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1.  Development of adaptive pneumatic tourniquet systems based on minimal inflation pressure for upper limb surgeries 
Background
Pneumatic tourniquets are medical devices that occlude blood flow to distal part of extremities and are commonly used in upper limb surgeries to provide a dry, clean and bloodless field. To decrease pressure-related injuries and potential risk of complications subjected to the high inflation pressure of pneumatic tourniquet, minimal inflation pressures are recommended.
Methods
A new occlusion pressure mathematical model for the upper limb was established based on the correlation analysis between several possible influencing parameters and the minimal pneumatic tourniquet pressure at which the peripheral pulse disappeared was recorded using a digital plethysmograph. A prototype of an adaptive pneumatic tourniquet which automatically varies the pressure in the tourniquet cuff according to the above prediction model was developed for the upper limb which used the lowest possible inflation pressure to achieve occlusion. The prototype comprises a blood pressure monitoring module, an inflatable tourniquet cuff, and a pressure relief mechanism to maintain an optimal cuff inflation pressure. Simulation experiments were conducted to verify the function and stability of the designed adaptive pneumatic tourniquet and clinical experiments using volunteers were undertaken to evaluate the performance of the prototype design in achieving adequate haemostasis in the upper limb.
Results
Results demonstrated that the mean arterial occlusion pressure was 152.3 ± 16.7 mmHg, obviously below the 250 to 300 mmHg previously recommended (J Bone Joint Surg Br 68:625-628, 1986 and Arthroscopy 11:307–311, 1995).
Conclusions
In conclusion, this adaptive method and apparatus which can provide minimal inflation pressure may be a clinically practical alternative for upper limb surgery performed with pneumatic tourniquets.
doi:10.1186/1475-925X-12-92
PMCID: PMC3848664  PMID: 24053348
Pneumatic tourniquet; Upper limb; Arterial occlusion pressure; Microprocessor
2.  Tourniquet use in upper limb surgery 
Hand (New York, N.Y.)  2010;6(2):165-173.
Tourniquets are compressive devices that occlude venous and arterial blood flow to limbs and are commonly used in upper limb surgery. With the potential risk of complications, there is some debate as to whether tourniquets should continue to be routinely used. In this review, we first look at the different designs, principles, and practical considerations associated with the use of tourniquets in the upper limb. The modern pneumatic tourniquet has many design features that enhance its safety profile. Current literature suggests that the risk of tourniquet-related complications can be significantly reduced by selecting cuff inflation pressures based on the limb occlusion pressure, and by a better understanding of the actual level of pressure within the soft tissue, and the effects of cuff width and contour. The evidence behind tourniquet time, placement, and limb exsanguination is also discussed as well as special considerations in patients with diabetes mellitus, hypertension, vascular calcification, sickle cell disease and obesity. We also provide an evidence-based review of the variety of local and systemic complications that may arise from the use of upper limb tourniquets including pain, leakage, and nerve, muscle, and skin injuries. The evidence in the literature suggests that upper limb tourniquets are beneficial in promoting optimum surgical conditions and modern tourniquet use is associated with a low rate of adverse events. With the improvement in knowledge and technology, the incidence of adverse events should continue to decrease. We recommend the use of tourniquets in upper limb surgery where no contraindications exist.
doi:10.1007/s11552-010-9312-6
PMCID: PMC3092892  PMID: 22654699
Tourniquet; Upper limb; Limb occlusion pressure; Complications
3.  Effect of different cuff widths on the motor nerve conduction of the median nerve: an experimental study 
Background
A bloodless operative field is considered mandatory for most surgical procedures on the upper and lower extremity. This is accomplished by using either an Esmarch bandage or a pneumatic tourniquet, but a number of complications are associated with both. Nerve palsy is one of the most frequently encountered complications of this procedure. Wider cuffs have been found to cause reduced risk of tourniquet induced injury to the underlying soft tissues than the narrower ones due to the fact that lower occlusion pressures are caused by the former. To address and investigate this question, conduction in the median nerve has been measured proximal to tourniquet as well as distal to the tourniquet. Parameters of nerve conduction measured are nerve conduction velocity, latency and amplitude.
Methods
Sphygmomanometer cuffs with widths 14 cm and 7 cm were applied to the upper extremities of 20 healthy, normotensive volunteers (9 males and 11 females with age ranging from 22 to 27). Systolic blood pressure was measured first and then the cuff was inflated to about 20–30 mm Hg above it and was kept inflated for 15 minutes. Recordings were done prior to, for the period of tourniquet inflation, and following release of the tourniquet.
Results
Nerve conduction was found to be more severely affected by the 14 cm cuff than the 7 cm cuff.
Conclusion
Wider cuffs resulted in more severe changes in the nerve. This brings us to the conclusion that though lower inflation pressures are required for the occlusion of the blood supply using wider cuffs, the nerve conduction is more severely affected by the wider ones. Both electrophysiological changes and occlusion pressure should be kept in mind while choosing the width of the cuff.
doi:10.1186/1749-799X-3-1
PMCID: PMC2235835  PMID: 18182119
4.  Clinical use of a new tourniquet system for foot and ankle surgery 
International Orthopaedics  2009;34(3):355-359.
