Studiesa
Pressure
Study (mm Hg) Duration (min) Findings Study Parameters

Arciero et al28 269 (avg) 87 NS EMG changes at 1 mo, NS atrophy at Tourniquet vs none in
1 mo, no differences at 6 or 12 mo ACL reconstruction
Clarke et al33 225 and 300 90 Higher pressure led to greater wound High vs low pressure
hypoxia without clinical complication for TKA
Daniel et al29 Range, 250–300 Range, 40–186 Decreased quadriceps strength and girth Tourniquet vs none in
at 12 wk in the tourniquet group. No ACL reconstruction
significant difference at 52 wk.
Dobner and Nitz34 393 (avg) 42 EMG changes at 6 wk. No EMG changes Clinical
at 5 mo. Posterior tibial nerve most
affected.
Fahmy and Patel30 500 Range, 115–127 Increased fibrinolytic activity returned to Knee arthrotomy
baseline after 30 min
Finsen and SBP + 100 Range, 12–70 No neurologic symptoms at 10 wk Calf tourniquet for
Kasseth35 forefoot surgery
Girardis et al36 350 Range, 75–108 Degree of hemodynamic and metabolic ACL reconstruction
alterations correlates with tourniquet
time
Hirota et al37 300 (avg) Range, 15–150 Amount of emboli in right atrium corre- Knee arthroscopy
lates with tourniquet time. No clinically
significant consequences.
Horlocker et al31 300 145 (avg) Overall risk of neurologic complication, Primary or revision
7.7%. The risk was higher with higher TKA
tourniquet times. Longer reperfusion
intervals were more beneficial. Nearly
all palsies recovered fully.
Kirkley et al38 300 <60 No difference in functional scores at 2, 6, Tourniquet vs none in
and 12 wk. Better visualization with knee arthroscopy
tourniquet up. Increased postoperative
pain with inflation time >30 min.
Kokki et al39 250 101 ± 34 Metabolic changes more significant with ACL reconstruction
longer tourniquet times. No clinical
complications.
350 108 ± 25 Metabolic changes more significant with ACL reconstruction
longer tourniquet times. No clinical
complications.
Konrad et al40 350 56 (mean) Increased pain and swelling in tourniquet Tourniquet vs none in
group at 6 wk. Trend toward decreased ankle ORIF
ROM in tourniquet group.
Lin et al41 480 60–90 Pulmonary functions parameters (Pao2, Tourniquet vs none for
a/A ratio) decrease with tourniquet use. lower extremity sur-
No clinical pulmonary complications. gery
Mittal et al32 SBP + 20–30 15 At 15 min, MNCV was 74% with a wide 14- vs 7-cm–wide cuff
cuff and 83% (avg) with a narrow cuff. on healthy volun-
Wide cuffs have a greater effect on teers
nerve conduction.
Orbay et al42 250–350 100.4 ± 2.4 No complications Narrow silicone ring
stockinette tourni-
quet vs 8-cm pneu-
matic tourniquet
250–350 101.2 ± 26.5 No complications Narrow silicone ring
stockinette tourni-
quet vs 8-cm pneu-
matic tourniquet

314 Journal of the American Academy of Orthopaedic Surgeons

 Peter G. Fitzgibbons, MD, et al

Table 3 (continued)
Findings of Clinical Tourniquet Studiesa
Pressure
Study (mm Hg) Duration (min) Findings Study Parameters

Reikerås and 250–350 Range, 78–125 At 4 h postdeflation, D-dimer and pro- TKA
Clementsen43 thrombin fragments are not significant
Rudkin et al44 250 Range, 2–90 Tourniquet time and age are risk factors Foot surgery
for tourniquet pain
Santavirta et al45 450 74 ± 30 Of 1,000 lower extremity cases, 85 ex- Meniscectomy, ankle
ceeded 2 h with no clinical complica- fracture, and TKA
tions reported
Vandenbussche 350 123 No nerve paralysis or wound healing TKA
et al46 difficulty at 3 mo
Weingarden et al47 350–450 53 Avg inflation time of patients with post- Meniscectomy
operative EMG changes, 59 min. Avg
inflation time of patients without post-
operative EMG changes, 41 min. Clin-
ical recovery time increased in pa-
tients with postoperative EMG
changes.

a/A ratio = arterial-alveolar oxygen tension ratio, ACL = anterior cruciate ligament, EMG = electromyography, MNCV = motor nerve conduction
velocity, NS = not statistically significant, ORIF = open reduction and internal fixation, ROM = range of motion, SBP = systolic blood pressure,
TKA = total knee arthroplasty
a
Levels of evidence of the cited studies: level I (28, 34, 38, 40, 41, 46), level II (29, 32, 33, 39, 42, 43, 47), level III (44, 45), level IV (30, 31,
35-37).

