Limb Surgery: Rethinking The Tourniquet
Sammy Othman, BA1, Ashley Pistorio, MD2, Michael Born, MD3.
1Drexel University College of Medicine, Philadelphia, PA, USA, 2Department of Plastic Surgery, University of Nevada, Las Vegas, Las Vegas, NV, USA, 3Department of Plastic and Reconstructive Surgery, York WellSpan Health, York, PA, USA.
Background: Pneumatic tourniquet use has long been an effective tool to achieve hemostatic control of the surgical field in upper extremity operations. Elevated cuff pressures have been associated with a variety of systemic and local adverse effects despite the various methods of pressure determination that exist currently, such as the use of a standard static 250 mmHg cuff pressure in all adult upper extremity procedures. This necessitates further investigation into reducing tourniquet pressures while maintaining visibility in the surgical field. We aim to demonstrate the usage of reduced tourniquet pressures, as well as examine for factors associated with these pressures and those associated with any adverse complications.
Methods: A prospective single surgeon study was conducted between 2016-2018 at a Level 1 Trauma Center and an Outpatient Surgical Center, with a total of 226 operations, involving a gradual reduction of cuff pressures over time from a standard baseline of limb occlusion pressure. Operations included various upper extremity procedures at the level of the hand and wrist under general anesthesia, and were monitored for breakthrough bleeding as well as intra-operative and post-operative adverse events.
Results: A gradual reduction of pressures was successfully achieved with a mean pressure of 187 mmHg and average time of tourniquet application being 25 minutes. We found chronological surgical number and patient BMI to be significantly associated with tourniquet pressure (p < .05, for both) A total of 4.4% (10/226) of cases resulted in breakthrough bleeding, but did not reliably occur with any discernable pressure thresholds, patient demographics, or operative factors (p < .05, for all). 3 of the 10 episodes occurred in the same patient.
Conclusion: Reduced tourniquet pressures can potentially help mitigate complications associated with tourniquet use. Our research shows reduced pressures are successful in maintaining field visibility and we encourage an adoption of pressures below 200 mm Hg in most procedures that require the use of a tourniquet.
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