This study reports the results of the clinical use of a new tourniquet system for surgery of foot and ankle that can determine tourniquet pressure in synchrony with systolic blood pressure (SBP). We prospectively applied additional pressure of 100 mmHg based on the SBP recorded before the skin incision in 100 consecutive procedures. There were 34 open reduction internal fixation procedures, 26 lateral colateral ligament repair or reconstruction, 16 Achilles tendon repairs, nine arthroscopic procedures such as removal of loose body or accessory bone and synovectomy, seven corrective osteotomy and eight others such as removal of tumour, ankle fusion, and bone graft. The average initial tourniquet pressure was 211 mmHg. The average maximum SBP change during surgery was 28 mmHg. All cases maintained an excellent operative field without measurable bleeding and there were no postoperative complications. Fifty-five cases had a lower intra-operative SBP than the initial value. Since a tourniquet should be applied at the lowest pressure possible for maintaining a bloodless surgical field, the new system appears to be practical and reasonable, as compared to conventional tourniquets, which maintain the initial pressure.
doi:10.1007/s00264-009-0804-3
PMCID: PMC2899285  PMID: 19455329
5.  Relation between preoperative autonomic function and blood pressure change after tourniquet deflation during total knee replacement arthroplasty 
Korean Journal of Anesthesiology  2012;62(2):154-160.
Background
Tourniquets are used to provide a bloodless surgical field for extremities. Hypotension due to vasodilation and bleeding after tourniquet deflation is a common event. Hemodynamic stability is modulated by the autonomic nervous system (ANS). Heart rate variability (HRV) is a sensitive method for detecting individuals who may be at risk of hemodynamic instability during general anesthesia. The purpose of this study was to investigate ANS function to predict hypotension after tourniquet deflation.
Methods
Eighty-six patients who underwent total knee replacement arthroplasty (TKRA) were studied. HRV, systolic blood pressure variability (SBPV) and baroreflex sensitivity (BRS) were analyzed. We assigned two groups depending on the lowest systolic blood pressure (SBP) or mean BP (MBP) after tourniquet release (Group H; SBP < 80 mmHg or MBP < 60 mmHg, Group S; SBP > 80 mmHg and MBP > 60 mmHg).
Results
Fifteen patients developed severe hypotension and ten patients were treated with ephedrine. Of the parameters of HRV, SBPV, and BRS, only BRSSEQ was significant being low in Group H. BRS and high-frequency SBPV were correlated with the degree of MBP change after tourniquet deflation.
Conclusions
Preoperative low BRS is associated with hypotension after tourniquet deflation, suggesting the importance of baroreflex regulation for intraoperative hemodynamic stability.
doi:10.4097/kjae.2012.62.2.154
PMCID: PMC3284738  PMID: 22379571
Baroreflex sensitivity; Heart rate variability; Hypotension; Systolic blood pressure variability; Tourniquet deflation
6.  The efficacy of tourniquet assisted total knee arthroplasty on patient-reported and performance-based physical function: a randomized controlled trial protocol 
Background
Surgical treatment of osteoarthritis with total knee arthroplasty (TKA) usually takes place in a complete bloodless field using a tourniquet. However, doing the surgery without a tourniquet may reduce muscle damage, post-surgery pain and led to improved functional rehabilitation and mobilization.
Methods/Design
A prospective, blinded, parallel-group, controlled superiority trial, with balanced randomization [1:1]. Patients aged 50 or older eligible for primary TKA for osteoarthritis will be consecutively recruited from Department of Orthopedic Surgery and Traumatology, Odense University Hospital, Denmark. A total of 80 patients will be randomly allocated to TKA with or without tourniquet application providing 40 patients for each of the two treatment arms. The tourniquet assisted TKA group will have an automatic, micro-processor-based pneumatic tourniquet inflated around the thigh during surgery. The non-tourniquet assisted TKA group will have surgery performed without application of a tourniquet. The primary aim is to compare tourniquet assisted to non-tourniquet assisted TKA on patient-reported physical function (KOOS-ADL). The secondary aim is to compare post-surgery pain, function in sports and recreation, quality of life, and performance-based physical function. The explorative outcomes include; use of pain medication, single-fiber muscle damage, and changes in mechanical muscle function. The primary endpoint will be at 3-months following surgical treatment, and the time-point for analysis of the primary outcome. However, follow-up will continue up to 1 year, and provide medium-term results. The treatment effect (difference in KOOS-ADL) will be analyzed using a random effects regression model, crude and adjusted results will be reported, if needed. Analyses will be based on the intention-to-treat (ITT). Subsequent per-protocol analysis may be necessary in the event of a substantial number of patients (> 15%) being lost during follow-up. The number needed to treat (NNT) for a positive effect of treatment (>10 points on KOOS-ADL) will be reported.