Nerve injury has been measured on
EMG and NCV studies, as well.9
One clinical study documented
changes on EMG in 62.5% of ortho-
paedic patients postoperatively.51
EMG abnormality lasted an average
of 51 days (patients were examined
monthly), and prolonged tourniquet
time contributed to the incidence and
severity of abnormalities. NCV stud-
ies in rabbits have shown significant
changes with compression lasting 2
and 4 hours at tourniquet pressure of
350 mm Hg, although notable
changes are mild or absent in distal
nerves.26,27 Clinically, the incidence of
peroneal and tibial nerve palsy rises
with tourniquet times >150 min-
utes.31
Metabolic Dysfunction
Studies measuring metabolic parame-
ters have attempted to address the
mechanisms underlying tourniquet-
induced injury of muscle and nerve tis-
sue. Lactic acid, pH, glucose, and reac-
tive oxygen metabolites such as
hypoxanthine and xanthine are acutely
affected by tourniquet use.52-55
Most studies have reported a rapid
return to normal local acid-base bal-
ance following tourniquet release.
For example, pH has been found to
normalize within 20 minutes follow-
ing pressure of 300 mm Hg for 3
hours in a canine model16 and within
40 minutes following pressure of 300
mm Hg for 4 hours in monkeys.7 In
humans, measurements in the right
atrium have demonstrated minor
changes in pH after tourniquet re-
lease, and metabolic indicators have
been found to normalize within 120
minutes of tourniquet cessation.7 In
dogs, adenosine triphosphate levels
do not fall at tourniquet durations of
<3 hours. Although the adenosine
triphosphate buffer phosphocreati-
nine drops markedly, it is usually re-
constituted within minutes.14
Coagulopathy and Deep
Vein Thrombosis
Several clinical studies have demon-
strated increased fibrinolytic activity
following tourniquet use, but no
clinically significant changes have
been documented.56-58 Multiple stud-
ies have investigated the role of the
tourniquet in the production of pul-
monary emboli and the resulting
clinically significant cardiopulmo-
nary symptoms. Pulmonary emboli
have been recorded by transesopha-
geal echocardiogram during knee
arthroscopies and arthroplasties per-
formed with and without tourni-
quets.37,57,59 In one study, the inci-
dence ranged from 6% to 79%
depending on the procedure per-
formed, with a nonstatistically sig-
nificant increased incidence of em-
boli in the patients on whom a
tourniquet was used.37 None of the
studies found clinically relevant cases
of pulmonary embolus. Another

