Pennsylvania Patient Safety Advisory Strategies for Avoiding Problems with the Use of Pneumatic Tourniquets ABSTRACT cuffs should not overlap beyond the Velcro when The Pennsylvania Patient Safety Authority has received applied. Several studies have reported that the use of 140 event reports associated with pneumatic tourni- wide tourniquet cuffs reduces the pressure needed to quets (December 2004 through December 2009). stop blood flow; as such, it is recommended that a Pneumatic tourniquets are used primarily to occlude cuff should be wider than half the limb’s diameter.1,2 blood flow and obtain a bloodless field during limb Contoured cuffs are desirable for limbs that are surgery. They also facilitate intravenous regional anes- excessively tapered (i.e., very muscular, obese); con- thesia, an alternative to general anesthesia for surgery ventional cuffs transmit pressure disproportionately involving the upper or lower limbs. In this application to the wider section of the limb rather than uniformly (also known as a Bier block), the tourniquet prevents across the cuff width.3 infused local anesthetic from flowing out of the limb and also provides a bloodless operating field. This Intravenous regional anesthesia (IVRA), more com- article considers tourniquet problems reported to the monly referred to as a Bier block, is performed with a Authority and reviews use and maintenance issues that dual-bladder cuff. After the limb is exsanguinated by can prevent these types of problems. (Pa Patient Saf compressing it with a spirally wrapped (Esmarch) ban- Advis 2010 Sep;7[3]:97-101.) dage, the bladder farthest from the operating site is inflated, and the anesthetic (e.g., lidocaine) is infused into the limb through an IV cannula. After the anes- thetic has been absorbed, typically within 20 minutes, In surgical applications, a pneumatic tourniquet should the second bladder is inflated over the anesthetized reliably maintain the minimum pressure necessary to tissue, and the first is deflated. This procedure stop blood flow in the limb. This minimum pressure requires a tourniquet controller to be interfaced with setting is affected by repositioning the limb during the the dual bladders so that the inflating gas can be procedure, by changes in systolic pressure, and by cuff channeled to either or both bladders. width compared to limb circumference. Pneumatic tourniquets typically consist of three basic components: Reported Problems (1) a cuff, (2) a means of inflating the cuff bladder, and (3) a controller (e.g., a pressure indicator, regula- From December 2004 through December 2009, 140 tor). Most tourniquet controllers also have a timer or events associated with the use of tourniquets in surgical an elapsed-time meter for tracking cuff inflation time procedures were reported to the Pennsylvania Patient because there is a limit to tolerable ischemia time. Safety Authority. The event reports are summarized as follows, accompanied by deidentified examples: There are several methods for inflating tourniquet cuffs. Many models operate from compressed-gas ■ Events associated with limb redness, bruising, or sources: air or nitrogen is delivered from a wall outlet swelling (41%). Bruising and/or swelling should or a cylinder with a regulator. Several models use an not occur and suggests excessive pressure. electric pump to compress ambient (i.e., room) air for Bruising noted along distal section of tourniquet. cuff inflation; these units are line powered and typi- cally have backup batteries. Patient complained of discomfort of her right upper arm. Anterior site is abraded and discolored with Cuff pressure is indicated by liquid crystal display abrasion. It appears the tourniquet was too tight. (LCD), light-emitting diode (LED) display, or an aneroid gauge; there may also be indicators for supply ■ Events citing skin tears or blisters (19%), which pressure and/or low battery. Most of the line-powered respectively suggest nonuniformly-applied cuff pad- and some of the compressed-gas units have alarms for ding and absorbed prepping solution. such conditions as excessive cuff pressure, cuff pressure Removed tourniquet at end of case. Noted bruised leaks, kinks in tubing, and mechanical failure. A few area anterior right thigh approximately 5 to 6 inches units incorporate a sensor