Discussion
This is the first randomized clinical trial comparing the efficacy of tourniquet assisted TKA on patient-reported physical function supported by a range of performance-based secondary outcome measures. As such it will provide high quality evidence that may help determine whether tourniquet should be used in future TKA procedures in patients with osteoarthritis of the knee.
Trial registration
ClinicalTrials NCT01891266.
doi:10.1186/1471-2474-15-110
PMCID: PMC3978123  PMID: 24678741
Tourniquet; Total knee arthroplasty; Patient-reported; Performance-based; Physical function
7.  Tourniquet Use During Cementation Only During Total Knee Arthroplasty: A Randomized Trial 
Background
Total knee arthroplasty with the use of a tourniquet during the entire operation has not been shown to improve the performance of the operation and may increase the risk of complications.
Questions/purposes
We asked whether the limited use of a tourniquet for cementation only would affect (1) surgical time; (2) postoperative pain and motion of the knee; (3) blood loss; or (4) complications such as risk of nerve injuries, quadriceps dysfunction, and drainage compared with use of a tourniquet throughout the procedure.
Methods
Seventy-one patients (79 knees) were randomized to either use of a tourniquet from the incision through cementation of the implants and deflated for closure (operative tourniquet group) or tourniquet use only during cementation (cementation tourniquet group). The initial study population was a minimum of 30 knees in each group as suggested for randomized studies by American Society for Testing and Materials standards; termination of the study was determined by power analysis performed after 40 knees in each group showed any statistical solution to our questions would require a minimum of 260 more cases. Patients were excluded who were considered in previous randomized studies as high risk for complications, which might be attributed to the tourniquet.
Results
There were no differences in terms of surgical time, pain scores, pain medicine requirements, range of motion, hemoglobin change, or total blood loss. One major complication (compartmental syndrome) occurred in a patient with tourniquet inflation until closure. No other complications were attributed to the use of a tourniquet.
Conclusions
With the numbers available, our results suggest that there are no important clinical differences between patients who had a tourniquet inflated throughout the procedure compared with those who had it inflated only during cementation. Tourniquet inflation for cementation only provides the benefit of bloodless bone for fixation and may eliminate the risks associated with prolonged tourniquet use.
Level of Evidence
Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-013-3124-2
PMCID: PMC3889429  PMID: 23836239
8.  In-vivo analysis of epicutaneous pressure distribution beneath a femoral tourniquet – an observational study 
Background
Compression of the tissue beneath tourniquets used in limb surgery is associated with varying degrees of soft tissue damage. The interaction between fluids and applied pressure seems to play an important role in the appearance of skin lesions. The extent of the transfer of force between the tourniquet and the skin, however, has yet to be studied. The aim of the present study was to quantify in-vivo the transfer of pressure between a tourniquet and the skin of the thigh.
Methods
Pressure under the tourniquet was measured using sensors in 25 consecutive patients over the course of elective surgical procedures. Linear mixed modeling was used to assess the homogeneity of the distribution of pressure around the circumference of the limb, variation in pressure values over time, and the influence of limb circumference and the Body-Mass-Index (BMI) on pressure transfer.
Results
Mean pressure on the skin was significantly lower than the inner pressure of the cuff (5.95%, 20.5 ± 9.36 mmHg, p < 0.01). There was a discrete, but significant (p < 0.001) increase in pressure within the first twenty minutes after inflation. Sensors located in the area of overlap of the cuff registered significantly higher pressure values (p < 0.01). BMI and leg circumference had no influence on the transfer of pressure to the surface of the skin (p = 0.88 and p = 0.51).
Conclusions
Pressure transfer around the circumference of the limb was distributed inhomogeneously. The measurement series revealed a global pressure drop compared to the initial pressure of the cuff. No relationship could be demonstrated between the pressure transferred to the skin and the BMI or limb circumference.
doi:10.1186/s12891-015-0454-0
PMCID: PMC4327976  PMID: 25637090
9.  Tourniquet-Free Hand Surgery Using the One-per-Mil Tumescent Technique 
Archives of Plastic Surgery  2013;40(2):129-133.
Background
A pneumatic tourniquet is generally used to achieve a bloodless operation field in hand surgery. However, this has changed with tumescent solution-based wide-awake surgery. This study is a preliminary prospective case series study to elaborate the formula and indications of the tumescent technique in hand surgery without a tourniquet.
Methods
Seven patients (age range, 4 months to 37 years) underwent hand or upper extremity surgery for conditions such as nerve palsy, electric burn defect, fingertip injury, contracture, constriction ring syndrome, or acrosyndactyly. A "one-per-mil" tumescent solution (epinephrine 1:1,000,000+20 mg lidocaine/50 mL saline) was used to create a bloodless operating field without a tourniquet. Observation was performed to document the amount of solution injected, the operation field clarity, and the postoperative pain.
Results
The "one per mil" epinephrine solution showed an effective hemostatic effect. The tumescent technique resulted in an almost bloodless operation field in the tendon and in the constriction ring syndrome surgeries, minimal bleeding in the flap and contracture release surgeries, and acceptable bleeding in acrosyndactyly surgery. The amount of solution injected ranged from 5.3 to 60 mL. No patient expressed significant postoperative pain. Flap surgeries showed mixed results. One flap was lost, while the others survived.