May 2012, Vol 20, No 5 315

Safe Tourniquet Use: A Review of the Evidence
Table 4
Recommendations for Safe
Tourniquet Use
Pressure
Anticipated inflation time <2.5 h
Upper extremity, ≤250 mm Hg
Lower extremity, ≤300 mm Hg
Anticipated inflation time >2.5 h
Consider measuring limb occlusion
pressure and using a safety margin
of 50–75 mm Hg
Consider using a wide, shaped cuff
Inflation time
Assess the operative situation at 2 h.
For anticipated duration >2.5 h, use a
10-min deflation interval at that point
and subsequent 1-h intervals.
study found a decreased rate of deep
vein thrombosis following tourni-
quet use, which was presumed to be
the result of increased fibrinolytic ac-
tivity.30
Clinical Recovery and Pain
More recent investigations have fo-
cused on the impact of tourniquet
use on clinical recovery and pain.
The parameters for gross injury to
extremities and frank necrosis of tis-
sue have been fairly well defined, but
these newer clinical studies attempt
to define the incidence of more sub-
tle injury that is reversible in the long
term but may have a measurable im-
pact on recovery.
Several studies have compared sur-
gery with and without tourniquet
use.28,29,38,41 Two such studies evalu-
ated patients undergoing anterior
cruciate ligament reconstruction.
With similar tourniquet durations
and inflation pressures, patients on
whom a tourniquet was used had in-
creased quadriceps atrophy and mea-
surable EMG changes28 as well as de-
creased strength29 compared with the
nontourniquet group at 4- to 12-
week follow-up. No differences were
found between patients at 1-year
follow-up in either study. Similarly,
316
Kirkley et al38 found no significant
differences in clinical parameters af-
ter knee arthroscopy. One level I
study that compared open reduction
and internal fixation of the ankle
with and without a tourniquet found
greater pain, swelling, and complica-
tions up to 6 weeks postoperatively
in the tourniquet group.40
Recommendations for
Tourniquet Use
Recommendations for safe tourni-
quet use are listed in Table 4. No one
protocol is appropriate for all situa-
tions and patients. The three factors
that must be considered in every case
are duration of tourniquet use, infla-
tion pressure, and tourniquet design.
Duration
One difficulty in applying the results
of experimental studies in clinical
practice is that durations studied
tend to increase in increments of ≥1
hour. Although this makes it more
feasible to conduct studies, it likely
contributes to the establishment of 2
hours as a common upper limit. A
threshold of 2.5 hours may have
clinical relevance, but this threshold
is nonexistent in basic science re-
search. In general, animal studies
suggest that at 2 hours of tourniquet
inflation, the histologic, electrophysi-
ologic, and functional impact of
the tourniquet, while measurable,
remains reversible.6,7,9,10,12-14,16,24,25,27
Most changes following tourniquet
times of 3 hours also were tempo-
rary, depending on the measurements
and duration of the study.6,7,11,13,23
Few clinical studies use tourniquet
times >2 hours. In one such study,
Horlocker et al31 evaluated pro-
longed tourniquet times in persons
undergoing revision total knee ar-
throplasty (average, 145 min). The
rate of postoperative tibial and/or
peroneal nerve palsy was 7.7%.
Journal of the American Academy of Orthopaedic Surgeons
Long-term consequences were few,
with complete recovery in 100% of
tibial palsies and 89% of peroneal
palsies. For procedures involving a
tourniquet time of ≥180 minutes, a
deflation interval of ≥30 minutes was
associated with fewer neurologic
complications (22% incidence) than
were those without a deflation inter-
val (42% incidence) or with an inter-
val <30 minutes (39% incidence).
High-quality clinical studies (levels
I and II) with tourniquet times of ≤2
hours indicate that although electro-
physiologic changes and muscle atro-
phy are detectable at short-term
follow-up, functional differences are
rare, and long-term outcomes are
equivalent between standard tourni-
quet groups and groups with low or
no tourniquet time.28,29,38-41,46,47 The
customary 2-hour tourniquet time
limit seems to be derived largely
from animal studies that begin to
show changes at 2 to 3 hours and
from clinical studies that demon-
strate few negative consequences
within that time limit. In the absence
of a compelling clinical need for con-
sistent tourniquet times >2 hours, a
controlled clinical study of pro-
longed tourniquet times is likely un-
necessary. No data contradict the
practice of maintaining tourniquet
inflation for >2 hours in the rare
clinical situations in which it is nec-
essary.
Reperfusion intervals have been
studied in animals and humans. Pro-
tocols differ substantially, but most
studies support the use of a reperfu-
sion interval and find that longer in-
tervals result in diminution of tissue
damage.14,31
Inflation Pressure
Many animal and human studies em-
ploy inflation pressures higher than
those typically used in clinical prac-
tice. Those human clinical studies
cited in Table 3 that employed fixed