for determining and tracking in length, probably from tourniquet and cast padding. limb occlusion pressure (LOP). Tourniquet controllers should have locking connectors that secure cuff tubing 18” tourniquet placed on left upper arm for surgery. to prevent leaks and inadvertent detachment. The con- Upon removal at end of procedure, patient was noted nectors must also be incompatible with Luer fittings to to have a blood blister approximately 8 inches around prevent accidental connection to intravenous (IV) tub- and 2 inches wide. ing and infusion pump administration sets. After removal of the underpadding, it was noted that Reusable and single-use tourniquet cuffs are available the patient had a 3 cm x 18 cm reddened area that in a wide variety of lengths and are closed with Vel- began at the edge of the tourniquet underpadding. cro™ and ribbon fasteners. Cuff selection should be The area had Betadine solution present, which was made according to the patient’s limb circumference; wiped off with a warm, damp towel. Vol. 7, No. 3—September 2010 REPRINTED ARTICLE - ©2010 Pennsylvania Patient Safety Authority Page 97 Pennsylvania Patient Safety Advisory ■ Events citing unintended deflation or “tourniquet numbness and tingling, which was relieved when the failure” (14%), suggesting a system leak, an unse- tourniquet was removed. cured cuff, a controller malfunction, or a surge in Patient complained that upper thigh hurt more blood pressure. than the surgery area. [Staff] discovered that the leg Tourniquet was plugged in, and it deflated in the tourniquet was intact but deflated. middle of the case. Lost all of the block anesthesia. ■ Events citing that the opposite limb was injected Unexpected amount of bleeding occurred. Pressure or incised (4%). increased to 400. Unusual bleeding continued, and Patient placed in prone position for left leg popliteal Velcro noted to have detached on cuff. posterior block. Block performed by the anesthesiolo- “BATT FAIL” after working well for 38 minutes. gist on left posterior popliteal area. Patient was then The alarm went off, and the tourniquet released. All put in supine position, and approximately a half the connections were checked and found to be intact. hour later the anesthesiologist returned to perform the Another tourniquet was obtained and put into service. tourniquet block on the front of the leg. The anesthe- A tourniquet failed after 150 mg lidocaine bolus IV, siologist blocked the right front leg. Bier block was delivered, giving a subsequent risk of A tourniquet was placed on the incorrect knee. seizure and cardiovascular complications. The incision was made on the incorrect knee by the ■ Events citing a cuff inflation time for more than surgeon. Time-out procedures were not followed; site two hours (8%); some reports also mentioned limb ID was already marked. The surgeon noted the lack tingling and/or numbness. of marking and stopped the procedure. Patient has had ongoing pain since block wore off, ■ Event citing use of an Esmarch bandage as a tour- along with a numbness in certain parts of the foot. niquet for more than two hours, which produced blistering (0.7%). Physician was informed that tourniquet was up for 120 minutes. He asked for 10 more minutes. When Surgeon using 4-inch esmark (sic) as tourniquet was 10 minutes were up, he asked for 10 more minutes. advised of tourniquet time at 60, 90, 105 minutes and When 10 minutes were up [again], he asked for 10 more repeatedly at 120 minutes [and] did not release esmark minutes. Tourniquet was up for a total of 145 minutes. until 132 minutes tourniquet time. Surgeon states he is in charge. Circulator advocating for patient. ■ Events in which the opposite limb was prepped and, in some cases, the cuff was applied (6%). Why Problems Occur A patient was admitted for right knee arthroscopy. Extended application time and/or excessive cuff pres- A tourniquet was placed on the left leg and inflated sure can cause tissue bruising, limb swelling, muscle by RN [registered nurse] at the request of the surgeon. ischemia, compartment syndrome, and extremity paral- The RN began to prep the left leg. The physician ysis from peripheral nerve damage. However, swelling did time-out and said “right knee.” Tourniquet was and nerve damage may also result from or be exacer- deflated