Conclusions
Epinephrine 1:1,000,000 in saline solution is a potential replacement for a tourniquet in hand surgery. Further studies are needed to delineate its safety for flap survival.
doi:10.5999/aps.2013.40.2.129
PMCID: PMC3605557  PMID: 23533019
Epinephrine; Lidocaine; Upper extremity
10.  Metabolic Effects of Tourniquet Application in Burn Patients 
BACKGROUND
Despite several studies investigating the pathophysiologic effects of tourniquet usage in extremity surgeries, there are not enough data about these effects in adhesion release surgeries of burn patients. In the light of numerous metabolic changes of burn tissues, we tried to determine whether there are any significant differences in metabolic responses of burn tissues to tourniquet ischemia in comparison to the findings of other studies in non burn tissue responses during tourniquet usage in extremity surgeries.
METHODS
From March 2009 to April 2011, eighteen patients who were candidates for performing upper extremity adhesion release surgeries were enrolled. Patients with renal, hepatic, metabolic and any other underlying diseases were excluded from the study. Blood samples for determination of pH, pCO2 and HCO3 were obtained from the occluded hand (as the local response indicator of the body to ischemia) and the other hand too (as the systemic response indicator). The time for blood sampling was just before tourniquet inflation, 30 seconds, one minute, three minutes and five minutes after cuff inflation.
RESULTS
Thirty seconds after tourniquet release, a rapid decrease was noticed in pH values (7.38±0.04-->7.21±0.08). This decrease was seen after 60s in the opposite hand (7.38±0.04-->7.27±0.01) and returned to the baseline values after 5 minutes in both hands. The blood PCO2 value in the occluded hand was found to be increased 30s after tourniquet release (34.93±3.96-->50.06±11.78), while this increase was seen after 180s in the opposite hand too (34.93±3.96-->38.98±9.21). HCO3 value increased after 30s (19.79±2.31-->20.62±2.37) in the occluded hand, but this increase was visible after 60s in the opposite hand. We found no significant difference in the response of burn patients to tourniquet ischemia in comparison to non-burn patients.
CONCLUSION
There was no extra risk in the application of tourniquet in extremity surgeries of burn patients in comparison to non-burn patients. So current protocols of tourniquet application in non-burn patients can be used for adhesion release surgeries in burn patients without any extra caution.
PMCID: PMC4236980  PMID: 25489520
Burn; Metabolic effects; Tourniquet
11.  Tourniquet time affects postoperative complications after knee arthroplasty 
International Orthopaedics  2013;37(5):827-832.
Purpose
Pneumatic tourniquets are frequently used in knee arthroplasty surgery. However, there is a lack of evidence to define safe tourniquet time in lower limb surgery. The primary aim of this study was to investigate whether tourniquet time influences the risk of postoperative complications after primary and secondary knee arthroplasty.
Methods
This study was a prospective register study. Since we wanted dispersion in tourniquet time, we included a consecutive series of 577 primary knee arthroplasties, 46 revision knee arthroplasties, and 18 patellar supplementing knee arthroplasties from a clinical audit database over a period of five years. The following postoperative complications were recorded: superficial wound infections, deep wound infections, deep vein thrombosis, pulmonary embolism, nerve injuries, compartment syndrome, cuff pressure injuries, and bandage injuries.
Results
Tourniquet time over 100 minutes was associated with an increased risk of complications after knee arthroplasty surgery (OR 2.2, CI 1.5–3.1). This increase in risk remained after adjusting for cuff pressure, sex, age, American Society of Anesthesiologists (ASA) classification, smoking, diabetes, and surgery indication (OR 2.4, CI 1.6–3.6).
Conclusions
Tourniquet time over 100 minutes increases the risk of complications after knee arthroplasty surgery and special attention is advocated to reduce the tourniquet time.
doi:10.1007/s00264-013-1826-4
PMCID: PMC3631475  PMID: 23417522
12.  The effect of tourniquet deflation on hemodynamics and regional cerebral oxygen saturation in aged patients undergoing total knee replacement surgery 
Korean Journal of Anesthesiology  2012;63(5):425-430.
Background
Inflation and deflation of a pneumatic tourniquet used in total knee replacement surgery induces various changes in patient's hemodynamic and metabolic status, which may result in serious complications, especially in aged patients. Near-infrared spectroscopy (NIRS) is a monitoring device designed to estimate the regional cerebral oxygen saturation. We evaluated the effect of tourniquet deflation on hemodynamics and regional cerebral oxygen saturation in aged patients undergoing total knee replacement surgery, using NIRS.
Methods
Twenty-eight American Society of Anesthesiologists physical status I or II patients, over the age of sixty-five years undergoing total knee replacement surgery, were included. Under general anesthesia, the mean arterial pressure (MAP), heart rate (HR), cardiac output (CO), stroke volume (SV), and regional cerebral oxygen saturation (rSO2) were recorded before induction of anesthesia and every 2 min after tourniquet deflation for 20 min. Arterial blood gas analysis was performed 5 min before, in addition to 0, and 10 min after tourniquet deflation.
