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Tourniquets

‘The use of a bloodless field is an integral part of much limb surgery, but may have become a ritual’. - Leslie Klenerman1

  The pneumatic tourniquet was introduced in 1904 by Harvey Cushing to maintain a bloodless field during extremity surgery.2 Since then its use has become routine, such that a cavalier approach to this potentially dangerous equipment can easily be adopted by the novice. Although modern tourniquets are designed to minimize the incidence of complications, their use is still associated with potentially serious morbidity and even mortality. Consequently, a thorough knowledge of their design, safety and the pathophysiology of tourniquet-induced skeletal muscle ischaemia-reperfusion injury is mandatory for their use. Advances in  molecular biology is increasing our understanding of the pathophysiology of tourniquet-induced ischaemia-reperfusion injury at the cellular level, therefore, allowing for more scientifically valid guidelines in the use of pneumatic tourniquets with respect to safe tourniquet-application times and inflation pressures.

 

Pneumatic tourniquet design and care

A modern pneumatic tourniquet system comprises several components which allow for safe and precise regulation of cuff pressure to minimise complications resulting from excessive inflation or accidental deflation of the cuff intra-operatively. There is a choice of gas (nitrogen) or air- generated facilities for tourniquet inflation from either mains supply or cylinders. Freon (dichlorodifluoromethane), an ozone-depleting chlorofluorocarbon (CFC), previously used for inflation in pneumatic tourniquet systems, was banned in the United States of America in 1996 for enviromental safety reasons.

 A modern system allows for pressure to be preset prior to inflation. Subsequently, a microprocessor ensures self-compensation, maintaining a constant preset cuff pressure, during limb movements and changes in limb size. A maximum pressure device prevents application of excessively high pressures (above 600 mm Hg). Additional safety is provided by a supply monitor which shuts down the system, while maintaining cuff pressure, if the gas or air supply is interrupted or if a leak occurs intraoperatively.

Inaccurate guages and malfunctioning valves, resulting in excessively high inflation cuff pressures, can lead to complications. Consquently, pneumatic tourniquets should be kept in good condition, by routinely checking all valves and guages.



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