and immediately removed. bated by other aspects of a procedure. Temporary nerve ■ Events describing “partial occlusion” (4%), which damage is a frequently reported tourniquet-related suggests a system leak, insufficient pressure setting, adverse event. Although nerve damage can be perma- incorrect cuff size and/or application, or a surge nent, it frequently resolves within a year. Compartment in intravascular pressure within the operative limb syndrome is a relatively rare tourniquet complication; from injection of the block. when it occurs, it is likely to require a fasciotomy. A patient experienced bradycardia and decreased The literature generally indicates that muscle ischemia responsiveness after administration of lidocaine in occurs within one to three hours. Accordingly, there is the form of a Bier block. The patient was treated no rule to determine how long a tourniquet may remain with medications (atropine, epinephrine, ephedrine, safely inflated; the length of time may vary with the age Narcan®, and Romazicon®), intubated, and of the patient and the vascularity of the extremity.4 transferred to the intensive care unit. [The patient’s] Applying padding under the cuffs of pneumatic tour- mental status is much improved. A question was niquets is a well-established and recommended prac- raised regarding the fit of the tourniquet. tice.2 However, a chemical burn can occur if a skin Doctor asked nurse to check tourniquet on right thigh preparation solution (e.g., Betadine, chlorhexidine) because he did not have hemostasis intraoperatively. runs beneath the tourniquet and is absorbed by the The tourniquet was found to have “unvelcroed.” padding. Padding may also produce uneven pressure [They] reapplied a tourniquet one size bigger. distribution if it overlaps or has areas of nonunifor- mity under the tourniquet cuff. The disadvantage of ■ Events citing that the cuff was not removed imme- cast padding, which is commonly used for tourniquet diately after deflation (4%). cuff padding, is that its fibers adhere to Velcro and [When a] patient returned from the postanesthesia may eventually comprise cuff closure. As an alterna- care unit, an operative tourniquet was found on tive, consider using a stockinette-stitch bandage for the patient’s arm. The patient had complained of cuff padding. Page 98 REPRINTED ARTICLE - ©2010 Pennsylvania Patient Safety Authority Vol. 7, No. 3—September 2010 Pennsylvania Patient Safety Advisory When cuff pressure is between systolic and diastolic the larger sizes, for the limbs of very muscular or levels, blood can flow into the limb, but constriction obese patients. of the veins will limit or prevent blood return, which As the Authority reports illustrate, it is essential may cause venous congestion and edema. Insufficient to verify the correct surgical site before applying LOP and unintended cuff deflation can also result in a tourniquet cuff. AORN provides extensive blood entering the surgical site, subsequently inter- guidance to help ensure proper cuff selection and rupting and lengthening the procedure, and in blood application. Select a cuff that will overlap between loss. Although less common, nerve damage from three and six inches when applied.7 In addition to hemorrhagic infiltration can also result from inad- selecting the correct length cuff, the recommended equate cuff pressure.4 practices state that the cuff should be wider than Another potential for injury with pneumatic tour- half the limb diameter where it is to be applied. If niquets occurs when they are used to provide intra- the limb is grossly tapered, a wider, contoured cuff venous regional anesthesia. High concentrations of will apply pressure to the limb more uniformly, and anesthetic can enter the systemic circulation and cause limb occlusion can be obtained at a lower inflation such adverse events as cardiovascular collapse, seizures, pressure. Before the cuff is inflated, the limb should cardiac arrest, and coma if either of the following be exsanguinated with an Esmarch bandage. occurs before the injected bolus is absorbed: cardiovas- Inflation Time cular pressure in the operative limb exceeds cuff pres- AORN recommends that tourniquet inflation time sure (e.g., from the injected bolus), or cuff falls below “be kept to a minimum” and notes that “safe