Results
The decrease of rSO2 was not significant during 20-min deflation period. MAP, CO and SV showed significant decrease during 2 to 12, 4 to 6 and 2 to 6-min period after tourniquet deflation, respectively (P < 0.05). There was no relationship between a maximal decrease of MAP and rSO2.
Conclusions
In aged patients undergoing total knee replacement surgery under general anesthesia, tourniquet deflation caused significant changes in hemodynamic and metabolic status, but not in regional cerebral oxygen saturation. It is recommended to monitor neurologic status, as well as hemodynamic and metabolic status to avoid serious complications, especially in aged patients.
doi:10.4097/kjae.2012.63.5.425
PMCID: PMC3506852  PMID: 23198036
Aged; Hemodynamics; Near-Infrared spectroscopy; Tourniquet
13.  Understanding of intra-operative tourniquets amongst orthopaedic surgeons and theatre staff – a questionnaire study 
INTRODUCTION
Pneumatic tourniquets are used frequently in orthopaedic theatres to provide a bloodless field whilst operating on the extremities. Their use has given rise to complications and preventable damage due to over-pressurisation and prolonged application. We designed a questionnaire to assess the knowledge on tourniquet use among operating department assistants (ODAs) and specialist registrars (SpRs) in orthopaedic surgery.
SUBJECTS AND METHODS
A questionnaire was constructed using set guidelines from the Association of periOperative Registered Nurses (AORN) for recommended practice of tourniquet application. This was distributed to orthopaedic registrars with varying levels of experience and ODAs from five different NHS hospitals. The unpaired, two tailed t-test was used to test for statistical significance of results.
RESULTS
A total of 54 completed questionnaires were collected for analysis. The study population included 29 orthopaedic SpRs and 25 ODAs. The mean score for the orthopaedic SpRs as a group was 41.3% (SD 6.85; range, 29.0–54.8%). The mean score for the ODAs was 46.7% (SD 9.64; range, 23.3–62.9%) with a P-value of 0.024.
CONCLUSIONS
Most surgeons are taught how to use pneumatic tourniquets by their senior colleagues as no formal teaching is given. Most of the complications are infrequent and preventable. However, their consequences can be devastating to the patient with medicolegal implications. Our results show suboptimal knowledge of tourniquets and their use among SpRs and ODAs. This study highlights the need for amendments in training to improve the knowledge and awareness of medical practitioners on the application and use of tourniquets to prevent adverse events and improve patient safety.
doi:10.1308/003588410X1251883644060
PMCID: PMC3080086  PMID: 20223078
Tourniquets; Education; Extremities; Orthopaedics; Ischaemia
14.  Tourniquet-Related Iatrogenic Femoral Nerve Palsy after Knee Surgery: Case Report and Review of the Literature 
Case Reports in Orthopedics  2013;2013:368290.
Purpose. Tourniquet-induced nerve injuries have been reported in the literature, but even if electromyography abnormalities in knee surgery are frequent, only two cases of permanent femoral nerve palsies have been reported, both after prolonged tourniquet time. We report a case of tourniquet-related permanent femoral nerve palsy after knee surgery. Case Report. We report a case of a 58-year-old woman who underwent surgical treatment of a patella fracture. Tourniquet was inflated to 310 mmHg for 45 minutes. After surgery, patient complained about paralysis of the quadriceps femoris with inability to extend the knee. Electromyography and nerve conduction study showed a severe axonal neuropathy of the left femoral nerve, without clinical remission after several months. Discussion. Even if complications are not rare, safe duration and pressure for tourniquet use remain a controversy. Nevertheless, subtle clinical lesions of the femoral nerve or even subclinical lesions only detectable by nerve conduction and EMG activity are frequent, so persistent neurologic dysfunction, even if rare, may be an underreported complication of tourniquet application. Elderly persons with muscle atrophy and flaccid, loose skin might be in risk for iatrogenic nerve injury secondary to tourniquet.
doi:10.1155/2013/368290
PMCID: PMC3858884  PMID: 24371536
15.  The effect of sterile versus non-sterile tourniquets on microbiological colonisation in lower limb surgery 
INTRODUCTION
Surgical tourniquets are commonplace in lower limb surgery. Several studies have shown that tourniquets can be a potential source of microbial contamination but have not compared the use of sterile versus non-sterile tourniquets in the same procedures.
METHODS
Patients undergoing elective orthopaedic lower limb surgery were randomised prospectively to use of non-sterile pneumatic tourniquet or sterile elastic exsanguination tourniquet (S-MART™, OHK Medical Devices, Haifa, Israel). Samples were taken from the ties of the non-sterile tourniquet prior to surgery and from the sterile tourniquets at the end of the operation in a sterile fashion. These were then sealed in universal containers and immediately analysed by the microbiology department on agar plates, cultured and incubated.
