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Extremity Tourniquets

- Factors Related to Extremity Injury:
    - duration of use;
           - it is thought that muscles are more sensitive than nerves to duration of tourniquet use;
           - use of tourniquet for > 2 hours & pressures of > 350 mm of mercury in lower extremity and 250 mm of mercury in upper extremity increases risk of compression neurapraxia;
           - intermittent reperfusion:
                   - classic teaching mandates that, if more than 2 hours is required, the tourniquet is deflated for 5 min during every 30 min of inflation time;
                   - in the report by Mohler LR, et al (1999), intermittent reperfusion failed to diminsh the clinical and functional  consequences of the neurologic injury;
                           - these authors point out that prolonged tourniquet times cause both muscle and nerve damage, and that most reports on tourniquet use have focused on muscle injury rather than nerve injury;
                           - they point out that a high percentage of patients demonstrate EMG abnormalities after routine tourniquet use which can last several months;
                           - in their study, any protective effect from intermittent reperfusion (for muscle recovery) was overshadowed by nerve injury which did not recover; 
                            - Intermittent reperfusion fails to prevent posttourniquet neurapraxia.
    tourniquet location:
           - tourniquet applied to forearm may allow longer patient tolerance of tourniquet (in cases of local anesthesia);
           - ref: A prospective, randomized, controlled trial of forearm versus upper arm tourniquet tolerance
    - inflation pressure;
           - it is thought that nerves are more sensitive than muscles to tourniquet inflation pressure;
           - insufficient pressure, resulting in passive congestion of part, w/ hemorrhagic infiltration of the nerve;
           - esmarch tourniquet:
                 - associated w/ high incidence of radial nerve palsy, which is most likey due to either insufficient or excessive tourniquet pressure;
    - size of the cuff;
           - tissure pressure (under the cuff) decreases w/ depth and toward the edges of the cuff;
           - hence, obese patients will require a wide cuff w/ high inflation pressure;
    - tourniquet comfort:
           - consider subcutaneous injection of marcaine just above the site of tourniquet application, in order to numb the cutaneous nerves that cause tourniquet discomfort;

- Techniques to Avoid Tourniquet Complications:
     - consider cooling the extremity (local hypothermia);
     - consider two tourniquets, juxta-posed and alternating their inflation on hourly intervals (thought to lessen direct pressure over ischemic muscles and nerves);
     - padding is used beneath the tourniquet to distribute the pressure more evenly in the arm and to avoid pinching the skin;
     - prepping solution may burn the skin and is avoided by placing a towel around the distal edge of the tourniquet to prevent the solution from soaking through;
     - in the upper extremity, a temporary radial nerve palsy can be a common manifestation of post-tourniquet syndrom;
     - relative contra-indications:
            - prosthetic vascular grafts;
            - patients at risk for pre-existing DVT (such as a multi-trauma patient who has remained immobilized for several weeks)

 - ref: Tourniquet cuff pressure: the gulf between science and practice.

- References:
       - Upper Extremity 
       - Lower Extremity

Surgical Tourniquets in Orthopaedics

Effect of irrigation and tourniquet application on aminoglycoside antibiotic concentrations in bone.

Optimizing tourniquet application and release times in extremity surgery. A biochemical and ultrastructural study.

Local hypothermia to prolong safe tourniquet time.

Effects of reperfusion intervals on skeletal muscle injury beneath and distal to a pneumatic tourniquet.

Physiologic changes during tourniquet use in children.

Regional hypothermia protects against tourniquet neuropathy.

Muscle injury induced beneath and distal to a pneumatic tourniquet: a quantitative animal study of effects of tourniquet pressure and duration.

The effect of tourniquet use and hemovac drainage on postoperative hemarthrosis.

Local hypothermia to prolong safe tourniquet time.

A histometric analysis of skeletal myofibers following 90 min of tourniquet ischemia and reperfusion.

Reversible changes of skeletal muscular capillaries after application of a tourniquet.

Effect of the timing of tourniquet release on postoperative hematoma formation: an experimental animal study [see comments.]

Wide tourniquets eliminate blood flow at low inflation pressures.

Changes in serum myoglobin levels caused by tourniquet ischemia under normothermic and hypothermic conditions.

A safe and effective low pressure tourniquet. A prospective evaluation.

A comparative study of the tolerance of skeletal muscle to ischemia. Tourniquet application compared with acute compartment syndrome.

Tourniquet hemostasis. A clinical study.

Systemic and local effects of the application of a tourniquet.

The effect of pneumatic tourniquets on the ultrastructure of skeletal muscle.

The acute effects of tourniquet ischemia on tissue and blood gas tensions in the primate limb.

Creatine phosphokinase release as a measure of tourniquet effect on skeletal muscle.

The use of lower tourniquet inflation pressures in extremity surgery facilitated by curved and wide tourniquets and an integrated cuff inflation system.

Occlusion of arterial flow in the extremities at subsystolic pressures through the use of wide tourniquet cuffs

The efficacy of tourniquet release in blood conservation after total knee arthroplasty.

The effect of post-operative bleeding on compartment pressure.

Venous embolization after deflation of lower extremity tourniquets.

Skeletal muscle damage during tourniquet-induced ischaemia. The initial step towards atrophy after orthopaedic surgery?

Avoiding tourniquet-induced neuropathy through cuff design.

The safety of the Esmarch tourniquet.

Occlusion of arterial flow in the extremities at subsystolic pressures through the use of wide tourniquet cuffs.

Use of a tourniquet in patients with sickle-cell disease.

Intermittent reperfusion fails to prevent posttourniquet neurapraxia

Evaluation of the Esmark bandage as a tourniquet for forefoot surgery.

Microbial colonization of tourniquets used in orthopedic surgery.

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