infla- diastolic pressure. Unintentional pressure loss can tion time has not been precisely determined” and result from a damaged tubing connector, deteriorated that “the surgeon should be informed of the duration tubing and cuff bladders, and failed or improperly of tourniquet time at regular, established intervals.” engaged cuff closures. It can also occur when cuff Factors such as the patient’s age and limb size or deflation is inadvertently activated. Although some the presence of vascular disease may also be relevant tourniquet models have an alarm that signals cuff pres- when determining safe tourniquet time. For pediatric sure loss, alarm activation is also likely to signal the patients, an inflation time less than 75 minutes for release of a toxic anesthetic bolus from the limb. lower extremities has been recommended.8 It also has In the past, some manufacturers of pneumatic tour- been recommended that the final decision of when niquets provided fittings that allowed connection of to deflate a tourniquet be made by the surgeon based oxygen and nitrous oxide as inflation sources, which on the risks and benefits of delaying deflation until is hazardous. Tourniquets inflated with oxygen or closure is complete.3 nitrous oxide can catch fire and burn violently upon Limb Occlusion Pressure contact with ignition sources present in the OR (e.g., Proper cuff inflation pressure is frequently defined as electrosurgical units, surgical lasers, fiberoptic light the minimum pressure above systolic that produces a sources). ECRI Institute has reported an event in bloodless field. However, rather than simply referenc- which leaked oxygen from a tourniquet connector was ing systolic pressure, it is desirable to base cuff pres- trapped under a surgical drape; the drape was ignited sure on actual LOP. AORN states that LOP can be by a disconnected fiberoptic cable, and a flash fire determined with a Doppler stethoscope located on an severely burned the patient’s legs.5 Tourniquets that artery distal to the cuff while the cuff bladder is gradu- can be connected to oxygen or nitrous oxide should ally inflated. LOP is equivalent to the cuff pressure at be removed from service.6 which the pulse stops and remains silent for several beats. AORN also recommends setting cuff inflation Risk Reduction Strategies for Avoiding pressure for adults at LOP plus the following pressures: Tourniquet Complications ■ 40 mm Hg if LOP is less than 130 mm Hg The Association of periOperative Registered Nurses’ (AORN) “Recommended Practices for the Use of the ■ 60 mm Hg if LOP is between 131 mm Hg and Pneumatic Tourniquets” includes 18 categories of 190 mm Hg detailed recommendations for nurses and physicians ■ 80 mm Hg if LOP is greater than 190 mg Hg who use pneumatic tourniquets.2 The following risk For pediatric patients, adding 50 mm Hg to LOP reduction strategies for tourniquet use are derived is recommended.9 The additional pressure allows from AORN’s recommended practices unless for any likely increase in blood pressure during the otherwise noted. (For additional information, see surgical procedure and/or for increased venous “Strategies for Pneumatic Tourniquet Use.”) pressure from injected anesthetic volume. The Cuff Selection and Application anesthetic for a Bier block is injected slowly (e.g., over 90 seconds); both cuffs of a double cuff tourniquet A complete selection of reusable or disposable cuffs should not be deflated for at least 20 minutes.10 needs to be available in each location where pneu- matic tourniquets are used. Cuff lengths of 8 or 10, Verifying Tourniquet Performance 12, 18, 24, and 34 inches are typically stocked. It is Prior to each procedure, AORN recommends that desirable to also have contoured cuffs, especially in users visually inspect cuffs, tubing, connectors, Vol. 7, No. 3—September 2010 REPRINTED ARTICLE - ©2010 Pennsylvania Patient Safety Authority Page 99 Pennsylvania Patient Safety Advisory Strategies for Pneumatic Tourniquet Use Before Patient Use — 80 mm Hg if LOP is greater than ■ Maintain an adequate selection of cuffs. 