RESULTS
Thirty-four non-sterile tourniquets were sampled prior to surgical application, twenty-three of which were contaminated with sev-eral different organisms including coagulase-negative Staphylococcus spp, Staphylococcus aureus, Sphingomonas pau-cimobilis, Bacillus spp, and coliforms. Thirty-six sterile tourniquets were used, with no associated contamination.
CONCLUSIONS
There was significant contamination of 68% of orthopaedic surgical tourniquets. These are used regularly in proce-dures involving the placement of prosthesis and metalwork, and can act as a potential source of infection. We recommend the use of sterile single-use disposable tourniquets where possible. The availability of an alternative should now set the new standard of care and we rec-ommend adopting this as a current NICE guideline for control of surgical site infection.
doi:10.1308/147870811X13137608455334
PMCID: PMC3566682  PMID: 22041233
Tourniquet; Equipment contamination; Orthopedic equipment; Lower extremity; Agar plate
16.  Tourniquets in orthopedic surgery 
Indian Journal of Orthopaedics  2012;46(4):377-383.
Tourniquets are commonly used in limb surgeries, be it orthopedic or plastic surgeries. But the inflation pressures, the duration, and release guidelines are still not clear. According to a survey, majority of orthopedic surgeons inflate the tourniquet to fixed pressures for the upper and the lower limbs without considering the baseline blood pressure of the patient on whom the tourniquets are being applied. This review was designed to recall and review the safe use of tourniquets and the various techniques that can be employed to minimize the complications of tourniquet use. Google, science direct, and pubmed were searched for appropriate literature and relevant articles were identified.
doi:10.4103/0019-5413.98824
PMCID: PMC3421924  PMID: 22912509
Tourniquet; orthopaedic surgery; tourniquet and complications
17.  A prospective randomised trial of tourniquet in varicose vein surgery. 
A prospective randomised trial of 50 patients was carried out to assess the autoclavable Lofquist cuff (Boazal, Sweden) as a tourniquet in varicose vein surgery and determine the effect on bleeding, bruising, cosmesis and patient pain and activity. Patients undergoing unilateral long saphenous vein ligation, stripping and avulsions were randomised to tourniquet or no tourniquet. Lofquist cuffs were applied after inflation to 120 mmHg to the upper thigh for the duration of the surgery. Varicose vein grade, duration of surgery, blood loss, extent of bruising at 7 days, pain and activity scores over the first week, and wound complications and cosmetic result at 6 weeks were recorded. Patients' age, sex, and varicose vein grade were similar in the two groups. Peroperative blood loss (median, range) was significantly reduced in the tourniquet group (0 ml, 0-20 ml) compared to the no tourniquet group (125 ml, 20-300; P < 0.01). Operative time and thigh bruising (median, range) were also reduced in the tourniquet group (30 min, 11-47 min; 72 cm2, 30-429 cm2), respectively, compared to the no tourniquet group (37 min, 18-50 min; 179 cm2, 24-669 cm2) both (P < 0.01). There was no difference in pain and activity scores in the two groups and cosmetic results were also similar. The use of the Lofquist cuff tourniquet during varicose vein surgery reduces peroperative blood loss, operative time and postoperative bruising without any obvious drawbacks.
PMCID: PMC2503503  PMID: 10932665
18.  Characterization of acute ischemia‐related physiological responses associated with remote ischemic preconditioning: a randomized controlled, crossover human study 
Physiological Reports  2014;2(11):e12200.
Abstract
Remote Ischemic Preconditioning (RIPC) is emerging as a new noninvasive intervention that has the potential to protect a number of organs against ischemia–reperfusion (IR) injury. The standard protocols normally used to deliver RIPC involve a number of cycles of inflation of a blood pressure (BP) cuff on the arm and/or leg to an inflation pressure of 200 mmHg followed by cuff deflation for a short period of time. There is little evidence to support what limb (upper or lower) or cuff inflation pressures are most effective to deliver this intervention without causing undue discomfort/pain in nonanesthetized humans. In this preliminary study, a dose–response assessment was performed using a range of cuff inflation pressures (140, 160, and 180 mmHg) to induce limb ischemia in upper and lower limbs. Physiological changes in the occluded limb and any pain/discomfort associated with RIPC with each cuff inflation pressure were determined. Results showed that ischemia can be induced in the upper limb at much lower cuff inflation pressures compared with the standard 200 mmHg pressure generally used for RIPC, provided the cuff inflation pressure is ~30 mmHg higher than the resting systolic BP. In the lower limb, a higher inflation pressure, (~55 mmHg > resting systolic BP), is required to induce ischemia. Cyclical changes in capillary blood O2, CO2, and lactate levels during the RIPC stimulus were observed. RIPC at higher cuff inflation pressures of 160 and 180 mmHg was better tolerated in the upper limb. In summary, limb ischemia for RIPC can be more easily induced at lower pressures and is much better tolerated in the upper limb in young healthy individuals. However, whether benefits of RIPC can also be derived with protocols delivered to the upper limb using lower cuff inflation pressures and with lesser discomfort compared to the lower limb, remains to be investigated.