inflation pressures reported an aver-
age thigh tourniquet pressure of 338
mm Hg.28-31,33,34,36-41,44-46 In a large
study of tourniquet use and its com-
plications, the average pressure was
300 mm Hg.37 Animal data clearly
demonstrate that higher inflation
pressures impart greater insult on
compressed nerve and muscle than
do lower pressures.10,13,50 Most of
these changes have been shown by
using tourniquet pressures up to
1,000 mm Hg, so it is difficult to ex-
trapolate from the literature the sig-
nificance of a difference in 25 or 50
mm Hg at lower pressures. Few clini-
cal studies show significant or fre-
quent pathology within the ranges
studied; thus, pressures employed
clinically (ie, ≤300 mm Hg) seem to
be well within a safe zone of use.
Several techniques have been de-
scribed for determining limb occlu-
sion pressure (LOP). Because this
measurement accounts for the spe-
cific tourniquet configuration and
limb girth, it would seem to be a
more accurate representation of arte-
rial occlusion than systolic blood
pressure. Techniques for measuring
LOP involve the use of a commercial
device, monitoring of the oblitera-
tion of distal pulses with a Doppler
stethoscope during cuff inflation, or
use of a formula based on limb cir-
cumference.60,61 One report indicates
that measurement and use of LOP
plus a safety margin may allow for a
tourniquet inflation pressure that is
lower than the standard fixed infla-
tion pressure.60 Both methods typi-
cally involve a pressure margin
above the LOP or systolic blood
pressure that should allow for intra-
operative variation in blood pres-
sure. No studies have demonstrated
a difference in clinical outcomes at-
tributable to the use of LOP in deter-
mining tourniquet pressure.
Recommendations for tourniquet
pressure setting commonly use lower
values for the upper extremity than
May 2012, Vol 20, No 5
for the lower extremity. No clinical
studies exist indicating that either ex-
tremity is more prone to injury than
the other. One study measuring the
pressure at which capillary bleeding
occurs found lower values for the
upper extremity than for the lower
extremity.62 A tourniquet pressure of
200 mm Hg in the upper extremity
and 250 mm Hg in the lower ex-
tremity was found to be adequate to
produce a bloodless field in normo-
tensive persons of average build.
This difference is presumably a func-
tion of limb girth, with occlusion oc-
curring at a lower pressure in the up-
per limb.
Tourniquet Design
The development of new tourniquets
has spurred debate regarding the
safety and efficacy of different types
of tourniquets. These debates largely
revolve around the effect of the
width of the tourniquet on both the
pressure setting required to achieve a
bloodless field and the pathogenesis
of soft-tissue injury.
In a baboon model, Ochoa et al10
demonstrated nerve damage directly
beneath the cuff and suggested that
the damage is caused by the gradient
of pressure at the edge of the cuff.
The width of the tourniquet itself
was not studied. However, the impli-
cation that use of a narrower cuff
might result in less nerve damage has
been used in part to justify the recent
development of a narrow nonpneu-
matic silicone ring tourniquet.63,64
A recent study found median nerve
conduction to be more severely affected
with the use of a 14-cm tourniquet
than with a 7-cm tourniquet following
15 minutes of inflation.32 With both
sizes of tourniquet, conduction nor-
malized by 30 minutes after defla-
tion. Other studies have suggested
that a wider cuff is safer because it
allows for the occlusion of blood
flow at a lower pressure.65,66 No
Peter G. Fitzgibbons, MD, et al
studies have demonstrated clinical
benefit in terms of neurologic
changes or functional outcomes with
the use of a particular tourniquet de-
sign.
Summary
Clinical situations involving tourniquet
use require at least three decisions: the
type (ie, shape) of tourniquet, inflation
pressure, and continuous duration of
occlusive pressure. These questions are
often addressed separately in recom-
mendations. However, studies have
shown that although each has its own
effect on target outcomes, these factors
are additive and the exact relationship
between them is unclear.9 For exam-
ple, the clinical difference between
120 and 140 minutes of tourniquet
time is not clear, and the additional
impact of 25 or 50 mm Hg more or
less inflation pressure on that time
difference is unknown.
The available clinical and basic sci-
entific data on tourniquet use do not
indicate a significant risk of compli-
cations within the confines of typical
use during orthopaedic surgery, and
no single standard exists for tourni-
quet use in all settings. In general,
for procedures involving <2 hours of
tourniquet time, standard practices
should suffice in terms of inflation
pressure and tourniquet design. Pre-
operative identification of proce-
dures that are likely to involve pro-
longed tourniquet times (ie, >2 hours)
allows the surgeon, anesthesiologist,
and operating room staff ample time to
agree on and institute measures that
may ameliorate known risks that are
difficult to clearly define. In such situ-
ations, recommendations include the
use of wide, shaped cuffs, the preoper-
ative measurement of LOP by either
Doppler stethoscope or commercial de-
vice, and the use of a reperfusion inter-
val at 2 hours for procedures lasting
>2.5 hours.
317
Safe Tourniquet Use: A Review of the Evidence
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Evidence-based Medicine: Levels of
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References 30, 31, and 35-37 are level
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