190 mm Hg. — Contoured cuffs are desirable for exces- ■ Set cuff inflation pressure for pediatric patients sively tapered limbs. at LOP plus 50 mm Hg. ■ Minimize cuff inflation time. — Do NOT reuse single-use cuffs. ■ Notify the surgical team of elapsed inflation time ■ Ensure electronic controllers are connected at regular intervals. to line power and/or have adequate battery capacity; perform self-test. ■ Monitor cuff pressure during the procedure, especially when repositioning the limb. ■ Select the proper size cuff, and look for cracked tubing and loose connectors. ■ Remove cuff and padding immediately after completing procedure. ■ Keep tubing off the floor and routed to avoid accidental contact by personnel. ■ Indicate the following in patient record: ■ Apply a soft padding uniformly to the operative — Times of inflation and deflation limb cuff site. — Inflation pressure(s) — Site of cuff placement After Applying a Tourniquet Cuff ■ Do not allow prepping solution to migrate — Controller ID number under cuff. Include Tourniquet Controllers in the Facility’s ■ Determine minimum limb occlusion pressure Technology Management Program (LOP). ■ Inventory tourniquet controllers so that they can — Place a Doppler stethoscope on a distal be identified and located in the event of hazard arterial pulse. and recall notices. — Increase cuff pressure until the pulse stops. ■ Schedule units for routine inspection and pre- ventive maintenance. ■ Set cuff inflation pressure for adult patients at LOP plus: Source: Association of periOperative Registered Nurses (AORN). Recommended practices for the use of the — 40 mm Hg if LOP is less than 130 mm Hg, pneumatic tourniquet. In: Perioperative standards and — 60 mm Hg if LOP is between 131 and recommended practices. 2007 ed. Denver (CO): AORN 190 mm Hg, or Inc; 2009:3753-85. and the security of the closure mechanism; some complications including muscle ischemia, nerve clinicians routinely inflate the cuff and check for damage, convulsions, and coma. As part of a risk leaks. Pneumatic tourniquet controllers should reduction strategy to reduce or eliminate adverse be included on a facility’s inventory of biomedical events related to their use, consider the following: equipment. This inventory practice facilitates ■ Share this article with all staff responsible for identification and location of units affected by a recall applying, monitoring, removing, and maintaining or other notification requiring user action. It also pneumatic tourniquets. facilitates scheduling and documentation of routine inspection and preventive maintenance activities ■ Review the procedure for determining LOP with that ensure safe and accurate equipment operation. clinicians who set cuff inflation pressure. Tubing, cuffs, and batteries are replaced as needed during these activities.11 Tourniquets with friction fit ■ Review the procedure for using a dual-bladder cuff connectors (e.g., slip-fit Luer connectors, hose barbs) with clinicians who deliver IVRA. should be removed from service.12 Units with Luer- ■ Ensure that the facility has an adequate selection lock connectors should also be removed from service of tourniquet cuff sizes and that staff know how to to avoid the risk of air embolism from inadvertent properly apply them. connection of tourniquet tubing to an intravenous manifold or infusion pump tubing connectors.12 ■ Develop a policy that addresses monitoring and documenting cuff pressure and inflation time dur- Conclusion ing a procedure. Pneumatic tourniquets are used to produce a Notes bloodless field during limb surgery and frequently 1. Moore MR, Garfin SR, Hargens AR. Wide tourniquets also to facilitate intravenous regional anesthesia. eliminate blood flow at low inflation pressures. J Hand However, their failure or misuse can lead to multiple Surg Am 1987 Nov;12(6):1006-11. Page 100 REPRINTED ARTICLE - ©2010 Pennsylvania Patient Safety Authority Vol. 7, No. 3—September 2010 Pennsylvania Patient Safety Advisory 2. Association of periOperative Registered Nurses (AORN). 2008 Feb [cited 2010 Jul 15]. Available from the Recommended practices for the use of the pneumatic Internet: http://www.accessdata.fda.gov/scripts/cdrh/ tourniquet. In: Perioperative standards and recommended prac- cfdocs/psn/transcript.cfm?show=72#2. tices. 2007 ed. Denver (CO): AORN Inc; 2009:3753-85. 