Remote Ischemic Preconditioning (RIPC) is emerging as a new noninvasive intervention that has the potential to protect a number of organs against ischemia‐reperfusion (IR) injury. Currently, there is little evidence to support what limb (upper or lower) or cuff inflation pressures are most effective to deliver this intervention without causing undue discomfort/pain in nonanesthetized humans. In this study we have demonstrated that limb ischemia for RIPC can be more easily induced at lower pressures and is much better tolerated in the upper limb compared with the lower limb, in young healthy individuals.
doi:10.14814/phy2.12200
PMCID: PMC4255807  PMID: 25413320
Characterization; cuff inflation pressure; remote ischemic preconditioning; tolerability
19.  The penile tourniquet 
Asian Journal of Andrology  2013;15(3):364-367.
Tourniquets are commonly used in penile surgery to achieve a bloodless operating field or produce artificial erections intraoperatively. Several techniques have been described, but there is a paucity of data and a lack of guidelines to direct their safe use. In penile surgery, it is the local rather than systemic effects of tourniquet use that are the main concern. Tourniquet time should be kept to a minimum, as the limited data available suggests that reperfusion injury can occur even after short periods of ischaemia. High risk groups such as diabetics and arteriopaths are at particular risk. Further studies are needed to determine safe tourniquet times and pressures.
doi:10.1038/aja.2012.164
PMCID: PMC3739663  PMID: 23542140
hypospadia; ischaemia; penile surgery; reperfusion injury; tourniquet
20.  A prospective trial of local versus general anaesthesia for arthroscopic surgery of the knee. 
We set out to determine if arthroscopic knee surgery was acceptable to patients and their surgeon when carried out using a local anaesthetic infiltration technique. Patients awaiting arthroscopy were randomly allocated to have either a local or a general anaesthetic. The same surgeon (NPT) carried out all the procedures. The demographic profile was similar in the two groups, as were the diagnosis and the surgical procedures. The only difference between the two groups was that those performed under local anaesthesia did not have a limb tourniquet inflated. The time spent in the theatre suite was similar in each group. This did not include the recovery time in the general anaesthetic group. The duration of the operation was longer in the local anaesthetic group (P = 0.05). A simple 0 to 10 scoring system indicated that patients preferred a local anaesthetic but the surgeon preferred to have the patient asleep (P > 0.05). Those having a local anaesthetic required less physiotherapy (P = 0.025) and more of them returned to work and sport earlier (P = 0.05). We attributed this to not having sustained pressure-induced tissue damage to the thigh muscle as they did not have a tourniquet inflated. We had a 4% failure rate in the local anaesthetic group. Arthroscopic surgery is already a well-established day case procedure and our findings have a financial implication (a saving of 25 pounds per case) as well as identifying a safer technique in the medically unfit. Unfortunately, this technique is not suitable for the investigation and treatment of all knee problems. There are certain constraints, viz the very anxious patient, acute problems, children, larger arthroscopic procedures and the inability to perform an examination under anaesthetic but, overall, it is a useful and effective way of performing a common surgical procedure.
PMCID: PMC2503043  PMID: 9326126
21.  Pulseless electrical activity during electroconvulsive therapy: a case report 
BMC Anesthesiology  2012;12:8.
Background
Arrhythmias resulting in cardiac arrest during electroconvulsive therapy have been reported. Most reported cases of cardiac arrest had asystole as the initial rhythm. Pulseless electrical activity as an initial rhythm of cardiac arrest during electroconvulsive therapy has never been reported. Also, thromboembolism after inflation of pneumatic tourniquet during lower limb surgery has been reported but never following tourniquet inflation during an electroconvulsive therapy.
Case presentation
We report a case involving an 81- year- old female who presented to us for an electroconvulsive therapy for severe depression and developed pulseless electrical activity immediately after electroconvulsive therapy. She was successfully resuscitated and was later found to have bilateral pulmonary emboli with a complete occlusion of the right lower lobe pulmonary artery. The source of embolus was from her left lower extremity deep venous thrombus, which we believe, got dislodged intraoperatively after inflation of pneumatic tourniquet. Our patient not only survived the massive pulmonary embolus, but also showed significant improvement in her mental status compared to her pre-admission level at the time of discharge to a sub-acute rehabilitation centre.
Conclusion
We recommend that patients who are elderly and at high risk of thromboembolism should selectively undergo a preoperative doppler ultrasound for deep venous thrombosis. Also, selective application of tourniquet in the upper limb, to monitor for seizure activity, would reduce the incidence of pulmonary thrombo-embolism as embolic events are significantly less from deep venous thromboses of upper extremities when compared to lower extremities.
doi:10.1186/1471-2253-12-8
PMCID: PMC3403950  PMID: 22650157
ECT; Pulseless electrical activity; Tourniquet; Pulmonary embolism
22.  Effects of Tourniquet Use on Quadriceps Function and Pain in Total Knee Arthroplasty 
Knee Surgery & Related Research  2014;26(4):207-213.
Purpose
A pneumatic tourniquet is commonly used in total knee arthroplasty (TKA) to improve surgical field visualisation but may result in quadriceps muscle ischaemia. We performed this study to analyse the effect of the tourniquet on recovery following TKA.
Materials and Methods
A prospective randomised single-blinded trial was undertaken to examine the effect of the tourniquet on post-operative pain, swelling, blood loss, quadriceps function and outcome following TKA. Twenty patients with osteoarthritis of the knee were randomised to tourniquet or no tourniquet groups. Quadriceps function was assessed using surface electromyography (EMG) during active knee extension.
Results
The no tourniquet group had significantly less pain in the early post-operative period compared to the tourniquet group. There was no difference in Oxford knee score, range of motion, or thigh and knee swelling up to 12 months post-operatively. Quadriceps function, measured by surface EMG, was compromised for the first six months post-surgery by tourniquet use. The radiological cement mantle at the bone prosthesis interface at 12-month follow-up was not affected by the absence of a tourniquet.
Conclusions
We believe that it is safe and beneficial for our patients to routinely perform TKA without a tourniquet.
doi:10.5792/ksrr.2014.26.4.207
PMCID: PMC4258487  PMID: 25505702
Knee; Arthroplasty; Tourniquet; Pain; Quadriceps
23.  Silicone ring tourniquet versus pneumatic cuff tourniquet in carpal tunnel release: a randomized comparative study 
Background
The aim of the present study was to compare the pain levels resulting from the use of a silicone ring tourniquet (SRT) to those resulting from the use of a classic pneumatic cuff tourniquet (PT) in patients undergoing carpal tunnel release under local anesthesia.
Materials and methods
Fifty patients that underwent carpal tunnel release under local anesthesia were randomized using the technique of stratified randomization by minimization. A forearm tourniquet was applied: a standard PT was used in 25 patients, and an SRT was used in the other 25 patients (the model of SRT used was selected according to the standard systolic blood pressure). Patient demographics and complications were recorded. Pain levels were assessed with the visual analogue scale and were recorded (a) just after tourniquet application, (b) 5 min after tourniquet application, and (c) just before tourniquet removal.
Results
There was no statistical significant difference in patient demographics between the two groups. The mean tourniquet time was similar for both groups (p = 1.000). The difference between the mean final pain level and the mean initial pain level was statistically significant for the SRT group (p = 0.010) and highly statistically significant for the PT group (p < 0.001). The mean final pain level for the PT group was higher than that for the SRT group (p = 0.043).
Conclusions
According to the findings of this study, in patients who underwent carpal tunnel release under local anesthesia, the pain levels at the end of the operation and those just before the removal of the tourniquet were higher in the PT group than in the SRT group of patients.
doi:10.1007/s10195-012-0223-x
PMCID: PMC3667358  PMID: 23361654
Tourniquet; Pneumatic tourniquet; Silicon ring tourniquet; Tourniquet pain
24.  Aqueous based Povidone-iodine related chemical burn under the tourniquet (a case report) and literature review 
Journal of Orthopaedics  2013;10(3):152-154.
Chemical burn under pneumatic tourniquet is an iatrogenic preventable injury and is rarely reported in the literature. The important mechanisms are maceration, irritation, and prolonged use of the tourniquet and pressure. This rare adverse complication occurred in a 35-year old man who underwent anterior cruciate ligament reconstruction of left knee. 5% aqueous based Povidone-Iodine was used as topical antiseptic and partial thickness burn occurred underneath the area of tourniquet application. Previous reports shows that chemical burns are more common in alcohol based Povidone-iodine than aqueous based. Chemical burn develops when Povidone- iodine does not adequately dry, pools beneath a dependent body part during surgery, or is placed under an occlusive device. To reduce the complications like chemical burn, awareness of the risk and the possible pathogenesis as well as the preventive measures is important in surgical practice.
doi:10.1016/j.jor.2013.07.007
PMCID: PMC3861682  PMID: 24396233
Chemical burn; Maceration; Irritation; Tourniquet
25.  A Case of Rhabdomyolysis Associated with Use of a Pneumatic Tourniquet during Arthroscopic Knee Surgery 
The common causes of rhabdomyolysis include trauma, hypoxia, drugs, toxins, infections and hyperthermia. Operative insults, including direct trauma and ischemia, have the potential to cause the development of rhabdomyolysis. Pneumatic tourniquets used during arthroscopic knee surgery to prevent blood loss have led to many complications such as nerve paralysis and vascular injuries. Rhabdomyolysis can also be caused by prolonged pneumatic tourniquet application without a midapplication release, and also from an increased application pressure, but the actual incidence of this is low. In order to prevent rhabdomyolysis, the clinicians must be aware of such risks and follow strict guidelines for the application time, the midapplication release and also the inflation pressure. Vigorous hydration and postoperative patient surveillance are helpful to prevent rhabdomyolysis. We have recently experienced a case of rhabdomyolysis after the arthroscopic knee surgery, and the rhabdomyolysis could have been associated with the use of a pneumatic tourniquet.
doi:10.3904/kjim.2010.25.1.105
PMCID: PMC2829407  PMID: 20195412
Rhabdomyolysis; Tourniquets; Kidney failure, acute

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