8. Lynn AM. Systemic responses to tourniquet release in 3. Noordin S, McEwen JA, Kragh JF, et al. Surgical children. Anesth Analg 1986 Aug;65(8):865-72. tourniquets in orthopaedics. J Bone Joint Surg Am 2009 9. Tredwell SJ, Wilmink M, Inkpen K, et al. Pediatric Dec;91(12):2958-67. tourniquets: analysis of cuff and limb interface, current 4. Canale ST, Beaty JH. Campbell’s operative orthopaedics. practice, and guidelines for use. J Pediatr Orthop 2001 11th ed. Vol 1. Philadelphia (PA): Mosby Elsevier; 2008. Sep-Oct;21(5):671-6. 5. ECRI Institute. OR fires caused by fiberoptic illumi- 10. Henderson CL, Warriner CB, McEwen JA, et al. ? nation systems [hazard report]. Health Devices 1982 A North American survey of intravenous regional Mar;11(5):148-9. anesthesia. Anesth Analg 1997 Oct;85(4):858-63. 6. ECRI Institute. Inappropriate use of oxygen to inflate 11. ECRI Institute. Inspection and preventive or power medical devices [hazard report]. Health Devices maintenance procedure for pneumatic tourniquets. 1982 Dec;12(2):54-5. BiomedicalBenchmark™ 2008 Oct; IPM procedure 443. 7. U.S. Food and Drug Administration (U.S. FDA). Safe 12. ECRI Institute. Preventing misconnections of lines and use of pneumatic tourniquet cuffs (April 2007) [online]. cables [guidance]. Health Devices 2006 Mar;35(3):81-95. ? Self-Assessment Questions The following questions about this article may be useful for inter- 4. All of the following statements about selecting and nal education and assessment. You may use the following examples applying tourniquet cuffs are accurate EXCEPT: or come up with your own. a. Cuff lengths of 8 to 34 inches need to be available to A tourniquet was applied to the left thigh of a hypertensive accommodate a typical range of limb sizes. obese patient for an arthroscopic meniscectomy. 60 cc of b. A cuff should be wider than half the limb diameter at 0.5% lidocaine was injected intravenously over approxi- the point of application. mately one minute. Less than 10 minutes after the injec- c. When applied, a cuff should overlap itself by at least tion, the patient’s heart rhythm became irregular and she 6 inches. began to seize. d. Contoured cuffs are desirable for the limbs of 1. These symptoms of lidocaine toxicity are attributable to all obese patients. of the following reasons EXCEPT: e. Dual-bladder cuffs are used to perform intravenous a. The cuff was inflated to 50 mm Hg above the patient’s regional analgesia. systolic pressure. 5. Which of the following statements about limb occlusion is b. The cuff was too wide. accurate? c. A contoured cuff was not used. a. It is approximately equal to diastolic pressure plus d. The limb was not properly exsanguinated. 80 mm Hg. e. The lidocaine bolus was injected too quickly. b. It is approximately equal to systolic pressure plus 2. All of the following problems associated with the use 40 mm Hg. of pneumatic tourniquets have been reported to the c. It is determined in the limb opposite the operative limb. Authority EXCEPT: d. It is the pressure selected on the tourniquet controller a. Skin tears and blisters to inflate the cuff. b. Limb tingling and numbness e. It is likely to increase during a surgical procedure. c. The wrong limb was prepped or injected d. Gangrene e. Bradycardia and decreased responsiveness during a Bier block 3. Select the practice that is unlikely to cause an adverse patient event. a. Select and apply a cuff that is narrower than half the diameter of the operative limb. b. Reuse a single-use cuff. c. Apply a cuff over cast padding. d. Allow prep solution to migrate under a cuff. e. Deflate both cuffs shortly after a injecting a regional block. Vol. 7, No. 3—September 2010 REPRINTED ARTICLE - ©2010 Pennsylvania Patient Safety Authority Page 101 PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 7, No. 3—September 2010. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2010 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to http://visitor.constantcontact.com/ d.jsp?m=1103390819542&p=oi. To see other articles or issues of the Advisory, visit our Web site at http://www.patientsafetyauthority.org. Click on “Patient Safety Advisories” in the left-hand menu bar. THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s Web An Independent Agency of the Commonwealth of Pennsylvania site at http://www.patientsafetyauthority.org. ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for nearly 40 years, ECRI Institute marries experience and independence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions.